Critical need for earlier diagnosis and referral of HIV-infected children in Africa

Care provided by nurses and other clinicians in primary health care settings in sub-Saharan Africa can result in good outcomes for children with HIV infection.

But the death rate is high during the first 90 days of therapy, pointing to a need for early intervention, according to a study in the October 24/31 issue of JAMA, a theme issue on poverty and human development.

This issue of JAMA: The Journal of the American Medical Association is being released early because of JAMA's participation in an international collaboration of more than 200 medical and scientific journals to publish articles simultaneously to raise awareness on the topic of the relationship between poverty and human development. This initiative is coordinated by the Council of Science Editors, and presentations regarding some of the studies in this Global Theme Issue will be webcast live from the National Institutes of Health (http://videocast.nih.gov/summary.asp?live=6239).

By the end of 2006, an estimated 2.3 million children worldwide were living with human immunodeficiency virus type 1 (HIV-1). Without treatment, approximately half will die by their second birthday. However, lives can be extended with combination antiretroviral therapy (ART), according to background information in the article. The Zambian Ministry of Health provides pediatric ART at primary care clinics in Lusaka, where many children are already infected with HIV, despite scale-up of perinatal prevention efforts.

Carolyn Bolton-Moore, M.B.B.Ch., of the Centre for Infectious Disease Research in Zambia, Lusaka, and colleagues assessed early clinical and immunologic outcomes of children enrolled in a pediatric treatment program at 18 government primary health facilities in Lusaka. Care was provided primarily by nurses and clinical officers (i.e., akin to physician assistants in the United States). After enrollment of 4,975 children into HIV care, 2,938 (59 percent) were started on ART.

“Overall, children receiving ART showed significant improvements in CD4 cell status, weight gain, and hemoglobin concentration,” the authors report.

Among 2,398 children who were still receiving ART at the time of analysis, 198 (8.3 percent) died during follow-up, and 112 of these deaths (56.6 percent) occurred within 90 days of the start of therapy.

“Mortality within the first 90 days of starting therapy was high, especially among the infants younger than 18 months,” the authors write. Among 223 children younger than 18 months who were receiving ART, 45 died (20.2 percent).

“Mortality is highest among underweight children and those who are severely immunosuppressed,” the authors write.

Survival rates were higher as the children's ages increased. Among 672 children age 18 to 59 months who were receiving ART, 64 died during follow-up (9.5 percent). And among 1,503 children 60 months or older, 89 died during follow-up (5.9 percent).

“These findings indicate the critical need for earlier diagnosis and referral of HIV-infected children,” the authors conclude. “Of course, the ultimate solution to the problem of pediatric AIDS lies in prevention of mother-to-child transmission and in preventing primary infection in women.”