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Cotreating children receiving ART for TB may reduce viral suppression
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Children with HIV who were also cotreated for tuberculosis had poorer virological outcomes than children who were not coinfected, according to data from a recent study.
“Compared with adults, children have always presented treatment challenges,” wrote Mark F. Cotton, MD, of Stellenbosch University, Tygerberg in Western Cape, South Africa, in an accompanying editorial. “The coexisting pandemics of human immunodeficiency virus infection and tuberculosis in high-prevalence settings such as sub-Saharan Africa have been especially devastating for infants and young children.”
Researchers in Johannesburg, South Africa, analyzed 254 HIV-infected children aged 6 to 104 weeks from the Nevirapine Resistance (NEVEREST) antiretroviral strategy study who received nevirapine to prevent mother-to-child transmission. The study’s objective was to examine viral suppression at 39 weeks after ART initiation. The researchers included children who were eligible for ART on the basis of immunological or clinical criteria but had not yet started treatment between April 2005 and July 2007.
Children aged 6 months or older received lopinavir-ritonavir (250 mg/m2), stavudine (1 mg/kg) and lamivudine (4 mg/kg) every 12 hours, according to the researchers. Children younger than 6 months or who were being treated for TB, however, received ritonavir (400-450 mg/m2), stavudine (1 mg/kg) and lamivudine (4 mg/kg) every 12 hours. They also received treatment for TB in accordance with South African guidelines, ie, rifampin and isoniazid for six months, with pyrazinamide during the initial two months. After 6 months of age or after completion of TB treatment, ritonavir was replaced with lopinavir-ritonavir.
Sixty-two children were receiving TB treatment at the start of ART. By 39 weeks, an additional 37 children began TB cotreatment.
The researchers also reported that 99 children who initiated ART were cotreated for TB during follow-up, with a mortality rate of 14%. By 39 weeks, 83.7% of these children achieved viral suppression to HIV RNA loads of less than 400 copies/mL by 9 months, which Cotton said was “a remarkable achievement.” However, children who were cotreated had a lower probability of viral suppression; 74% compared with 94% in the other children.
Other factors, such as lower pre-ART weight, higher baseline HIV RNA load and WHO disease stage, were also predictors of lower probability of viral suppression, according to the researchers.
“Early antiretroviral therapy in the first few weeks of life will reduce mortality and morbidity from HIV infection and also reduce the risk of acquiring tuberculosis. However, tuberculosis will remain a problem. There is a need to institute effective and tolerable treatment for both infections,” Cotton wrote.
For more information:
- Cotton MF. J Infect Dis. 2010; 201:1113-1114.
- Reitz C. J Infect Dis. 2010;201:1121-1131.