Despite positive outcomes, treatment gaps in pediatric HIV care remain in the ‘cure all’ era


In 2015, the World Health Organization (WHO) revised its global HIV guidelines to remove CD4-based clinical staging criteria for initiation of antiretroviral therapy (ART) and expand ART eligibility to children. Approved the “Treat All” approach.

A “cure all” approach called for greater equity in HIV care; Pediatrics showed that ART penetration continues to lag in children. The authors also said closing the gap in pediatric HIV treatment requires a comprehensive approach that addresses structural issues such as enhanced family-based services and case-finding.

The researchers summarized country-level estimates of ART prevalence and AIDS mortality over an 11-year period, with particular attention to the proportion of children under age 15 receiving ART and the number of deaths per 100,000 population. . They also collected information on the years in which ‘Treat All’ was implemented in national guidelines for 91 of the 173 countries and also provided estimates. The authors analyzed the data using multivariate two-way fixed-effects negative binomial regression and calculated the adjusted prevalence rate ratio (adjusted IRR) with 95% CI to determine whether the ‘Treat All’ expansion was We evaluated the coverage of pediatric ART and its potential impact on AIDS mortality.

Of note, 89% of 91 countries had adopted “Treat All” as a national HIV treatment guideline by 2018, and 1 country had not formally adopted this approach by 2020. was only one country.

The authors found that the prevalence of pediatric ART tripled from 16% to 54% between 2010 and 2020. However, pediatric uptake continues to lag consistently behind adult uptake of ART, which rose from 26% in 2010 to 74% in 2020. Meanwhile, the number of AIDS-related deaths fell by more than half from 240,000 to 99,000 in 10 years.

After implementation of the plan, the increase in pediatric ART adoption continued to increase pre-to post-implementation, but post-implementation reduced the rate of increase by 6% (adjusted IRR, 0.94; 95% CI, 0.91-0.98). . Similarly, childhood AIDS mortality rates continued to decline from pre- to post-implementation, but the rate of decline decreased by 8% (adjusted IRR, 1.08; 95% CI, 1.05-1.11).

Pediatric ART adoption rates increased in all regions, but the most significant increases were observed in the following regions:

  • Asia Pacific (23% – 81%, P. < .005)
  • East and Southern Africa (18% to 57%, P. < .001)
  • Middle East and North Africa (8% to 47%, P. < .001)
  • West and Central Africa (7%-35%, P. < .001)

The most significant declines in pediatric ART expansion were in eastern and southern Africa (adjusted IRR, 0.91; 95% CI, 0.87-0.95) and western and central Africa (adjusted IRR, 0.93; 95% CI, 0.87-0.99). ).

On the other hand, the Asia-Pacific (adjusted IRR, 1.26; 95% CI, 1.07–1.49), Caribbean (adjusted IRR, 1.04; 95% CI, 1.01–1.06), and Eastern AIDS mortality rates decreased. most prominently seen. and southern Africa (adjusted IRR, 1.10; 95% CI, 1.08–1.14).

Considering all these data, the authors said that great strides have been made in expanding ART coverage and reducing mortality among children living with HIV. However, effective control of the HIV epidemic in both children and adults requires additional strategies beyond the current ‘cure all’ approach. This is particularly important in regions with high HIV prevalence and poor treatment outcomes for childhood HIV, such as West and Central Africa.

“Despite significant increases in pediatric treatment coverage and declines in AIDS mortality over the past decade, our findings are important to accelerate momentum for global HIV treatment equity for children. , suggesting that complementary approaches to ‘cure all’ need to be expanded,” the authors concluded. “Early diagnosis of infants, targeted case-finding strategies (i.e., integration with adult index testing efforts), and prioritization of family-based service delivery models will close the pediatric HIV treatment gap in the ‘Treat All’ era.” It’s the key to filling it.”

reference

Rosen JG, Muraleetharan O, Walker A, Srivastava M. Pediatric antiretroviral therapy coverage and AIDS mortality in the ‘cure all’ era. Pediatrics. Published online May 17, 2023. doi:10.1542/peds.2022-059013



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