HIV treatment proving effective for children in Côte d'Ivoire

Children treated with highly active antiretroviral therapy (HAART) in Côte d’Ivoire have a high probability of survival after two years of follow-up, according to a report published in the September 24^th edition of the journal AIDS.

After two years of treatment 72.8% of children with a baseline CD4 percentage below 5% (severely immune suppressed) were still alive, compared to 97.8% of children with a baseline CD4 percentage of 5% or above.

Treatment for children in developing countries is often difficult due to the cost of paediatric formulations of antiretrovirals and the difficulty of diagnosing HIV infection until children have very severe disease. Data on the impact of treatment for children in such settings has been lacking.

The French Agence Nationale de Recherches sur le SIDA (ANRS) has been conducting follow-up of children receiving antiretroviral treatment in Côte d’Ivoire since October 2000, and now has follow-up data on 78 children who have received an average of 21 months of treatment.

Children received treatment with two nucleoside analogues and either nelfinavir (61 children) or efavirenz (17). All but 13 received the drugs as adult formulations since the average age of children starting treatment in this cohort was high in comparison with children in developed world cohorts (average age 7.2 years). All but two had been infected through mother to child transmission, and almost half had already lost one parent.

Nine children died while taking antiretroviral treatment. In all but one case the child had very advanced disease before starting treatment, and death occurred an average of 182 days after starting treatment.

After an average of 339 days on HAART, 49% of 73 children had viral load below 250 copies/ml. Data were available on 50 children who had taken an average of 756 days of medication, showing that 50% had viral load below 250 copies/ml at this point. These levels, the authors note, are similar to those seen in Western European paediatric cohorts.

Significant reductions in the incidence of pneumonia and acute diarrhoea were observed when comparing the pre-treatment period (348 child months) with the time on treatment (1447 child months); in both cases an approximate threefold reduction was seen. However when analysed by age, no reduction in incidence of either condition was seen in children of 6.5 years or over.

Twelve children changed at least one drug during the treatment period, seven due to adverse events predominantly associated with nucleoside analogues (suspected pancreatitis, liver enzyme elevations, anaemia).

Eight children were forced to interrupt treatment for a median of 25 days due to a shortage of some drugs within the public health system.

Adherence was judged to be good, with problems identified in only 16 cases. In twelve cases adherence improved after treatment was simplified to reduce the number of pills. More serious problems were reported in four cases: conflict between parents and child resulted in a refusal to take pills in one case, whilst in another household supervision of pill taking by two adults led to confusions over dosing. In only two cases was the prolonged duration of treatment judged to be causing problems with adherence.

“These results were obtained in an observational cohort…and also despite periods of drug shortage and the inclusion of some children at a very advanced disease stage when treatment was started,” state the authors.

However they also caution: “Children enrolled in this cohort benefited from a well-structured medical and psychological environment…management of even trivial infections was optimal and there was support to encourage compliance. In an environment lacking these elements, the results of antiretroviral therapy may be very different.”