Early antiretroviral therapy improves neurodevelopment in HIV-positive infants

Starting antiretroviral therapy soon after birth improves neurodevelopment in HIV-positive infants, South African investigators report in the online edition of AIDS. The development observed in children who started treatment early was in most respects similar to that seen in HIV-negative children.

“Our findings show that children with HIV who start ART [antiretroviral therapy] earlier have better short-term neurodevelopment,” comment the investigators.

Up to a quarter of HIV-infected infants in resource-rich countries experience delays in neurodevelopment: walking, talking, hand-eye coordination, hearing and interpersonal development. Studies conducted in poorer countries – where HIV therapy is started later – have also revealed evidence of neurodevelopmental delay.

Antiretroviral therapy has transformed the prognosis of children infected with HIV at birth. Despite this improvement in prognosis, little is known about the impact of early HIV treatment on the neurodevelopment of children.

HIV-infected infants in the CHER study were randomised to start early HIV therapy (before three months of age) or to defer treatment until warranted according to immunological and clinical need. The children enrolled in this study therefore provided a suitable population in which to assess the impact of early treatment on neurodevelopment. This was assessed using the Griffiths Mental Development Scales (GMDS), a validated measure of neurodevelopment in infants. The assessment was conducted after a mean of eleven months and had five subscales: locomotor; personal-social; hearing and language; eye and hand co-ordination; and performance.

A total of 64 infants who started early therapy and 26 children who deferred treatment were included in the study. Also included in the investigators’ analysis were 28 HIV-exposed but uninfected children and 34 children who were not exposed to HIV.

Children in the early- and deferred-treatment arms had similar demographic and HIV-related characteristics. Those in the early-treatment arm started treatment a mean of 8.4 weeks after birth. The mean age at the start of therapy for children in the deferred-treatment arm was 31 weeks. By the time neurodevelopment was assessed, 92% of infants in the deferred-treatment arm had started treatment.

Rates of hospital admission were higher among children who deferred treatment compared to those who started treatment early (46 vs 30%). The investigators believe that this difference showed the benefits of early therapy for the general prognosis of children.

Overall GMDS scores were significantly higher for the children who started early treatment than for those who delayed treatment (106.3 vs 100.1; p = 0.02). Early treatment was also associated with higher locomotor scores (97.7 vs 88.9; p < 0.001).

With the exception of locomotor scores, all outcomes for children in the early treatment arm were similar to those seen in HIV-negative children.  

“These findings support the earliest possible diagnosis of HIV and initiation of ART in infants," conclude the authors. “However, caution should be exercised in extrapolating to long-term predictions.”