Virological biomarkers of HIV remission in children: implications for pediatric cure strategies.

PURPOSE OF REVIEW: Sustained antiretroviral therapy (ART)-free HIV remission has been observed in a few early-treated children, highlighting the potential for pediatric HIV cure strategies. However, the risks associated with analytical treatment interruption (ATI) underscore the need for reliable virological biomarkers that can identify participants for ATI studies, predict viral rebound or remission and guide clinical decision-making. This review summarizes evidence on virological biomarkers of HIV remission with relevance to pediatric populations.

RECENT FINDINGS: Advances in reservoir measurement have revealed that early ART initiation in children restricts reservoir size and alters reservoir quality. Total and intact HIV DNA, cell-associated HIV RNA, residual plasma viremia measured by ultrasensitive assays, and viral genetic and clonal features each capture aspects of HIV persistence and show associations with time to viral rebound. Markers of residual viral activity, including cell-associated HIV RNA, ultrasensitive plasma HIV RNA, and p24 antigen, may be predictors of rebound timing in early-treated cohorts.

SUMMARY: Current evidence supports integrated, multi-dimensional virological biomarker strategies rather than reliance on single assays to predict pediatric HIV remission. Harmonization, validation in longitudinal pediatric cohorts, ethical feasibility and further research will be critical to identifying and translating these biomarkers for pediatric cure trials.