Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA.
Pediatr Infect Dis J. 2012 Jan;31(1):53-60. doi: 10.1097/INF.0b013e31823515a2.
Treatment with highly active antiretroviral therapy (HAART) reduces overall perinatal human immunodeficiency virus (HIV) type 1-related mortality. The effect of timing of HAART initiation on reduction of morbidity is not well defined. We evaluated the association of timing of HAART initiation on progression to moderate or severe disease.
Retrospective, population-based study of 196 perinatally HIV-infected children followed from birth in northern California from 1988 to 2009.
Of 196 children, 58% received HAART and were followed for a median of 6.2 years after HAART initiation. HAART use was associated with improved survival to the age of 5 years: no HAART, 50% versus HAART, 88%; P < 0.0001. However, the advantage of initial HAART over mono or dual therapy transitioning to HAART was small and not statistically significant (P = 0.23). Starting HAART before the development of moderate or severe disease delayed the median age of diagnosis of moderate disease from 0.4 years (interquartile range, [0.3-0.8]) without HAART to 3.0 years ([interquartile range, 1.9-5.8]; P < 0.0001) with HAART. HAART initiation after progression to moderate or severe disease was associated with decreased progression to severe disease or death, respectively (moderate to severe: 8% [3/36] with HAART vs. 84% [70/83] with no HAART, P < 0.0001; severe to death: 9% [6/68] with HAART vs. 73% [49/67] with no HAART, P < 0.0001).
In perinatal HIV infection, HAART is associated with delayed progression and reduced mortality regardless of disease severity at HAART initiation. This finding reinforces US guidelines regarding HAART initiation at >1 year of age if children present with most clinical category B diagnoses, regardless of CD4 measurements or plasma HIV RNA level.
高效抗逆转录病毒疗法（HAART）的治疗可降低围产期人类免疫缺陷病毒（HIV）1 型相关的总死亡率。但 HAART 启动时机对发病率降低的影响尚不清楚。我们评估了 HAART 启动时机与向中重度疾病进展的相关性。
回顾性、基于人群的研究，纳入 1988 年至 2009 年在加利福尼亚州北部出生并接受随访的 196 名围产期 HIV 感染儿童。
196 名儿童中，58%接受了 HAART，并在 HAART 启动后中位随访 6.2 年。HAART 的使用与 5 岁时的生存率提高相关：未接受 HAART 的儿童为 50%，而接受 HAART 的儿童为 88%；P＜0.0001。然而，与单药或二联疗法转换为 HAART 相比，初始 HAART 的优势较小且无统计学意义（P=0.23）。在出现中重度疾病之前开始 HAART，可将无 HAART 治疗时中度疾病的中位诊断年龄（四分位间距，[0.3-0.8]）从 0.4 岁推迟至 HAART 治疗时的 3.0 岁（四分位间距，[1.9-5.8]；P＜0.0001）。在进展为中重度疾病后开始 HAART，分别与进展为重度疾病或死亡减少相关（中重度：HAART 组为 8%（3/36），无 HAART 组为 84%（70/83），P＜0.0001；重度至死亡：HAART 组为 9%（6/68），无 HAART 组为 73%（49/67），P＜0.0001）。
在围产期 HIV 感染中，HAART 可延迟疾病进展并降低死亡率，无论 HAART 启动时疾病严重程度如何。这一发现强化了美国指南，即如果儿童出现大多数临床 B 类诊断，无论 CD4 测量值或血浆 HIV RNA 水平如何，均应在 1 岁以上开始 HAART。
