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Dilemma with 6 year old child
Sep 5, 2004

6 years old child, both parents died of Aids. Presentedlast year with TB and received a full course of TB treatment. At that time he had generalized Lymphadenopathy and failure to thrive. An HIV testwas positive. When he finished his TBtreatment, I asked for a CD4 and Viral Load. The results on the 14th. Jan. 2004 were CD4 487,5 - 12,5% and the viral load 26.912copies/ml

Hb 9.3 g/dl - WBc 7.500 - Lym 51,5 % -# 3.900.

On the 9th. June2004 he had a CD4 of 396 - 11.3%

Now he is stable, with his Lymphadenopathy as before, and withno particular problems. His TBis radiologically and clinically cured. His weight and height is not increasing , but he is not losing weight. He haddiarrhoea a few times which resolved easily. He has had some dermatitisbut no oral candidiasis.

According to our guidelines, children over 6 years areconsidered according toadult criteria for starting antiretrovirals. i.e. CD4 Percentages are ignored and ART is started when the CD4 is below 200. Since this child's CD4 is 396, he technically does not qualify for Antiretroviral Therapy.

1) Does he need Antiretroviral Therapy?

2)At what age does one apply adult critera for starting Antiretroviral Therapy?

Response from Dr. Pierone

The U.S. pediatric HIV treatment guidelines differ from adult and adolescent guidelines and are available at this link.

The pediatric guidelines (for age 1 year to 13 years) look more to the CD4 count percentage. This child would be in a category in which treatment could be considered because the CD4 cell percentage is less than 25%. On the other hand, the viral load is less than 100,000 so the readings are a gray zone.

One must realize that all guidelines are not hard and fast and vary according to the country that comes up with them. The adult guidelines in the United States the guidelines generally call for treatment in the 200 to 350 CD4 count range. In other countries treatment is deferred until CD4 count is less than 200.

So in summary, this situation does not fall into a hard rule category and is a judgment call to be made based on your assessment of the big picture. Best of luck!



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