Efforts to expand early care and treatment for pediatric HIV have dramatically decreased HIV and AIDS-related deaths among children. There is clear evidence that initiating antiretroviral therapy (ART) in children before they show signs of illness dramatically improves their health and development, not just in childhood, but throughout their lifetime.
[Photo: Dr. Irene Njuguna]
The benefits of initiating ART among children during hospitalization are less understood. Because these children are already very sick with a weakened immune system, they may not fully benefit from ART and have tragically high death rates once they enter the hospital. A new study conducted by researchers at the University of Washington School of Public Health seeks to understand the timing of ART treatment of these children.
The study, published in The Lancet HIV, looked at whether starting ART in hospitalized children urgently improves their outcomes and helps more children survive. In this context, “urgently” means in 48 hours of HIV identification and enrollment in care, rather than the standard 7 – 14 days, referred to as “post-stabilization ART.” The study compared trial results of 191 children, ages 0 – 12, who were eligible to receive ART in 48 hours or eight days at four hospitals in Kenya.
In the study, the research team did not observe differences in mortality rates, drug toxicity, immune system reactions, or adherence in children between the group who started ART urgently and those who received post-stabilization ART. Although the team did not see reduced mortality, they concluded that administering ART urgently to children was a safe and feasible approach.
“Ultimately, the ideal method to improve child survival is rapidly identifying HIV-infected children and initiating ART before symptoms of infectious diseases worsen,” says lead author Dr. Irene Njuguna, a Kenyan physician and doctoral student in the department of epidemiology. “In cases when hospitalization episodes occur and HIV is identified, the study supports World Health Organization guidelines to initiate ART within the first week of HIV diagnosis even among hospitalized children with other diagnoses and not to wait to start ART until after hospital discharge.”
In many limited resource settings, however, putting the guideline into practice can be challenging, especially with limited access to methods to rapidly detect HIV in infants. Of the children enrolled in the study, more than a third were previously hospitalized, but not started on ART.
The research team observed high mortality in the first few weeks following ART initiation, with 21 percent, or almost one in four, dying by six months post-hospitalization. The high mortality rate among hospitalized HIV-infected children emphasizes the need for rapid HIV diagnoses and treatment as a matter of urgency.