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The AIDS Beacon

Revaccination May Be Necessary For HIV+ Children

Revaccination against vaccine-preventable illnesses, such as measles and tetanus, may be necessary in HIV-positive children after starting antiretroviral therapy, according to researchers at the John Hopkins School of Public Health.

In addition, children on antiretroviral therapy may need repeated vaccines or higher dosages to retain their immunity against illnesses over the long-term.

“It’s clear that many HIV-infected children on treatment remain susceptible to vaccine-preventable diseases and would benefit from revaccination,” said Catherine Sutcliffe, lead author of the review, in correspondence with The Beacon.

“Most children receiving treatment responded well to revaccination, although levels of immunity still decreased over time,” she added.

Previous studies have shown that children with HIV often do not respond as effectively to vaccines as children without HIV. This can lead to weaker immunity to vaccine-preventable illnesses or loss of immunity over time.

Starting highly active antiretroviral therapy (HAART) helps restore the immune system and boost immune responses. However, it is not known whether this helps improve immunity from vaccines that were given before starting antiretroviral therapy, or whether children starting HAART instead need to be revaccinated.

To answer this question, the researchers examined previously published studies in which children were vaccinated before starting HAART and their levels of immunity were measured again afterward.

The researchers found that results were mixed, with some children showing improved immunity after starting antiretroviral therapy while others lost their vaccine protection.

For example, one study of children vaccinated with the measles-mumps-rubella (MMR) vaccine found that 40 percent of the children who failed to achieve a vaccine response before starting HAART gained immunity afterward.

However, the same study also found that 53 percent of children who had gained immunity to MMR before HAART lost their immunity after starting antiretroviral therapy.

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The AIDS Beacon

HHS Releases Updated Guidelines for Treatment of HIV-Positive Children and Teens

The United States Department of Health and Human Services has released an updated version of its “Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection.”

The guidelines contain updated recommendations in several areas, including diagnosis of HIV in infants, start of antiretroviral therapy, selection of antiretrovirals, and adherence to antiretroviral therapy in children and teenagers.

The guidelines now also include a rating system to indicate the strength of each recommendation, and formatting changes have been implemented to improve readability. For example, a section on drug side effects in children that includes information on risk factors, symptoms, preventative measures, and treatment options is now presented in a table format for ease of use.

The guidelines are intended for use by doctors and other health care professionals when treating HIV-positive children and teens.

Key updates to various sections of the guidelines are summarized below.

Diagnosis Of HIV In Infants

The guidelines now recommend HIV testing at birth for infants who are at high risk for contracting the virus. This includes babies born to HIV-positive mothers who did not receive prenatal care or prenatal antiretroviral therapy, or who had HIV viral loads (amount of virus in the blood) greater than 1,000 copies per milliliter near the time of delivery.

HIV infection in adults is usually diagnosed by looking for antibodies – proteins made by the immune system to help identify and fight bacteria and viruses. In infants, however, tests for HIV antibodies may lead to false-positive results, as children of this age group often still carry their mothers’ HIV antibodies.

To avoid a false diagnosis, the guidelines continue to recommend tests that detect the virus itself to determine HIV status in infants younger than 18 months. This includes HIV DNA PCR assays and HIV RNA tests, both of which can detect the HIV virus directly.

The guide also continues to recommend that babies be tested for HIV at 14 to 21 days after birth, age 1 to 2 months, and 4 to 6 months of age.

Start Of Antiretroviral Therapy

Suggestions for when to initiate antiretroviral therapy vary according to age group.

Antiretroviral therapy is now recommended for children older than 12 months who have normal CD4 (white blood cell) counts but HIV viral loads of 100,000 copies per milliliter of blood or higher, even if their symptoms are mild or nonexistent.

For children under the age of 12 months, the guidelines continue to recommend starting antiretroviral therapy regardless of CD4 count, viral load, or the presence or absence of symptoms. Several studies have shown that starting therapy early in children of this age significantly reduces the chances a child will progress to AIDS or die.

In children with normal CD4 counts whose HIV viral loads are less than 100,000 copies per milliliter, and who have mild or no symptoms, initiation of treatment can be either considered or deferred.

Selection Of Antiretroviral Drugs For Treatment Naïve Patients

As with adults, all HIV-positive children should be treated using combination therapy that includes at least three different antiretroviral drugs from two different classes.

However, the updated guidelines now indicate that non-nucleoside reverse transcriptase inhibitor (NNRTI)-based therapy is not recommended for children younger than 3 years of age who have been exposed to single dose Viramune (nevirapine).

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