Antiretroviral therapy of pediatric HIV infection: making hope a reality

Over the past 3 years, the treatment and prognosis of HIV-1 infection have been revolutionized by a better understanding of the pathogenesis of HIV-1 infection, the ability to monitor viral replication and drug resistance in the host, and the availability of potent combination chemotherapy. While most of the studies that have led to this transformation have been done in adults, the results can be applied to the care of children. Data from trials of highly active antiretroviral therapy (HAART) in children are now being presented or published. Although the basic principles of antiretroviral therapy of HIV-1 infection do not differ between adults and children, there are important differences in the natural history of the disease and in issues related to medication administration and adherence to therapy. Progression of disease may be more rapid in children and is often very rapid in infants. Administration of medication to infants and children can be difficult, especially when the medication tastes bad. Finally, whereas an adult patient is free to decline therapy, however foolish such a decision may seem to the health-care professional, the failure to administer effective medication to a child for a condition that threatens serious morbidity or death constitutes medical neglect. In this review we will discuss the basic principles underlying pediatric antiretroviral therapy and address the issue of adherence, the major impediment to treatment success.