Elena Alonso, Médecins Sans Frontières (MSF) medical advisor for HIV/AIDS-TB programs.
Why is there an enormous difference in the percentage of children who are born with HIV in developed countries versus in sub-Saharan Africa?
First, in many places in sub-Saharan Africa, mothers do not have access to prenatal care. As a result, many are not tested, and since they don’t know they are HIV positive, they aren’t given treatment to reduce the risk of transmission.
In the best case scenario, when mothers are given preventative treatment with antiretrovirals, to what extent does it reduce the risk of the baby being born with HIV?
In Western countries, the maternal-infant transmission rate is less than 1 percent. Without access to treatment, transmission occurs in up to 40 percent of cases. It’s clear that access to prenatal care and to preventative treatment makes a difference.
When maternal-infant transmission hasn’t been prevented what is the solution for the children?
The solution is early diagnosis with PCR (polymerase chain reaction) to be able to start treatment before the child’s immune system deteriorates and he or she develops opportunistic diseases, which are often irreversible, such as encephalopathy, or even worse, dies before two years of age, as do 60 percent of children who are born HIV positive.
So, if the child is tested and is positive, when should treatment start?
As soon as the positive results are known. That’s the advantage of being able to test a child with PCR six weeks after birth. The rapid tests, in contrast, can only yield a definitive diagnosis after 18 months of age. Unfortunately, not all countries have laboratories with the technical and technological capacity to analyze PCR tests.
Recently, in May, the World Health Organization revised its pediatric protocols, recommending that doctors not wait for a child to present symptoms before starting treatment. This will cause a very important quality of life improvement for the child and should mean a better prognosis.
Research and development of new treatments are not as advanced in pediatrics as they are for adults. Have there been important advances recently?
In mid-2007, the first pediatric fixed-dose combinations (FDCs) came on the market in the form of pills, which, although they have been very difficult to implement in the field, are a first step in facilitating correct dosages in the treatment of children. Liquid medications make this very important part of treatment difficult and increase the risk of resistance, if the children’s mothers or caretakers are not able to calculate the dosage correctly. It’s important to note that these first FDCs are from generic laboratories. For adults there is much more variety. It’s as if children in developing countries are of no interest to pharmaceutical companies. And there are few drug studies for children. We barely have studies that allow for the possibility that new medicines could be made in pediatric forms. When you have patients whose ages are counted in weeks, it is crucial to have appropriate dosages.
If there are still huge deficiencies in the fight against pediatric HIV/AIDS, is the same true for the opportunistic diseases that affect the smallest children?
For tuberculosis the deficiency you’re asking about is especially important. The greatest challenge we face is diagnosing tuberculosis since children are not able to produce valid samples of sputum to be tested with microscopes, which is what is normally used. Added to that, the sputum test for HIV positive patients, regardless of age, is not very sensitive. This means that many diagnoses are based on clinical guesses, especially in most contexts in sub-Saharan Africa.
However, MSF has experience in situations involving human and material difficulties. How can a pediatric HIV/AIDS program that includes antiretroviral treatment be carried out with good results?
The most significant example is the program that the Ministry of Health of Zimbabwe and MSF are conducting in a pediatric clinic in Bulawayo, where almost 2,000 children are being treated with ARVs. In Zimbabwe, the will to implement a simplified strategy and not be negatively affected by the urgent economic crisis and a significant lack of human resources has been crucial to guaranteeing children’s access to the program. Health and psycho-social care, as well as a focus on access to family treatment, are also important factors for these children’s adherence to treatment.
So there is reason to hope for important improvements in the fight against pediatric AIDS?
Among the 140,000 people living with HIV/AIDS that MSF is treating in 27 countries, there are more than 10,000 children. Each one of these little children, like those who are successfully being treated in Zimbabwe, is a good reason to hope that access to early testing and treatment improves as soon as possible.