Opportunistic infections and other clinical manifestations of HIV disease in children.

As the decade draws to a close, physicians can be cautiously optimistic about the prevention and treatment of opportunistic infections in children with HIV disease. As more children receive therapy with powerful antiretroviral regimens, fewer are likely to be at risk for opportunistic pathogens. The widespread use of protease inhibitor combination therapies has already resulted in a dramatic decrease in morbidity and mortality in the population of HIV-infected adults. The same effect has been seen at pediatric care centers throughout the United States. Clinicians caring for HIV-infected children are now considering the safety of discontinuing prophylactic therapies for children with sustained immunologic improvement on antiretroviral therapy. For children who remain at risk, prophylactic regimens for PCP and MAC have been shown to decrease the risk for these infections. Preventive regimens for several other opportunistic infections are also available. The understanding of the pathogenesis of HIV and many of the opportunistic pathogens has led to the development of a variety of efficacious therapies for these infections. Despite these advances, physicians can anticipate that HIV-infected children will continue to develop opportunistic infections and other related complications. Some children fail to respond to antiretroviral therapies, whereas others are unable to tolerate the complex medication regimens. Prophylactic therapies are not 100% protective and, despite improved treatments, few opportunistic infections are cured. Most require lifelong maintenance therapy in the absence of immune reconstitution. Drug interactions, complex dosing schedules, adverse side effects, and high costs further limit the efficacy of these therapies. The prophylaxis, diagnosis, and treatment of opportunistic infections are likely to remain integral components of HIV care for the near and distant future.