Good anti-HIV treatment outcomes for children in conflict zones

Displaced HIV-positive children who start antiretroviral therapy can do as well as children who start anti-HIV drugs in politically stable settings, according to a small study conducted in northern Uganda and published in the May 31^st edition of AIDS. But the investigators note that maintaining good outcomes in their population is likely to be challenging, particularly because of population movement.

It is estimated that there are approximately 2.5 million HIV-infected children around the world, with the latest figures showing that only 200,000 are accessing antiretroviral therapy.

Childhood mortality is high in African countries affected by armed conflict and this mortality can be increased by HIV.

Evidence from the Democratic Republic of the Congo has shown that HIV-positive adults in areas of armed conflict can achieve clinical and immunological outcomes comparable to adults in politically stable regions. Until now there has been no information about antiretroviral outcomes amongst HIV-infected children in conflict settings.

Northern Uganda has been politically unstable for over 20 years and it is thought that between 2002 and 2008 some 1.6 million individuals in the region were displaced and were living in camps.

In 2005, The AIDS Support Organization (TASO) began providing antiretroviral therapy to adults and children in these camps and it is now one of the largest free HIV treatment programmes in the area.

Investigators from TASO wished to evaluate outcomes amongst the children who received antiretroviral therapy in these camps. They therefore looked at changes in CD4 cell count and percentage, mortality, and rates of opportunistic infections amongst children who started anti-HIV drugs.

By February 2008, TASO had provided anti-HIV treatment to 57 children. These children had a median age of eight years and the average period of follow-up after the commencement of anti-HIV drugs was 227 days.

All the children, 60% of whom were girls, received treatment with an anti-HIV treatment combination that included two NRTIs and an NNRTI. A total of 25 children (44%) had experienced the death of one or both parents.

The investigators found that both orphans and non-orphans had comparable changes in CD4 cell count, CD4 percentage, and weight after starting anti-HIV treatment. Rates of adherence to antiretroviral therapy were excellent, with 92% of children taking the target 95% or more of their doses. Three children were found to have tuberculosis before starting anti-HIV treatment and one was diagnosed with the infection after commencing antiretroviral therapy.

“Our results are consistent with combination antiretroviral therapy outcomes from other small pediatric cohorts in politically stable sub-Saharan African countries”, write the investigators.

Guidelines had previously suggested that it was not feasible to deliver anti-HIV treatment in complex emergency settings. But the investigators write “there is now emerging evidence that treating HIV-positive individuals in these settings is imperative from both public health and humanitarian perspectives” Indeed, the UN High Commissioner for Refugees has recently developed operational guidelines for the management of antiretroviral therapy in displaced populations.

But the TASO investigators note that population movement is likely to be an issue for their patient group and during 2008 they expect 35% to be relocated “home,” 45% to be in transit, and only 20% to remain in the camps. The investigators therefore conclude, “community-based and clinical measure[s] should be put in place to ensure that families and children travelling long distances continue to receive combination antiretroviral therapy without interruption.”