December 7, 2015 — Since the first World AIDS Day in 1988, the first day in December has been a day to remember those who have died in the epidemic and to acknowledge progress made in treatment and prevention of HIV/AIDS. At the Harvard T.H. Chan School of Public Health, researchers spoke about recent advances and challenges in treating children with HIV/AIDS at an event titled “World AIDS Day Update: Pediatric HIV/AIDS” on December 1. According to UNAIDS, about 2.6 million children under age 15 are living with HIV.
Sandra Burchett, director of the Boston Children’s Hospital AIDS Program (CHAPS) and an associate professor of pediatrics at Harvard Medical School, reviewed new U.S. guidelines for initiating antiretroviral (ARV) therapy for HIV-positive babies at the earliest opportunity. Burchett estimates that in the U.S., only about 50 babies a year are now born with HIV. Though the U.S. generally does a good job treating children with HIV, Burchett listed a number of challenges that occur when adolescents transition to adult HIV care, including adherence to treatment, mental health issues, and risky behavior such as unprotected sex.
Shifting the focus to Africa, Christopher Rowley, an infectious diseases specialist at Beth Israel Deaconess Medical Center (BIDMC) and research associate at Harvard Chan School, outlined the challenges as more and more HIV-positive people begin taking ARVs as soon as they’re diagnosed, as was recently recommended by the World Health Organization (WHO). Currently 15 million people receive ARVs worldwide. If all countries adopt the new WHO guidelines and overcome current funding and infrastructure limitations, that number could potentially grow to 37 million—the total number of HIV-infected people worldwide. Over two-thirds of those people—26 million—live in sub-Saharan Africa.
Increased use of ARVs will lead to increased drug resistance, said Rowley. In Botswana, drug resistance had been extremely rare, but Rowley recently found an alarming increase. “In a three-year span, we have basically gone from no resistance to about 8% resistance to first-line therapy,” he said. He and colleagues have devised a fast-acting, inexpensive drug-resistance test that they will soon test in antenatal clinics. If resistance is identified, “not only can you start an HIV-positive mother on a new regimen if necessary,” said Rowley, “but you also help ensure that her baby is born HIV-free.”
Rebecca Zash, an infectious diseases fellow at BIDMC and a research associate at Harvard Chan School, spoke about adverse birth outcomes of babies born to HIV-positive women taking ARVs.
Since the growth of ARV programs to prevent mother-to-child transmission of HIV, over a million pediatric infections worldwide have been averted. Today there are fewer adverse outcomes than in the pre-ARV era, yet babies born to mothers taking ARVs still have a higher risk of stillbirth, preterm delivery, and low birth weight. Zash and her colleagues are working to establish which ARV regimens are healthiest for both mothers and babies.
With success there are new challenges, noted the researchers. “While the mother-to-child transmission rate has declined markedly over time, the child mortality rate has remained relatively steady and unacceptably high,” said Shahin Lockman, an infectious disease specialist at Brigham and Women’s Hospital and an associate professor in the Department of Immunology and Infectious Diseases at Harvard Chan School. “It is important for us to understand the short- and long-term health consequences of in utero ARV exposure and HIV exposure on HIV-exposed but uninfected (HEU) children.” Lockman’s team is investigating why the more than 1.2 million HEU infants born annually have a much higher mortality rate than unexposed children.
photo: Noah Leavitt