The occurrence of certain clinical events while receiving antiretroviral therapy is evidence of HIV disease progression and/or a poor prognosis for infants and children.
Progressive neurodevelopmental deterioration (i.e., persistence or progression of deterioration documented on repeated testing as demonstrated by the presence of two or more of the following findings: impairment in brain growth, decline of cognitive function documented by psychometric testing, or clinical motor dysfunction). In such cases, the new treatment regimen should optimally include at least one antiretroviral drug with substantial central nervous system penetration (e.g., ZDV or NVP, which have CSF/plasma ratios >0.2).
Growth failure (i.e., persistent decline in weight-growth velocity despite adequate nutritional support and without other explanation).
Disease progression (i.e., advancement from one pediatric clinical category to another [Table 2]). Prognosis is poorer as patients progress to more advanced clinical categories. However, in patients with stable immunologic and virologic parameters, progression from one clinical category to another (e.g., from clinical category A to category B) may not represent an indication to change therapy. For example, development of new opportunistic infections, particularly in patients who have severe immunosuppression at the time therapy was initiated, may not reflect a failure of antiretroviral therapy but rather persistence of immunologic dysfunction despite adequate antiviral response. Thus, in patients whose disease progression is not associated with neurologic deterioration or growth failure, consider virologic and immunologic parameters when deciding whether to change therapy.