From the Faculty Advisory Committee

Recently I was admiring a “model teenager” in my clinic who had been taking highly active antiretroviral treatment (haart) for his perinatally acquired HIV infection for several years. On this occasion, I was very pleased with his clinical condition but puzzled by the fact that his viral load had been gradually creeping upward. After some heart-to-heart questions from my nurse, he revealed to her that, in fact, he didn’t “feel like taking the meds” and had been flushing his pills down the toilet for the past six months. My nurse and I were dumbfounded by this revelation, which demonstrated our blindness to the turmoil that lay beneath the surface of our model teenager.

As a pediatric AIDS physician at Children’s Hospital in Boston, I have been delighted with the advances in treatment regimens that have slowed many children’s HIV disease progression and allowed them to live, at least on the surface, normal lives. The new drugs have helped to change the perception of pediatric AIDS as an immediate death sentence. But the problems have most emphatically not gone away.

I have dedicated the past 15 years of my life to pediatric AIDS, and I am especially pleased that this issue of the Harvard AIDS Review is devoted to the topic of children and AIDS. This focus is important because the field of pediatric AIDS has truly matured. We have been able to reduce mother-to-child transmission dramatically by the application of antiretroviral treatments, but there remain important unsolved problems. We still don’t know the proper balance between the benefits of preventive treatment, which have been amply demonstrated, and the possible long- or short-term toxicities of these drugs. More important, in parts of the world where breastfeeding is a critical part of safe nutrition during the first months or years of life, women with HIV put their infants at risk as long as they breastfeed. The best way of preventing infection in these settings is still not clear.

With the introduction of ZDV more than ten years ago, I predicted that although it was unlikely we could ever cure HIV infections, we would be able to slow the progression of this infection down to a crawl. While treatments have become more effective against the virus, there are many side effects, and the need for rigid adherence to complex and onerous medication schedules presents a particular problem for children. We badly need less toxic drugs, more tolerable drugs, and drugs that can be taken fewer times a day.

There is a widely held belief among AIDS specialists that because of the notable successes in prevention of mother-to-child transmission of HIV, the pediatric problem in this country has been solved. Nothing could be further from the truth. The epidemic continues among adolescents. Infected children of all ages are staying well and living much longer. The burden on HIV clinics such as our own at the Children’s Hospital grows every year. As the number of living HIV-infected children continues to rise, treating these children becomes increasingly complicated, as illustrated by our model teenager.

In the meantime, I am looking forward to seeing the first child born with HIV go to college. I’m going to work on this, because I am sure it’s something that can and will happen.

Kenneth McIntosh, MD
Harvard AIDS Institute
Faculty Advisory Committee