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Approach to the management of paediatric HIV spontaneous controllers
Peter Zuidewind1, Mark Cotton1, Shaun Barnabas1
1Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa.
Insights
Paediatric HIV spontaneous controllers (HSCs) are rare individuals who control HIV without antiretroviral treatment (ART). This case series highlights challenges in diagnosing and managing these unique patients, ultimately requiring ART for all three.
Area of Science:
- Pediatrics
- Infectious Diseases
- Immunology
Background:
- Paediatric HIV spontaneous controllers (HSCs) are a rare, understudied group with potential to inform HIV treatment strategies.
- Optimal management of HSCs is challenging due to their rarity and difficulty in diagnosis before antiretroviral treatment (ART) initiation.
Purpose of the Study:
- To describe the diagnosis, history, and management of three paediatric HSCs.
- To assist clinicians in recognizing paediatric HSCs and navigating clinical dilemmas in their management.
- To inform decision-making regarding ART initiation in paediatric HSCs.
Main Methods:
- Case series describing three paediatric HSCs (two girls, one boy) followed for 2, 1.25, and 10.4 years before ART.
- Monitoring of viral loads, CD4:CD8 ratios, and other clinical factors.
- Analysis of factors influencing the decision to initiate ART.
Main Results:
- All three patients maintained low but detectable viral loads and mostly marginally low CD4:CD8 ratios.
- ART was initiated due to a gradual decline in virological control.
- Factors supporting ART initiation included viral load blips, increasing viral load, CD4 percentage, CD4:CD8 ratio, Hepatitis C serology, and high-sensitivity C-reactive protein.
Conclusions:
- The case series aids in recognizing paediatric HSCs and highlights management challenges, including diagnosis and ART initiation decisions.
- Individualized decision-making for ART initiation is crucial, considering factors like viral control and immune status.
- All three patients eventually required ART, suggesting universal ART initiation may be beneficial for paediatric HSCs, warranting further research.
Abstract:
Paediatric HIV spontaneous controllers (HSCs) are a unique and understudied population with potential to inform alternative treatment options for patients living with HIV. As HSCs are so rare and often not recognised prior to antiretroviral treatment (ART) initiation, it can be difficult for clinicians to optimally manage this group. We describe the diagnosis, history and management of three paediatric HSCs, two girls and a boy who were followed for 2, 1.25 and 10.4 years, respectively, before starting ART. All had low but detectable viral loads throughout follow-up but mostly marginally low CD4:CD8 ratios. The reason for starting ART in all was a gradual tendency to poorer virological control. This case series should assist in recognising paediatric HSCs. Clinical dilemmas arising in the management of paediatric HSCs include arriving at a correct HIV-positive diagnosis, correct diagnosis as an HSC, as well as whether to initiate ART. Decision-making for initiation of ART in paediatric HSCs should be individualised. Factors supporting ART initiation in these patients included increased frequency of viral load blips, increasing detectable viral load, CD4 percentage and CD4:CD8 ratio. Other factors included Hepatitis C serology and highly sensitive C-reactive protein. All three patients ultimately required ART, which supports universal initiation of ART in paediatric HSCs, but further research is required.
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