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ART use averting huge numbers of opportunistic infections among HIV-positive children in lower-income countries
Michael Carter, 2016-06-27 07:40:00
There has been a
decrease in cases of many opportunistic infections (OIs) among HIV-positive
children in low- and middle-income countries thanks to antiretroviral therapy
(ART), a meta-analysis published the June 15th edition of Clinical Infectious Diseases shows.
Investigators estimated that use of ART is averting over 161,000 opportunistic
infections each year, saving $17 million per annum.
review based on study data from a > 20 year period shows an overall trend of
reduced incidence and prevalence for most OIs after ART initiation, and
substantial impact and cost savings on OIs averted with earlier ART
initiation,” comment the authors. “This systematic review and meta-analysis is
the most comprehensive assessment of incidence and prevalence of the 14 most
important OIs and other infections and the effect of ART among HIV-infected
children in [low- and middle-income countries].”
An estimated 2.6
million children worldwide are infected with HIV, the overwhelming majority
(88%) of whom live in sub-Saharan Africa. Scale-up of ART in low- and
middle-income countries has been less successful in children compared to
adults. It’s been estimated that only a third of ART-eligible children are
currently receiving therapy compared to two-third of adults.
opportunistic infections among HIV-infected children in richer countries
declined significantly after the introduction of ART. However, less is known
about the continuing burden of opportunistic infections among HIV-infected
children in less wealthy settings. A clearer understanding of this important
question is needed so that appropriate interventions can be designed.
team of investigators therefore conducted a systematic review and meta-analysis
to evaluate the incidence and prevalence of 14 common HIV-related opportunistic
infections and other infections and the impact of ART among HIV-positive
children (aged under 18) in sub-Saharan Africa, Asia and Latin America.
at least 50 HIV-positive children conducted between 1990 and 2013 and reporting
on incidence and/or prevalence of at least one of 14 common HIV-related
opportunistic infections were eligible for inclusion.
The risk of
opportunistic infections for ART-naïve and ART-experienced children was
calculated. Using 2010 WHO treatment guidelines (treatment for all HIV-positive
children aged under two years; for 2 to 4 years olds with a CD4 percentage
below 25%; for 5-14 year olds with a CD4 count below 350 cells/mm3),
the investigators also estimated the number of opportunistic infections and money
saved due to the scale-up of ART.
A total of 88
studies involving approximately 66,000 children were included.
opportunistic infections was reported in 35 studies. The most common infections
in ART-naïve children were bacterial pneumonia (25%), pulmonary TB (10%), oral
and esophageal thrush (8%) and extra-pulmonary TB (7%). A similar profile of
disease was observed among ART-treated children, with bacterial pneumonia
(22%), TB (9%) and varicella zoster (8%) the most common.
examined in 60 studies. The most prevalent infections were bacterial pneumonia
(33%), oral and esophageal thrush (25%) and sepsis (23%).
Use of ART had a
dramatic impact on the incidence of several infections, especially Cryptosporidium diarrhoea (OR, 0.10; 95%
CI, 0.05-0.22), toxoplasmosis (OR, 0.33; 95% CI, 0.13-0.43) and extra-pulmonary
TB (OR, 0.15; 95% CI, 0.10-0.21).
estimated that use of ART prevented 161,000 opportunistic infections annually,
saving a total of $17,700,000 each year. More than 90% of the savings came from
the averted cases of TB.
The authors note
that since 2015 WHO guidelines have recommended ART for all HIV-infected
children. “This is critical as scale-up of ART has been successful in children,”
they conclude. “Strong mother-child prevention programs, expansion of access to
early infant diagnosis, and more robust procurement and supply management
systems, including improved pediatric ART formulation, are also critical to reducing
the adult-pediatric ART coverage gap, with an ultimate goal of eliminating the
pediatric HIV burden.”