The goals of treatment for HIV-infected children are to maximally suppress the viral load, prevent destruction of the immune system and decrease the development of resistant HIV strains. The Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children published treatment guidelines for infants, children and prepubertal adolescents infected with HIV in February of 2009.
Detection
It is imperative to detect HIV infection early in infants because of its potential for rapid progression. The Working Group, among multiple other institutions, advocates the routine testing of all pregnant women for HIV. Infants born to HIV-positive mothers are commonly tested for the presence of HIV at birth, between 14 and 21 days, 1 and 2 months, and 4 and 6 months. The commencement of antiretroviral treatment is recommended for all HIV-infected infants under the age of 12 months. In children, the exact time for the initiation of treatment is debated. The Working Group recommends that all children who display symptoms of AIDS begin treatment and that treatment should be considered even for those who are asymptomatic.
Testing
Infants and children are tested every 3 to 4 months for the concentration of HIV in their blood and their percentage of CD4 cells. CD4 is a marker on immune system cells that are most commonly infected and destroyed by HIV. The CD4 count is utilized as an index for defining the progression of HIV infection. The Working Group reported that studies have demonstrated that the development of AIDS and AIDS-associated mortality in children is predicted by the percentage of circulating CD4 cells.
Treatment Regimens
Adults, children and infants that are infected with HIV are treated with a combination of at least three antiretroviral drugs simultaneously--an approach called highly active antiretroviral therapy, or HAART. This intensive approach is required to significantly decrease the viral load and prevent the replication of drug-resistant HIV strains. The Working Group prefers the following treatment regimens for infants, children and prepubertal adolescents infected with HIV; efavirenz in combination with two nucleotide reverse transcriptase inhibitors for children aged 3 years or older; nevirapine in combination with nucleotide reverse transcriptase inhibitors for children who are younger than 3 years and adhere better to a liquid formulation; the protease inhibitor based regimen of lopinavir/ritonavir in combination with two nucleotide reverse transcriptase inhibitors. None of these treatment regimens cure HIV infection, and they are necessary for the rest of a person's life.
Treatment Benefits
The Working Group noted that HIV mortality in children has decreased between 81 and 93 percent since the introduction of HAART. Highly active antiretroviral drug therapy has not only improved survival, but also reduced the occurrence of opportunistic infections and improved growth and neurocognitive function in HIV-infected children.
Management of Complications
One of the primary AIDS-associated disorders in children is pain, most often resulting from chronic inflammation of nerves and organs. Multiple pain medications are approved for use in children, and the appropriate pain management therapy is dependent on the cause and location of the pain. The Centers for Disease Control and Prevention reported that 19 percent of children infected with HIV had wasting syndrome in 2005. Additionally, HIV-infected children also fail to grow properly. The Working Group recommends nutrition monitoring and vitamin supplements to combat these morbidities. As more and more persons continue to live longer with AIDS, the complications of long-term intensive drug therapy, genetic factors and chronic immune suppression will continue to present new and potentially serious challenges for patients and the medical community.
