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Thor A. Wagner, Lisa M. Frenkel, Yet Another Reason to Treat HIV Infection, Clinical Infectious Diseases, Volume 54, Issue 7, 1 April 2012, Pages 1010–1012, https://doi.org/10.1093/cid/cir1041
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(See the Major Article by Ruel et al, on pages 1001–9.)
Antiretroviral therapy (ART) has allowed a cohort of children who were perinatally infected with human immunodeficiency virus (HIV) to reach early adulthood, but their risk of death, non-AIDS-defining infections, cancers and organ failure remain elevated compared with uninfected populations [1]. Although ART dramatically improves the survival of infants [2] and children [1] and appears to improve the growth and neurologic function when initiated in older children [3, 4], less is known about the optimal time to initiate ART in older, asymptomatic children to prevent indolent HIV-associated morbidities, including loss of cognitive functions. The recommended CD4 cell count at which to start ART in adults and adolescents has been progressively revised upward [5]; however, this threshold remains controversial, and resulted in the split judgment by the 2011 Department of Health and Human Services panel on whether to recommend ART for all adults [5]. Current World Health Organization guidelines recommend the use of adult immunologic criteria (CD4 cell count, <350 cells/μL) to determine when to initiate ART in children >5 years of age [6]. This leaves many relatively asymptomatic HIV-infected children with moderately decreased CD4 T-cell counts untreated, which could place them at risk for HIV-associated morbidity. (Normal CD4 cell counts in children 5–12 years of age range from 980 to 1200 cells/μL [7, 8]). In this issue of Clinical Infectious Diseases, Ruel et al [9] present a case-control study that demonstrates neurocognitive and motor dysfunction in “asymptomatic” HIV-infected children 6–12 years of age who do not qualify for ART. Their findings suggest that the World Health Organization guidelines do not capture early neurologic disease and provide a rationale to explore whether earlier ART would benefit these children.
