Polly Clayden, HIV i-Base
There are limited data describing outcomes for infants initiating treatment at less than 1 year.
The MTCT Plus Initiative showed data from sites in eight African countries and Thailand comparing infants with older children initiated between February 2003 and September 2008. 
The investigators looked at change in CD4 percentage from baseline using linear modelling adjusted for duration of highly active antiretroviral therapy (HAART), country, baseline CD4 percentage, NVP exposure for PMTCT, and age at initiation.
Of 542 children initiating treatment and followed up for a median of 30 months (intraquartile range (IQR) 12 – 39), 190 (35%) were aged <12 months at initiation and the remainder >12 months (median 36 months, IQR 19.5 – 67), 51% were male, and18% had Centers for Disease Control (CDC) stage C disease.
The infants had a higher mortality rate than the older children, 7.5 v. 3.2/100 person-years. Of 31 (54%) infant deaths, 81% occurred within 3 months of treatment initiation.
Among the children for whom data were available there was no difference between infants and older children in change of CD4 percentage from baseline. Baseline CD4 percentage (p<0 .01) and time on HAART (p<0.001) were significantly associated with an increase in CD4 percentage in multivariate analysis.
In this analysis, although infants initiating HAART had a higher mortality at the start of treatment, the infants who survived had good immunological response over >3 years of follow-up, similar to that of older children.
A South African review of infants initiated on HAART at the Family Clinic for HIV at Tygerberg Hospital and Ikwezi community clinic from June 2007 to August 2008 showed high levels of virological suppression to 24 weeks. 
Infants received lopinavir/ritonavir (LPV/r) with stavudine (d4T) and lamivudine (3TC) in accordance with South African guidelines. Of 98 initiated, 47 had 24 weeks of follow-up. Of the remainder, 6 (6%) were lost to follow-up, 6 (6%) died and 33 (33.7%) were transferred.
The median age at initiation was 4.5 months and 33 (70%) infants were =6 months old (median age 3.68 months). All had immunological or clinical criteria for treatment. The majority, 42/47 (89.4%) of all infants and 30/33 (91%) =6 months of age, had WHO stage 3 or 4 disease.
Tuberculosis (TB) is a common co-morbidity in this population, and 11/47 infants required co-therapy with rifampicin (given with additional ritonavir).
At 24 weeks 37/47 children (79%) in the > 6 months age group and 26/33 (82%) aged <6 months had viral loads <50 copies/mL.
The investigators noted that the low age of initiation of treatment in this cohort reflected young infants with severe HIV disease rather than early initiation of treatment to prevent mortality and morbidity.
This article first appeared in issue 36 of the Journal of HIV Medicine, the journal of the Southern African Clinicians Society.
Unless otherwise stated, all references are to the programme and abstracts of the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 19 – 22 July 2009, Cape Town.
7. Carter RJ et al. Immunologic response and survival of infants initiating antiretroviral treatment (ART) at less than one year of age compared to older children enrolled at MTCT-Plus Initiative sites in 8 African countries and Thailand. Abstract MOPEB048. http://www.ias2009.org/pag/Abstracts.aspx?AID=2021 8. Rabie H et al. 24 week outcome of infants started on lopinavir/ ritonavir based HAART in a resource limited setting. Abstract MOPEB076. http://www.ias2009.org/pag/Abstracts.aspx?AID=492