Children face a serious service delivery gap: paediatric studies in Toronto

9 September 2006. Related: Conference reports, Paediatric care, World AIDS 16 Toronto 2006.

Polly Clayden, HIV i-Base

Access to paediatric HIV care and treatment in most resource limited settings remains inadequate, with few programmes meeting the WHO target that 10% of people receiving ART be children.

In her plenary talk Ruth Nduati gave a comprehensive outline of the global impact of HIV on children. [1]

She emphasised that a child’s risk of death is halved if his or her mother remains alive, and she stressed, “Care of the infected and uninfected child must include treatment of their mothers and families.” Dr Nduati outlined many of the obstacles to care and treatment, which have been recurrent themes throughout the conference, highlighting that the “WHO training package used in many countries does not include children, that is why many countries do not treat children.”

And despite a growing paediatric evidence base in both industrialised and resource limited countries, “There has been a failure to translate the most successful clinical trials to a public health success.”

Accumulating data shows children from resource limited settings benefit from antiretroviral treatment (ART)

However, albeit mostly on a small scale, many oral and poster abstracts including these from Zambia, Brazil and Medecins sans Frontiers report favourable outcomes for children receiving ART.

In Zambia 1,726 children of a median age of 6 years at initiation, receiving NNRTI-containing ART, achieved “dramatic increases” in CD4 response with concomitant reductions in mortality (8.7/100 child years), which was reduced to half the rate seen in adults. [2]

In Brazil, a cohort followed since 1983, showed decreases in mortality over time: whereas half of the children died within 20 months of diagnosis at the beginning of the epidemic, the median survival improved with more than half still alive by the end of the study and 75% of children diagnosed in 1997 and 1998 were still alive after four years follow-up. This was attributed to ART access and earlier age of diagnosis. [3]

Medecins sans Frontiers reported 80% of children still alive after 24 months of treatment in their multi-centre cohort and that survival is accompanied by substantial gains in CD4 counts [4]. Less than 1% of children failed and the majority of treatment switches (3.5%) were due to drug toxicities.

All presenting authors reported an under representation of very young children (below 18 months) in their cohorts due to difficulties accessing infant diagnostics, the lack of availability and cost of age-appropriate paediatric antiretroviral formulations, and the reluctance of healthcare workers to treat this age group.

UNICEF estimates that 660,000 children urgently require antiretroviral treatment, most of them in sub-Saharan Africa. Children need to be on national agendas and government-based targets must define treatment needs. And as the Brazilian investigators noted: “A free and universal access to ART, even in a country that lacks an ideal health infrastructure, can make a substantial difference in survival”. These results argue strongly for making such treatment available to children elsewhere in the developing world.”

References:

1. Nduati R. Children and AIDS. XVI International AIDS Conference, Toronto, Canada.13 – 18 August 2006. Plenary presentation WEPL02.
2. Mbewe M, Bolton C, Levy J et al. Children enrolled in a public HIV care and treatment program in Lusaka, Zambia: rapid scale-up and first-year clinical outcomes. XVI International AIDS Conference,Toronto, Canada.13 – 18 August 2006. Oral abstract MOAB0201.
3. Matida L.H., Novaes A., Moncau J.E.C et al. Impact of free and universal access to antiretroviral treatment on the survival among Brazilian children with AIDS. XVI International AIDS Conference,Toronto, Canada.13 – 18 August 2006. Oral abstract MOAB0202.
4. Olson D, Sauvageot D, Ferradini L et al. Anti-retroviral therapy (ART) outcomes in children < 13 years of age in resource-poor countries (RPCs): a Medecins sans Frontiers (MSF) cohort. XVI International AIDS Conference,Toronto, Canada.13 – 18 August 2006. Oral abstract MOAB0203.
5. Ngashi N, Luo C, Mulenga D et al. Forecasting HIV treatment needs in children to guide policy, planning and scale up: a multi-country experience from India, Malawi, Cameroon, Rwanda and Cote d’Ivoire. XVI International AIDS Conference, Toronto, Canada.13 – 18 August 2006. Oral abstract MOAB0205.