Roger Bacon, 1214-1294 leon Jlevin, MB BC/I, FCPaed (SA), DTM&H mcot@gerga.sun.ac.za gray@pixie.co.za ethbil@netactive.co.za e-mail e-mail e-mail Mark Cotton: Glenda Gray: Lean Levin: REFERENCES [as suggested by one of the international exp- erts), but it was felt that a unique guideline was desirable for southern African paediatricians. The international guide- lines are lengthy and often difficult to follow, particularly for those who are inexperienced in ARV therapy. It is hoped that the local guidelines will prove useful for those who are starting to use ARV therapy and it is hoped that it will also encourage paediatricians to further their knowledge in this fascinating, complex and ever-changing field. In this vein, it is perhaps sad that there are so few paed- iatricians in South Africa actively involved in treating patients with ARV drugs. The Paediatric Subcommittee of the Southern African HIV Clinicians Society is uniquely poised to help transport our paediatricians 'beyond the guidelines'. Lectures and workshops on ARV therapy, run by experienced paediatricians and other clinicians, are available through the Society on request. Additionally, the Society is happy to respond to any queries that might arise on paediatric ARV therapy, and has access to an extensive network of internat- ional paediatricians for consultation. It is hoped that the Paediatric HIV Treatment Guidelines will prove a useful companion in practice. 1. The Working Group on Antiretroviral Therapy and Medical Management of HIV-infected Children convened by the National Pediatric and Family HIV Resource (enter [NPHRCI. the Health Resources and Sef\lices Admin- istration IHRSAI. and National Institutes of Health [NIH). Guidelines for the use af Antiretroviral Agenrs in Pediatric HlV Infection. Published and updated r~ularly on the web. www.hivatis.arg. 2 Luzuriaga K, et al. JVira/2000; 74:6984-6991. For more information on the activities of the Paediatric Subcommittee of the HIV Clinicians Society, contact the society directly, or the following: Medical men don't know the drugs thet) use nor their cost.' COMMENT PAEDIATRIC ANTlRETROVIRAL THERAPY Beyond the Guidelines THf SOUTHtRN AFRICAN JOURNAL OF HIV MfOICINf -----------NOVfMHtR 2000 The truth of the above quotation has not dated in 800 years. Nowhere in clinical medicine today is it more relevant than in the treatment of HIV patients using antiretro- viral (ARV) therapy. In the South African set- ting, the cost issue is clearly important and very often limits the treatment that can be prescribed. Therefore, when drawing up the Paediatric HIV Treatment Guidelines for the Southern African HIV Clinicians Society, consideration was given to the fact that treatment options might vary from state-of-the-art comb- inations to cheaper options suitable for use in a reSQurce- limited setting. Indeed, it is felt that in some aspects these guidelines are, more progressive than the American guidelines. A recent excit- ing development, addressed in the Society's Guideline but not elsewhere, is the treatment of infants under 3 months of age. Since most of these patients acquire their infection at around the time of birth, we really are dealing with acute primary HIV infection. These children have a good response to therapy, and viral suppression may be so significant that they develop a normal, functioning immune system. At the age of about 18 months, when infected children normally lose their maternal HIV antibodies, the HIV ELISA can become negative [the DNA PCR, however, remains positive). This reflects the extent to which their virus is suppressed and hidden from the immune system, thus minimising an antibody response.' Although the numbers of children are small, there is a definite suggestion that these results are achieved more readily with a 4-drug regimen than a 3-d rug regimen IK Luzuriaga - personal communication); hence the inclusion of a 4-drug regimen in the Guidelines for patients under 3 months of age. Another important difference in the Society's Guideline is that the dosage regimens incorporate the latest pharmaco- kinetic data and therefore dosages occasionally differ from those found in the drug package inserts. Because infants and children metabolise their drugs at a faster rate than adults, relatively larger dosages are necessary in this patient group. Consideration was given to utilising the international guidelines, with modifications, for the South African setting