An article written by an international group of researchers reports that there is an urgent need to develop formulations of current antiretroviral therapy (ART) treatments suitable for young children, in particular, tablets that are a combination of different HIV drugs, which can be dispersed or crushed and mixed with food or liquids. The article was published in this week’s PLoS Medicine.

Even though the risk of HIV infection is highest in young children, they also represent the group that is most neglected amongst those affected by the HIV epidemic. Only 23% of children who needed ART in low- and middle-income countries actually received the treatment in 2010.

International experts led by Andrew Prendergast from Queen Mary, University of London argue in a Policy Forum article: “While elimination of childhood infection is the most important goal, it is unclear what will be achievable by 2015.”

The authors highlight the multiple challenges of treating young children and infants with HIV. Amongst this group of HIV patients’ the disease usually progresses rapidly, with a peak in mortality rates within the first few months of life. The rapid growth of children requires a frequent change in drug dosage.

The authors conclude after a review of evidence from studies in infants with HIV, that initiating ART at an early stage reduces the death toll of children by 4 times compared with starting treatment at a later stage. The researchers also highlight the risk of treatment failure is 2 times higher in young children that start a first-line ART regimen containing the drug nevirapine than those who start a regimen with a different type of drug called lopinavir/ritonavir. The team does point out though that using lopinavir/ritonavir in infants presents a challenge due to its high cost and the fact that it is unpalatable with a potential for long-term toxicity.

They state:

“The current recommendation for universal, lifelong treatment may be difficult to sustain in low and middle income countries because of cost, long-term toxicity, and eventual likelihood of virological failure.”

The authors argue that an alternative approach might be initiating early ART during infanthood and then stop the regimen when risk of disease progression is lower, providing that treatment interruption is sufficiently long to have beneficial reductions in toxicity and cost and providing sufficient capacity to closely monitor children on an ART break.

Next year, the WHO treatment guidelines for children and infants with HIV will be revised. The researchers stress the urgent need to consider the practical implications and to support a policy with the best treatment options.

They conclude:

“Recommendations must therefore balance evidence with feasibility, and policymakers must continue to advocate a pipeline of appropriate pediatric antiretroviral drugs to enable evidence to be put into practice.”

Written by Petra Rattue