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Early diagnosis and treatment options for children living with HIV

Early diagnosis and treatment options for children living with HIV. Dr Siobhan Crowley Paediatric & Family HIV Care World Heath Organization, Email: crowleys@who.int http://www.who.int/hiv/paediatric/en/index.html. Overview . Progress Rationale for early diagnosis and treatment

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Early diagnosis and treatment options for children living with HIV

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  1. Early diagnosis and treatment options for children living with HIV Dr Siobhan Crowley Paediatric & Family HIV Care World Heath Organization, Email: crowleys@who.int http://www.who.int/hiv/paediatric/en/index.html

  2. Overview • Progress • Rationale for early diagnosis and treatment • Ways forward • Revised WHO recommendations

  3. More children are receiving ART • Increased from 75,000 in 2005 to almost 200,000 in 2007 • 19 of 20 countries with highest PMTCT burden are in sub-Saharan Africa • 90% of burden is in 20 countries Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, WHO/UNAIDS/UNICEF 2008

  4. ART outcomes - more good news • National programmes reporting good outcomes • 1 year survival estimated as 93-95% • 2 year survival 91%

  5. # programme reporting Sutcliffe. Lancet Infect Dis 2008;8: 477–89

  6. Children are Starting Treatment Late Meta-analysis 1,195 children from 8 African clinical trials 53% >5 years of age, 70% severe immune deficiency, 12% aged < 12 months (KIDS-ART-LINC) Arrive 2008

  7. 6% excess mortality Starting ART when severely immunodeficient increases mortality Arrive E et al. 14th CROI, Los Angeles, CA, 2007 Abs. 727 • 73% median age > 5 years of age, > 50% start with severe immune deficiency, most deaths within 6 months of starting ART. • Risk factors for death: • low CD4 • < 18 months age • WHO stage 3/4 • Viral load greater than 6·0 log • severe malnutrition Sutcliffe et al. Lancet Infect Dis 2008;8: 477–89

  8. 1.00 0.80 Deferred Immediate 0.60 0.40 0.20 0.00 0 3 6 9 12 Month 0 Month 3 Month 6 Month 9 Month 12 Deferred 125 104 72 44 22 Immediate 252 213 145 99 52 CHER STUDY : 76% Reduction in the Risk of Death with Immediate Compared to Deferred ART P = 0.0002 Most deaths occurred within first 6 months (i.e., before age 10 months) Failure Probability 16% deferred 4% immediate Time to Death (months) Patients at risk

  9. Entry points for children - Malawi Kenya - IPD 69% Cote D' Ivoire 64% IPD 12% PMTCT 24% PLHA Index 18%

  10. Southern Africa – HIV prevalence in population based surveys Botswana Swaziland South Africa Source: CSO, Measure DHS. Swaziland Demographic and Health Survey 2006-7. Preliminary report, 2007. NACA, CSO. Botswana AIDS Impact Survey II 2004. Central Statistics Office: Gaborone, Botswana, 2005. Shisana, O., et al., South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2005. HSRC Press: Cape Town, 2005. SLIDE courtesy of E Gouws UNAIDS

  11. In 2007: • only 8% of HIV exposed infants tested in 1st 2 months of life • only 4 % started on co-trimoxazole Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, WHO/UNAIDS/UNICEF 2008

  12. Ways forward • Each infection can and should be prevented • Early diagnosis prior to disease progression • Earlier initiation of ART • Expand PITC and screening for HIV in health care facilities

  13. WHO recommendations for provider initiated testing approaches infants & children

  14. WHO -new recommendations for starting ART in infants • http://www.who.int/hiv/pub/paediatric/WHO_Paediatric_ART_guideline_rev_mreport_2008.pdf

  15. What ART to Start in infants –2008 revision NVP triple ART No infant or maternal ARV exposure 18% 34% PI triple ART# Sd NVP or NNRTI containing ART MTCT ARV Exposure NVP triple ART Non NNRTI exposure Unknown infant maternal MTCT Exposure NVP triple ART # If no PI is available use NVP triple ART Simplified weight based dosing availabe at; http://www.who.int/hiv/paediatric/en/index.html

  16. Immunological thresholds to start ART # Absolute CD4 count is naturally less constant and more age-dependent than %CD4; it is not therefore appropriate to define a single threshold.

  17. Thank you Please feel free to contact me if you need more information Dr Siobhan Crowley crowleys@who.int Acknowledgments: HIV Care and treatment: Technical Reference group Paediatric ARV dosing working group WHO colleagues Lynne Mofenson Eleanor Gouws F Dabis/V Leroy Robert Gass/Patricia Doughty

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