Antiretroviral Therapy in Children with Tuberculosis: Progress toward Defining the Issues

Compared with adults, children have always presented treatment challenges. The coexisting pandemics of human immunodeficiency virus (HIV) infection and tuberculosis in high-prevalence settings such as sub-Saharan Africa have been especially devastating for infants and young children. The difficulties are well illustrated in the thoughtful article by Reitz et al [1] in this issue of the Journal, in which they report on the virological outcomes in children <2 years of age in the Nevirapine Resistance (NEVEREST) antiretroviral strategy study in Johannesburg, South Africa. Fourteen percent of children died and 39% required cotreatment for tuberculosis. The difficulties of diagnosing tuberculosis in infants are also well illustrated in this article and reflect “reality on the ground,” where clinicians initiate treatment on the basis of a constellation of symptoms such as failure to thrive, suggestive radiological findings, and contact with a source case. The appropriateness of this strategy is supported by the recent documentation of a culture-confirmed tuberculosis incidence rate of 1596 per 100,000 HIV-infected infants as opposed to 65.9 per 100,000 in HIV-uninfected infants <1 year of age in the South African Western Cape [2].