When to initiate antiretroviral therapy in HIV-infected children?

Administration of highly active antiretroviral treatment (HAART) has led in the developed world to a dramatic reduction in the incidence of HIV related pediatric mortality. HAART is now the standard-of-care therapy in infected children but the occurrence of short- and long-term drug-related toxic effects and emergence of drug-resistant viral variants temper its success. In children, both CD4 cell percent and viral load have independent predictive value for disease progression, CD4 cell being the stronger predictor of AIDS and death. Concerning children aged 12 months or older current French recommendations for immediate therapy are based on the presence of clinical symptoms (of categories B or C) or the occurrence of a severe immunodeficiency (CD4 cell percent <15%). In infants, risk of disease progression is higher and the viral load and CD4 percent are less reliable markers. HAART should theoretically be initiated in all infants in order to prevent HIV encephalopathy and early death. However, viral failure under HAART is often encountered in children less than 12 months because of high levels of replication as well as limited data on pharmacokinetics and drug dosing. A possible alternative approach for infants without risk factor for early progression is to defer HAART under close monitoring. (C) 2004 Elsevier SAS. Tous droits reserves.