Objective. To describe plasma human immunodeficiency virus type 1 (HIV-1) RNA levels in African HIV-1-infected children in relation to the timing of infection and disease progression. Methods. A retrospective cohort study was conducted of 80 children who were born to HIV-1-positive mothers and clinically followed from birth to 18 months of age in the ANRS 049 Ditrame project, Abidjan, Côte d’Ivoire (West Africa). The diagnosis and timing of pediatric HIV-1 infection were determined prospectively according to HIV-1 DNA polymerase chain reaction results. A total of 364 HIV-1 RNA viral load (VL) measurements were assessed retrospectively. Kaplan-Meier analyses and proportional hazards models were used to evaluate the prognostic value of pediatric VL and covariates for HIV disease progression or death. Results. Mean initial positive VL was significantly lower among children who were infected in utero (4.94 log10/mL, n = 12) than in children who were infected later (5.6–6.1 log10/mL, n = 68). In the first 6 months after diagnosis, HIV-1 RNA levels peaked (≥6 log10/mL), regardless of timing of infection. Then, a slow decline (overall slope, −0.076 log10 copies/mL/mo) was observed until 18 months of age. A 1 log10 higher value of the pediatric peak VL (risk ratio [RR]: 1.85; 95% confidence interval [CI]: 1.0–3.44) and of the maternal VL at delivery (RR: 1.90; CI: 1.16–3.12) were independently associated with an increased risk of rapid progression to acquired immune deficiency syndrome (AIDS) or death at 18 months of life (23 AIDS diagnoses and 31 deaths). Disease progression or death was more rapid for girls than for boys (RR: 2.26; CI: 1.39–4.96). Conclusions. In Africa, pediatric HIV-1 RNA levels are very close to those described in industrialized countries and seem to be predictive of AIDS stage or death, as in industrialized countries. With antiretroviral therapy becoming more widely available, the early identification and monitoring of pediatric HIV disease remains of paramount importance in Africa.