WHO Guidelines Call for Prompt HIV Testing and Treatment of Newborns

From Medscape Medical News

Norra MacReady

July 22, 2010 (Vienna, Austria) — Infants born to mothers who are HIV-positive should have their HIV status determined at birth or soon after, with a diagnosis of HIV infection confirmed within 4 to 6 weeks of age, so that treatment can be initiated as early as possible, according to new guidelines issued by the World Health Organization (WHO). The guidelines are available at on the WHO Web site.

As many as one third of HIV-infected infants die before their first birthday, WHO officials said here at AIDS 2010: XVIII International AIDS Conference, in announcing the new treatment guidelines. By age 2 years, mortality is roughly 50%. Prompt diagnosis and treatment improve survival dramatically. "Compelling data show unequivocally that early initiation of treatment reduces mortality 5-fold," Shaffiq Essajee, MD, medical officer, pediatrics and family care, in the HIV Department of WHO, told Medscape Medical News.

WHO is trying to eliminate mother-to-child transmission of HIV completely, perhaps as early as 2015.

"We are expanding significantly the recommendation to identify potentially infected children," Dr. Essajee said. "Previously, we advocated for testing sick children in hospital care settings and children known to be exposed through mother-to-child transmission. Now we're going one step further, saying that every child should have their exposure status ascertained as soon as possible. That's the only way we can then link that child to the appropriate care, testing, and treatment services that they need to prevent the morbidity and mortality that occurs in [HIV-positive] children."

Officials in regions with a high burden of HIV disease, defined as prevalence of more than 1% in the general population, are urged to adopt a strategy of ascertaining a neonate's HIV exposure status and beginning treatment as soon as possible. The very high mortality rates among infected children during their first 2 years of life "makes infants and children the most vulnerable of all people living with HIV," Dr. Essajee said.

WHO has done a good job of closing the treatment gap between children and adults, Dr. Essajee said. By the end of 2008, 276,000 children were receiving treatment; by the following year, that number was up to 355,000. However, until now, most of those efforts have been directed at older children, with distressing consequences. "By the time a child reaches 5 years of age, only 1 in 5 has survived," Dr. Essajee added.

"In the recommendations launched today, we're saying any child under the age of 2 should be treated, because mortality in this age group is so high," said Chewe Luo, MD, PhD, senior advisor for HIV-AIDS in the program division of the United Nations Children's Fund.

Many children are still going undiagnosed, Dr. Luo told Medscape Medical News. "What's critical about these guidelines is that they call for screening these babies as early as 6 weeks, and once you've made the diagnosis, you refer them for treatment."

Infants in impoverished, high-risk regions can have their blood samples dried on filter paper and sent to laboratories for analysis. "This works very well in field conditions," Dr. Luo said. Treatment can begin as soon as the diagnosis is confirmed.

Treatment for HIV-infected children basically is the same as it is for adults — lifelong triple therapy using several different classes of drugs — Dr. Essajee said. Management becomes more complicated if the mother has been on the antiretroviral drug nevirapine during pregnancy, as children exposed to nevirapine in utero may develop resistance to it, so pediatric regimens ideally should include protease inhibitors, as well as triple therapy.

However, Dr. Essajee acknowledges that protease inhibitors can be pricey. "So we tell clinicians that if you don't have access to these expensive and hard-to-get protease inhibitors, treat anyway with the nevirapine you have available, because it's not inevitable that every child will develop a resistance mutation, and even if they do, it's not inevitable that the clinical impact of that resistance mutation will be treatment failure for the child."

"So even if you don't have access to protease inhibitors, don't fall short of initiating aggressive treatment simply because you can't abide by the letter of the law as the WHO has defined it," Dr. Luo urged.

Neither Dr. Essajee nor Dr. Luo has disclosed any relevant financial relationships.

AIDS 2010: XVIII International AIDS Conference. Presented July 20, 2010.