Earlier pediatric HAART may reduce HIV mortality in developing countries

Peacock-Villada E. Pediatrics. 2011;doi:10.1542/peds.2009-2701.

Children in developing countries were older at the time of HIV diagnosis with more advanced stages of disease than children in developed countries. Continued improvement of interventions, including nutritional support and treating and preventing coinfections, may help improve survival rates in RLCs, according to researchers from the University of Washington in Seattle.

Pediatric HIV mortality disparities between resource-limited countries (RLCs) and developed countries were wide but better than expected based on mortality rates in the general population, according to results from the first meta-analysis systematically comparing highly antiretroviral therapy outcomes in both populations.

The emergence of new pediatric studies involving patients with HIV in Africa since funding to the region increased in 2004 has enabled researchers to quantify differences between the two populations for the first time.

“HAART programs in RLCs have reported efficient and comparable increases in CD4 counts and decline in viral loads as programs in developed countries,” Elizabeth Peacock-Villada, MD, and colleagues, wrote in Pediatrics. “Significantly lower baseline CD4 levels observed in RLCs 12 months after HAART are likely a result of markedly lower baseline CD4 levels.”

The researchers selected studies from both regions in which HAART was administered to more than 20 patients aged younger than 21 years. There were 40 studies performed in RLCs (n=17,875) and 28 studies performed in developed nations (n=1,835). The cohorts included data on post-HAART mortality, weight-for-age z score, CD4 count and viral load changes.

Resource-limited regions in the analyses included children from Africa (20 studies); Asia and Eastern Europe (four studies); and South American and the Caribbean (two studies).

The researchers found that mean percentage of deaths per cohort (7.6 vs. 1.6; P<.001) and mean deaths per 100 child-years after HAART (8 vs. 0.9; P<.001) were significantly higher in the studies conducted in RLCs. Overall, CD4 counts were lower among children in RLCs (12% vs. 23%; P=.01), whereas baseline viral loads were higher (5.5 vs. 4.7 log₁₀ copies/mL; P<.001).

Analyses revealed that there was a large difference between baseline weight-for-age z score in RLCs and developing countries (–2.2 vs. –0.4; P<.003).

“Resource-limited cohorts involved children with significantly lower baseline CD4 counts and [weight-for-age z score] and higher viral loads, all of which would be expected to contribute to increased mortality rates,” the researchers wrote. “Efforts to initiate HAART earlier would be expected to identify children before substantial immunosuppression, which should translate into improved survival rates.”

Continued improvement of interventions, including nutritional support and treating and preventing coinfections, may help improve survival rates in RLCs, according to the researchers. They said they expect that HIV-related mortality rates will continue to decline as more treatments become available earlier.

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