The use of HAART has led to a 80% fall in mortality and 50% reduction in progression to AIDS in HIV-positive children in the UK and Ireland according to a study published in the November 1st edition of the British Medical Journal. The study also found that although there was an 80% reduction in hospital admission rates for HIV-positive children since the reduction of HAART, the increased number of HIV-positive children in the British Isles meant that the total number of admissions only fell by a quarter, meaning that there is still considerable demand on inpatient serives.
Paediatric HIV surveillance started in 1986, and by October 2002 a total of 944 had been infected with HIV by their mother in the UK and Ireland and were included in the study analysis . Data were gathered from the national study of HIV in pregnancy and children (NSHPC). From April 2000 the collaborative HIV paediatric study also provided data for investigators.
Investigators wished to establish the changes in mortality, progression to AIDS and rates of hospitalisation since HAART became available for the treatment of paediatric HIV in mid 1997.
Demographics
Half of the 944 children included in the study were girls, and 628 (67%) were Africans. In 1994-95 20% of HIV-positive children in the UK and Ireland were born abroad, and this figure increased substantially to 60% in 2001-02, reflecting changes in the wider epidemiology of the HIV epidemic in the British Isles.
The median age at which children were first seen by paediatric HIV services remained stable at six months, however, the age at which children born abroad first presented increased significantly from two and a half years in 1991 to five and a quarter years in 1994, remaining constant thereafter.
Mortality and progression to AIDS
A total of 193 (20%) of children are known to have died. However, although the number of children infected with HIV by their mother has increased steadily over time, the annual number of deaths fell markedly from 1996 onwards.
Before 1997 the crude mortality rate was 9.3 per 100 child years, and declined markedly to 3.3 per 100 child years in 1997, 2.7 per 100 child years in 1998, 1.2 per 100 child years in 1999, 1.3 per 100 child years in 2000, and 2.0 per 100 child years in 2001-02 (trend p
Improvement in mortality was most markedly improved after 1997 in children aged over one year (adjusted hazard ratio 0.19, 95% CI 0.12 – 0.30) than in infants aged under one year (adjusted hazard ratio 0.72, 95% CI 0.36 – 1.48, p=0.003).
Since the introduction of paediatric HAART, 54 children are know to have died, the overwhelming majority of whom were born to mothers whose HIV status was not known during pregnancy (n=48, 89%). Information on antiretroviral use was available for 36 of the children who died; 14 did not receive HAART, six died within six months of starting HAART, and 16 within a median of ten months of initiating it.
Since 1986, a total of 438 children progressed to AIDS, with 40% developing an AIDS defining condition within a month of presentation. The introduction of HAART led to a marked decline in rates of progression to AIDS from 15.4 per 100 child years before 1997 to 3.0 per 100 child years in 2001-02 (p
Use of antiretroviral therapy
In 1996 only 1% of HIV-positive children were taking HAART, this increased to 69% in 2001-02. There was a shift overtime away from regimens containing protease inhibitors to ones containing NNRTIs, mirroring changes in prescribing patterns in adults over the same period.
Of the 371 children taking antiretroviral therapy in 2000 or later, 48 (13%) were taking four drugs, 301 (81%) three, and 22 (6%) two drugs. A total of 91 different drug combinations were being prescribed.
Hospitalisation
Admission to hospital fell markedly amongst HIV-positive children with the introduction of HAART, from 4.4 per 100 child years in 1996 to 0.9 per 100 child years in 2001-02. However, the number of total admissions fell by only 250, due to an increase in the total number of HIV-positive children in the UK and Ireland.
Commenting on their findings, the investigators note, “our study is among the first to report reductions in hospital admissions over time in children with HIV, paralleling reductions in mortality and morbidity.
Conclusions
The investigators conclude, “rates of death, progression to AIDS, and hospital admission in children with HIV in the UK and Ireland have fallen significantly.” They add, however, “despite the marked reduction in hospital admission rates, total admissions have declined only by one quarter since 1996, underlying the need for continued inpatient as well as outpatient services.” What’s more, the increased number of children arriving with HIV in the British Isles from abroad, and the fact that HIV-positive children are living longer means that demand on specialist paediatric HIV services is likely to continue to increase.
Reference
Gibb DM et al. Decline in mortality, AIDS and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland. British Medical Journal 327: 1019 – 1022, 2003.