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Background: Early anti-retroviral therapy (ART), in vertically HIV-1 infected children, can lead to reversion of pro-viral HIV DNA PCR test to negative. This may pose clinical dilemmas to healthcare workers (HCWs) leading to misclassification of HIV status. We followed five children who had DNA PCR and antibody reversions, in whom primary healthcare providers erroneously ruled-out HIV infection.
Description: Review of the medical records revealed that three of them were females. Four were tested positive with single HIV DNA PCR within six months of age and one at 10 months. Four started ART before the age of 1 year and one at 21 months. Viral loads (VLs) were undetectable in all children by 21-35 months of treatment. After about 2 years of ART, HIV antibody and DNA PCR tests turned negative in all cases. Undetectable VLs in these children prompted HCWs to repeat DNA PCR and antibody tests, both of which returned negative. HCWs then mistakenly informed the parents that their children were HIV un-infected. To clear the clinical dilemma, we instituted structured treatment interruption with close follow up and VL monitoring.
Lessons learned: Following structured treatment interruption for a median duration of 6 weeks, we detected high level rebound viremias in all children in the range of 135,409 and 8,400,337 RNA copies/ml. CD4 loss of up to 15% was observed within 3 months from the points of ART interruption. Care givers received counseling and the children were re-started and maintained on ART. All children fully suppressed the virus again within 6 to 9 months of re-treatment and maintained suppression for 18 to 24 months now.
Conclusions/Next steps: These cases illustrated pro-viral HIV DNA reversions in vertically HIV-1 infected children, on ART, following durable viral suppression. The rapid post-treatment interruption viral rebound illustrated that prolonged viral remission is unlikely unless very early treatment is started. Treatment interruptions lead to significant immunologic destructions and shall not be implemented in such children in resource constrained settings. Reversion phenomena may become commoner with increasing access to early ART in vertically infected children in Africa. HCWs shall be made aware of such phenomena and children should receive timely HIV disclosure.