Orphans in Kenya respond well to antiretroviral therapy

The children in the study

This study looked at 279 children who started antiretroviral therapy at any of the nine AMPATH clinic sites in west Kenya, between August 2002 and February 2005. Just over half were boys, and 54% were orphaned (defined, for this study, as having lost either their mother or both parents).

More orphans dropped out of the study over time: there was an average of 33 weeks of follow-up data for orphans, compared to 41 weeks for non-orphans, which made some of the comparisons less conclusive (see below). The children were an average of 6 years old when they started treatment, but orphans tended to start later – at 8.3 versus 4.7 years of age.

Researchers have found that orphaned HIV-positive children in Kenya respond just as well to antiretroviral therapy as do children whose parents are alive. However, antiretroviral therapy alone did not compensate for the slowed development seen in these children; their nutritional needs have to be addressed as well.

Over 1 million of Kenya’s 29.5 million people are HIV-positive, and over 100,000 of these are children. In addition, 650,000 Kenyan children have been orphaned due to AIDS. Efforts are being made to provide antiretroviral treatment to Kenyans in need, but at present only about 7,500 children are receiving therapy.

The Academic Model for the Prevention and Treatment of HIV-AIDS (AMPATH), based in Eldoret (Kenya’s fifth-largest city), is the country’s largest HIV/AIDS care and research program. In this study (published in the December 1^st issue of the Journal of Acquired Immune Deficiency Syndromes), AMPATH researchers investigated how being orphaned affected children’s responses to antiretroviral therapy. They suspected that orphaned children may have had more problems which could reduce the effectiveness of treatment, especially with adherence to therapy. On the contrary, they found that most orphans responded just as well to treatment as other HIV-positive children.

Effects on growth

Not surprisingly, most HIV-positive children were smaller than normal, in both height and weight, when they were first seen – even more so for the orphans. After treatment started, orphans gained weight and height just as quickly as the other children, but never made up for the initial differences.

After 70 weeks of treatment, the data suggest that the orphans began to lag further behind the other children in terms of weight gain; however, less data were available, so this is not certain.

Adherence and treatment success

Adherence rates were mostly reported by caregivers – parents, relatives, and guardians. Rates were very high overall; perfect adherence (over the previous month) was reported for more than 71% of the children, and 75% of known orphans.

To measure treatment ‘success’, the researchers primarily used changes in CD4 cell percentage rather than CD4 cell count or viral load. (CD4 percentage describes the number of CD4+ cells as a proportion of the total number of white blood cells.) Children began treatment at an average CD4 percentage of 10%. (Recommendations call for treatment to start at CD4 percentages less than 15% in children under six, and at CD4 cell counts less than 200 cells/mm³ in children six or older.) Percentages rose steeply (by an average of 11%) over the first 30 weeks of treatment, then largely levelled off. (Similar responses have been seen in other studies.) Responses in orphans did not differ from those in other children, but older children tended to have better responses. Less than 1% of the children had to be switched to second-line therapy due to treatment failure – “a remarkable achievement”, as the researchers state.

Mortality was not statistically worse for either group – approximately 93% of the children survived at least one year into the study, and “the observed mortality rate is relatively low over almost three years of observation considering the reported death rates for children in Africa.”

Researchers’ conclusions

Contrary to their initial suspicions, researchers found “no effect of orphan status on [antiretroviral] adherence, rise in CD4%, or in … adjusted weight and height, at least in the short term, or mortality.” Therefore, they conclude, “this project has confirmed the feasibility of providing [antiretrovirals] to children in resource-poor settings in sub-Saharan Africa… However, HIV-positive children did not overcome developmental lags present before initiation of therapy.”