Experience with and resources for managing the pediatric HIV epidemic have lagged behind those for the adult epidemic. Problems encountered in expansion of pediatric HIV/AIDS treatment have included limited access to appropriate diagnostic testing for infants and young children, and the narrow range of available pediatric formulations or FDCs.2,4
Only the KIDS-ART-LINC group has previously published an assessment of regional-level ART accessibility and availability of resources for children in developing countries.5
The objective of this survey was to learn how clinical practices varied and what resources were available in TREAT Asia Pediatric Program sites. Although the sites participating in this survey were predominantly in urban settings and often university-affiliated, hospital-based clinics, these sites are commonly national referral centers that provide advice and direction for pediatric HIV care throughout the region. Consequently, the survey characterizes resources reflecting the highest levels of HIV care and treatment for children in many of these Asian countries.
Although sites were generally not involved with prenatal maternal PMTCT interventions, most provided infant antiretrovirals and diagnostic testing with PCR. Almost all sites responding to the survey promoted formula feeding to avoid breastfeeding-associated transmission. This is in contrast to multiple studies in sub-Saharan Africa that have demonstrated improved survival with exclusive breastfeeding.6–8
A number of Asian countries (e.g., Thailand, Vietnam, Malaysia) have made commitments to support formula provision, and acceptability among HIV-positive mothers is high.9–11
Although at the time of the survey few sites reported starting treatment for all HIV-infected infants, the availability of early infant diagnostic testing increases their ability to follow WHO recommendations, released after the survey was completed, to initiate ART in all HIV-infected infants less than 12 months of age whenever feasible.12
Even by early 2008, 89% of all children under care were already on ART. This is higher than the 73% on ART in the KIDS-ART-LINC cohort in 2007, but similar to the 91% of vertically infected children on ART in the NICHD International Site Development Initiative (NISDI) regional cohort in Latin American and the Caribbean in 2008.5,13
Reports of second-line ART use in sub-Saharan Africa have also been much lower than the 20% of children on their second or salvage regimen in the TREAT Asia cohort.13–15
This may be related to the early availability of antiretrovirals in some of the surveyed countries that led to the use of less durable mono- or dual-nucleoside reverse transcriptase inhibitor regimens.14,16,17
The increasing numbers of children in Asia developing treatment failure will require broader access to genotyping and pediatric protease inhibitors to help construct more complex ART regimens.17,18
In order to ensure that children with HIV can live into adulthood, public health programs need to plan for the procurement and delivery of pediatric second-line and salvage regimens.
Access to diagnostic and monitoring HIV tests was almost universal at the sites surveyed and largely supported through government funding. This allowed sites to more closely monitor children to determine when to start and when to switch regimens. The optimal intervals for CD4 and viral load testing remain unknown, but more frequent monitoring (i.e., at least every 6 months) could be beneficial for treatment failure monitoring. The median viral loads and age of children at the time of failure in two recent Thai studies were 5.3 log and 4.1 years in Bangkok, and 4.2 log and 7.6 years in northern Thailand, respectively.19,20
Delayed ART switching can lead to greater accumulation of resistance mutations,21
making access to regular viral load testing for early identification of virologic failure a priority for ensuring long-term durability of pediatric ART.
The survey was limited by the level of detail that could be collected, particularly with regards to the ART histories of children in the cohort. The level of clinical resources and laboratory capacity seen in this cohort also may not be generalizable to other clinical centers within each country represented. However, HIV care is centralized in some countries in the region because of the smaller numbers of children needing care and having fewer clinicians with pediatric HIV expertise. Participating sites also play an important leadership role in driving and developing the pediatric HIV care agenda in Asia.
This site survey provides the first assessment of the state of resource provision and pediatric HIV management practices at a number of tertiary-level pediatric sites providing HIV care in Asia. The results emphasize the importance of identifying optimal second-line regimens, and expanding pediatric antiretroviral and FDC options. Moreover, that 38% of children in this survey were 10–18 years old underscores the importance of preparing for managing social and treatment issues in adolescents. Future research through this regional cohort will explore ART outcomes and optimal monitoring strategies.