pediatrics
Human Immunodeficiency Virus (HIV) Infection in Infants and Children
Prognosis for HIV Infection in Infants and Children
In the pre-ART era, 10 to 15% of children from high-resource countries and perhaps 50 to 80% of children from low-resource countries died before age 4 years; however, with appropriate combination ART regimens, most perinatally infected children survive well into adulthood. Increasing numbers of these perinatally infected young adults have given birth to or fathered their own children. Nevertheless, if opportunistic infections occur, particularlyPneumocystispneumonia, progressive neurologic disease, or severe wasting, the prognosis is poor unless virologic and immunologic control is regained with combination ART. Mortality due toPneumocystispneumonia ranges from 5 to 40% if treated and is almost 100% if untreated. Prognosis is also poor for children in whom virus is detected early (ie, by 7 days of life) or who develop symptoms in the first year of life. There have been several reported cases of adults in whom replication-competent HIV was eradicated (ie, these people were "cured" for > 5 years). These adults each required a hematopoietic stem cell transplant for leukemia. The donor cells were homozygous for the CCR5-delta 32 mutation, which made the engrafted lymphocytes resistant to infection with CCR5-tropic HIV; subsequently, HIV has remained undetectable. It is likely that ART, bone marrow ablation, and graft-vs-host disease also contributed to these cures. At least one infant born to a mother with HIV infection who had not received prenatal care or prenatal (or intrapartum) ART was preliminarily thought to have been cured but upon further clinical follow-up was found to have persistent HIV infection. This infant was given combination ART at high doses (not yet known to be safe and effective for general use) beginning on day 2 of life through 15 months of age, after which time it was inadvertently interrupted. Nevertheless, at 24 months of age the infant had no detectable replicating virus RNA (a "functional cure") but did have detectable proviral DNA. Subsequently, however, HIV replication ensued. No infants or children have been permanently cured of their HIV infection, and it is not yet known if cure is possible. What is known, however, is that HIV infection is a treatable infection that is already compatible with long-term survival if effective ART is given. Future research will undoubtedly uncover ways to improve ART tolerance and efficacy and perhaps help achieve the goal of curative therapy.At present, interruption of ART in either infancy, childhood, or adulthood is not recommended. 