Early diagnosis and treatment options for children living with HIV

Dr Siobhan CrowleyPaediatric & Family HIV Care World Heath Organization,Email: crowleys@who.inthttp://www.who.int/hiv/paediatric/en/index.html

Overview ProgressRationale for early diagnosis and treatment Ways forward Revised WHO recommendations

More children are receiving ART Increased from 75,000 in 2005 to almost 200,000 in 2007 19 of 20 countries with highest PMTCT burden are in sub-Saharan Africa90% of burden is in 20 countries

Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, WHO/UNAIDS/UNICEF 2008

ART outcomes - more good newsNational programmes reporting good outcomes1 year survival estimated as 93-95%2 year survival 91%

# programme reporting Sutcliffe. Lancet Infect Dis 2008;8: 47789

Children are Starting Treatment LateMeta-analysis 1,195 children from 8 African clinical trials 53% >5 years of age, 70% severe immune deficiency, 12% aged < 12 months (KIDS-ART-LINC) Arrive 2008

Starting ART when severely immunodeficient increases mortality 73% median age > 5 years of age, > 50% start with severe immune deficiency, most deaths within 6 months of starting ART. Risk factors for death: low CD4 < 18 months age WHO stage 3/4 Viral load greater than 60 log severe malnutritionArrive E et al. 14th CROI, Los Angeles, CA, 2007 Abs. 727Sutcliffe et al. Lancet Infect Dis 2008;8: 47789

Months from ART startProbability of Death After Starting ARTImmune Deficient at Start ARTNot Immune Deficient at Start ART6 months7.8%1.8%12 months8.2%2.2%

CHER STUDY : 76% Reduction in the Risk of Death with Immediate Compared to Deferred ARTTime to Death (months)Failure ProbabilityPatients at riskP = 0.0002Most deaths occurred within first 6 months (i.e., before age 10 months)immediatedeferred16%4%

Entry points for children - Malawi18%Kenya -IPD 69% Cote D' Ivoire64% IPD12% PMTCT24% PLHA Index

Southern Africa HIV prevalence in population based surveys Source: CSO, Measure DHS. Swaziland Demographic and Health Survey 2006-7. Preliminary report, 2007. NACA, CSO. Botswana AIDS Impact Survey II 2004. Central Statistics Office: Gaborone, Botswana, 2005. Shisana, O., et al., South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2005. HSRC Press: Cape Town, 2005. SLIDE courtesy of E Gouws UNAIDS

BotswanaSwazilandSouth Africa

In 2007: only 8% of HIV exposed infants tested in 1st 2 months of life only 4 % started on co-trimoxazole Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, WHO/UNAIDS/UNICEF 2008

Ways forward Each infection can and should be prevented Early diagnosis prior to disease progression Earlier initiation of ART Expand PITC and screening for HIV in health care facilities

WHO recommendations for provider initiated testing approaches infants & children

WHO -new recommendations for starting ART in infants http://www.who.int/hiv/pub/paediatric/WHO_Paediatric_ART_guideline_rev_mreport_2008.pdf

What ART to Start in infants 2008 revision

No infant or maternal ARV exposureMTCT ARV Exposure Sd NVP or NNRTI containing ARTNon NNRTI exposureUnknown infantmaternal MTCTExposure NVP triple ARTPI triple ART#NVP triple ARTNVP triple ART# If no PI is available use NVP triple ARTSimplified weight based dosing availabe at; http://www.who.int/hiv/paediatric/en/index.html34%18%

Immunological thresholds to start ART # Absolute CD4 count is naturally less constant and more age-dependent than %CD4; it is not therefore appropriate to define a single threshold.

Please feel free to contact me if you need more information Dr Siobhan Crowley crowleys@who.int

Acknowledgments:HIV Care and treatment: Technical Reference groupPaediatric ARV dosing working group WHO colleaguesLynne MofensonEleanor GouwsF Dabis/V LeroyRobert Gass/Patricia Doughty

Thank you

The number of children receiving ART increased form about 75,000 in 2005 to almost 200,000 in 2007, However, many children living with HIV are still not receiving treatment, and mortality among them remains high.

The estimation of need for ART will need to be revised based on these recent revised criteria for eligibility for ART in infants , hence coverage is not providedMost children receiving ART are older and the mortality in the first few months of starting ART remains high, retention in care continues to decline beyond the first year , and most children are starting ART very late Average age of children starting ART in the KIDS-ART-LINC Cohort Collaboration (17 participating clinics) was 4.9 years ( with only 12% 25%ART nave except for pMTCTAge