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Background Depletion of CD4 T-cell counts or progression of human immunodeficiency virus (HIV) disease occurs rapidly in children, but few data address the efficacy of aggressive therapy for HIV-infected children.
Methods We evaluated the safety, tolerability, and activity of three regimens of antiretroviral therapy in a multicenter, open-label, phase 1–2 trial. Children infected with HIV type 1 (HIV-1) were stratified at entry according to age — three months or younger (early therapy) or older than three months (delayed therapy) — and assigned sequentially to one of three regimens. Children continued to receive treatment for up to 200 weeks if the plasma HIV-1 RNA level was less than 1000 copies per milliliter by 16 weeks.
Results Plasma HIV-1 RNA levels fell from a median of 5.3 log copies per milliliter (range, 3.3 to 6.4 log copies per milliliter) at baseline to less than 1000 copies per milliliter at 16 weeks in 32 of 52 infants (62 percent). Plasma HIV-1 RNA levels were below 400 copies per milliliter at 48 weeks in 26 infants (50 percent) and at 200 weeks in 23 infants (44 percent). An intention-to-treat analysis revealed that significantly more children who received stavudine, lamivudine, nevirapine, and nelfinavir had plasma HIV-1 RNA levels of less than 400 copies per milliliter at 48 weeks (83 percent) and 200 weeks (72 percent) than children who received reverse-transcriptase inhibitors alone (P=0.001 and P=0.01, respectively). Fewer infants in the delayed-therapy group than in the early-therapy group (30 percent vs. 60 percent) had plasma HIV-1 RNA levels of less than 400 copies per milliliter at 200 weeks (P=0.03). Treatment-associated adverse effects were infrequent.
Conclusions In this phase 1–2 trial involving HIV-1–infected children, an age of three months or younger at the initiation of therapy and treatment with stavudine, lamivudine, nevirapine, and nelfinavir were associated with improved long-term viral suppression. Larger, randomized trials are required to define the optimal time to initiate therapy and the optimal regimen for these infants.
Source Information
From the Department of Pediatrics and Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Mass. (K.L., M.M., J.L.S.); the National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Md. (L.M.); the Statistical and Data Analysis Center, Harvard School of Public Health, Boston (P.B.); and the Frontier Science and Technology Research Foundation, Amherst, N.Y. (B.G.).
Address reprint requests to Dr. Luzuriaga at the University of Massachusetts Medical School, Pediatrics/Molecular Medicine, 373 Plantation St., Suite 318, Biotech 2, Worcester, MA 01605, or at katherine.luzuriaga{at}umassmed.edu.
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