Don't delay antiretroviral therapy in HIV positive infants
Last Updated: 2010-11-30 11:28:03 -0400 (Reuters Health)
By C. Vidya Shankar, MD
NEW YORK (Reuters Health) - In HIV-positive infants, waiting to start antiretroviral therapy (ART) until the treatment criteria are met may reduce long-term survival, a new study from Thailand shows. However, a similar approach in older children doesn't appear to adversely affect survival.
The five-year survival probability among infants who were started on ART after fulfilling the criteria was 76.7% as compared to 94.8% among those initiated at an older age, the researchers found.
These findings support the WHO recommendations that advise initiation of ART soon after diagnosis in children less than two years of age, Dr. Intira J. Collins, lead author from the London School of Hygiene and Tropical Medicine, told Reuters Health. "These findings are most applicable to developing countries, as most developed countries already provide immediate treatment of HIV-infected infants."
"At that time of the study, access to therapy in Thailand was limited. The children who started therapy before one year of age were those in obvious need of therapy," Dr. Collins pointed out. However, "evidence is accumulating that children respond better when they start treatment in better immune/clinical status, suggesting that there is no gain in waiting to initiate therapy," she emphasized.
In their prospective study reported in the December15th issue of Clinical Infectious Diseases, the researchers examined the five-year survival in 578 HIV-positive children from hospitals in Thailand with mother-child infection. Of these, 111 infants were enrolled from birth while the rest were older children who were enrolled as and when they reported to hospitals for starting ART.
All children were started on ART only after fulfilling clinical and immunological criteria. Overall, 59 children were started on ART before one year of age and the remaining 519 after one year. Twenty-nine infants and 216 older children completed the five-year follow up.
The researchers report that 13 infants who were started on ART before one year of age and 29 who were initiated on ART later died during the course of the five-year follow up.
The probability of survival was 84.3% after one year and 76.7% after five years in those initiated on ART in infancy and 95.7% and 94.8% among the older children, respectively.
In their multivariate analysis, the risk of mortality was highest among infants who were started on ART before 12 months of age (adjusted hazard ratio 7.1).
"The optimal time to start ART in infants and children is somewhat age-dependent and dependent on the child's immune status," Prof. Michael Brady, Chair and Professor of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, told Reuters Health. Dr. Brady wasn't connected with the study.
He said infants should be started on ART soon after diagnosis. However, older children can wait till they meet the criteria as they are less likely to be "rapid progressors," Dr. Brady commented. Access to care, treatment compliance and initial response to treatment are some of the predictors of a good outcome, he said.
"The emphasis is for infants to start therapy as soon as they are known to be HIV infected, ideally within the first 3 months of life and before they develop symptoms or become immunocompromised," Dr. Collins concluded.
SOURCE:http://link.reuters.com/cuq77q
Clin Infect Dis 2010;51:1449-1457.
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