When should children infected with HIV start medication?

The advent of effective medications for treating HIV dramatically improved the outlook for both adults and children infected with HIV who had access to treatment, but the optimal timing for starting treatment remains controversial, particularly in children.

A debate article in this week's PLoS Medicine lays out the case for deferred treatment against the case for early initiation of treatment in children infected with HIV.

In laying out the case for deferred treatment, Dr Steven Welch (Consultant in Paediatric HIV and Infectious Diseases, Heartlands Hospital, Birmingham, UK) says that, "it remains rational to consider an individual child's and family's wishes and circumstances as well as the child's risk of disease progression in deciding when to start treatment." The hasty and injudicious use of antiretroviral medications in children, he argues, risks creating a cohort that has learned poor adherence habits, is infected with multi-drug-resistant viruses, and has been exposed to unnecessary cumulative drug toxicities.

Arguing the case for early initiation, Professor Di Gibb (Professor in Epidemiology and a Consultant Paediatrician at the Medical Research Council Clinical Trials Unit, London, UK), says that "deferring treatment initiation for as long as possible is no longer an option." Professor Gibb lays out several reasons why she believes that early initiation is even more important in children than in adults—for example, children with HIV grow better if they receive antiretroviral medication.

Both authors point out that there has never been a clinical trial conducted on determining when to start antiretroviral medications in children, and they conclude by saying that the time has come to conduct such a trial.