When to start treatment

When to start treatment

The World Health Organization (WHO) now recommends that all diagnosed infants and children less than two years of age should begin antiretroviral therapy regardless of the child's clinical or immunological stage.¹³ (Children under 12-months with clinically diagnosed presumptive severe HIV should also begin treatment, but confirmation of infection should be obtained as soon as possible.)

The Children with HIV Early Antiretroviral Therapy (CHER) study of infants (aged six-to-twelve weeks) in South Africa compared the outcomes of those starting limited treatment immediately with those deferring treatment until CD4 percentage dropped below certain levels or if symptomatic and severe disease occurred. (The study's criteria for deferred treatment were only slightly different from South African or WHO guidelines.) It found the risk of death for infants who began treatment immediately was 76% lower than the deferred treatment group.¹⁴

Doctors at the Rixile HIV clinic treat an ill HIV positive child, Tintswalo, South Africa

The United States recommends treatment for all infants with HIV, regardless of CD4 percentage, clinical status or viral load.¹⁵ The 2009 guidelines produced by the Paediatric European Network for Treatment of AIDS (PENTA) also advocate treatment for all infected children under 12 months regardless of clinical or immunological stage.¹⁶ Other countries’ guidelines may be revised to reflect WHO recommendations and the CHER study’s findings.

While there is an emerging consensus on initiating therapy immediately in infected infants, there is ongoing debate as to when treatment should begin in young children. According to US and PENTA guidelines treatment is recommended if significant symptoms are evident or percentage CD4 count has decreased to below 20-25% for children aged between one and five years.^{17 18} WHO 2010 recommendations suggest the initiation of ART for all HIV-infected children between two and five years with either a CD4 count of 750 or below, or a CD4 percentage of 25 or below, whichever is lower, irrespective of clinical status.¹⁹

Arguments for earlier treatment include: evidence that disease progression is faster in young children; that there is an association between severe HIV disease and persistent neurocognitive deficits in adolescent long-term survivors of perinatally acquired HIV;²⁰ and that ART can reduce tuberculosis, encephalopathy and bacterial infections that occur even at high CD4 levels, as well as improve physical growth. Advocates for earlier treatment also point to studies showing that the risk of disease progression is identical between adults and over-5s so it follows that any argument for earlier initiation in adults should also apply to older children. Arguments for deferring treatment include a lack of information on the long term effect of doing so, and the additional cost and burden of adherence due to a longer overall period of treatment.