Starting antiretroviral treatment in children with HIV

Starting antiretroviral treatment in children with HIV

There is a complex balance between the immediate benefits of providing treatment to children who are not showing any symptoms of AIDS-related illness, and concerns about long-term resistance and antiretroviral drug side effects if treatment is started too early.

CD4 counts in children

To judge whether an HIV-positive person requires treatment, a CD4 test is usually carried out. This measures the number of T-helper cells – white blood cells that are attacked by HIV – in an individual’s blood. It can either measure the absolute number of CD4 cells, or the percentage of white blood cells that are CD4 cells, in a sample of blood.

A falling CD4 count is a sign that HIV is progressing, and that the immune system is becoming weaker. However, it is difficult to judge the health of a child's immune system based on CD4 count. Absolute CD4 counts vary with age, and younger children usually have a much higher CD4 count than adults. Percentage CD4 count on the other hand does not vary in the same way as absolute CD4 count, and is therefore recommended for children under five.

In some cases, viral load testing (which measures the amount of HIV in an individual’s blood) is used alongside CD4 testing to guide decisions about treatment.

Starting treatment based on clinical symptoms

In resource-poor communities, the technology needed for CD4 counts and viral load testing is not always available. In the absence of these facilities, healthcare workers sometimes have to make a presumption that a child should begin treatment based on their stage of HIV infection as defined by a range of cancers and infections that are present.