Pediatric HIV Still a Problem
My expectation is that our adult medicine colleagues are the ones who will see serious heart disease in these patients, probably in their 20s or 30s, just as the adults are now getting coronary artery disease in their 30s, 40s, and 50s. Currently there is disagreement about how aggressively to treat cardiovascular risk factors in these children. Some argue that these kids have HIV and we should simply leave them alone. My attitude is that because these children have HIV and may live into their 50s, 60s, or 70s, we can't afford to leave them alone.
Body changes—typically increased weight and fat deposition in the trunk—are also a major problem, especially for the teenagers. Girls often have enlarged breasts, big abdomens, a “buffalo hump,” and very large shoulders. Boys tend to develop barrel chests and gynecomastia. As you can imagine, these changes are quite disturbing to teenagers, and may lead them to stop taking their medications. While this syndrome, lipodystrophy, is being extensively studied in adults, little progress has been made in understanding its pathogenesis in children and adolescents.
Disclosure may be yet another problem for many HIV-infected teenagers. We've had several young adolescent patients who don't know their diagnosis. The parents often think they're protecting their kids by not telling them, but we believe that the more the children know, the more likely they are to take an active part in their own care as they mature. We begin discussing disclosure with families when their child reaches 8-10 years of age, depending on individual maturity and intellectual capacity.
A fourth cause for concern—and possibly the greatest—comes from a recent study published by the Pediatric AIDS Clinical Trials Group, in which I participate. We found that neuropsychological function was significantly poorer among HIV-infected children, and was worse with higher viral loads. Moreover, only one measure of neuropsychological functioning improved after effective viral suppression with combination protease inhibitor therapy, and that improvement was relatively minor (Pediatrics 2005;115:380-7).
While it had been previously recognized that HIV-infected children have cognitive and behavioral difficulties, this is the first time it has been looked at with regard to response to HAART therapy. Although the correlation with viral load suggests the problem is disease related, we have not yet determined the relative contributions of disease, treatment, and the often adverse socioeconomic environments these children live in.
We must continue to search for better and safer approaches to preventing vertical transmission. Currently, we give antiretrovirals as early as the second trimester, continue them through labor and delivery, and in the newborn for up to 6 weeks. With all the new drugs that are being introduced, we must be certain that the therapies we're delivering are safe. Now that 98%-99% of these children won't have HIV, we have to make sure they don't have toxicity from the medications, either.
We need to find safer regimens without losing what we've accomplished in preventing vertical transmission, which is in my mind the biggest accomplishment in the prevention of HIV to date.
