HIVAN/ECI April 2006 Journal Club

?“Experiences in paediatric ART (antiretroviral treatment) in KwaZulu-Natal?” was the subject of discussion at the April 2006 Journal Club meeting at the UKZN School of Medicine. First Dr Holly France gave an overview of the paediatric ART programme running at Ridge House, the antiretroviral (ARV) clinic attached to McCord Hospital. This was followed by a presentation from Dr Gurpreet Kindra on the Structured Treatment Interruption study that was carried out at King Edward IV Hospital.

McCord Hospital is a semi-private state subsidized hospital in Overport in Durban, KZN, and it has a large programme to provide antiretroviral (ARV) treatment to adults and children. In July 2004 the programme was initiated with PEPFAR funding. Dr Holly France, a paediatrician at the hospital, explained the procedure for children to access ARVs. Children are assessed clinically and undergo three training sessions before commencing on ART. If suffering from TB, the usual practice is that unless the child is very sick, ARV treatment is postponed for two months in order to give the TB medication time to work. After initiating ART, children are seen every two weeks for a short while and then appointments are scheduled monthly.

Of the first 151 children enrolled onto ARV treatment since July 2004, none have been lost to follow up. However, 13 children died in the first 5 months of receiving therapy, mainly from chronic gastroenteritis. The age range of children accessing ARVs was 4 months to 15 years (median age 5.7 years). 70% of children were in WHO stage 3 or 4 and 33% of all children had TB at baseline. The increase in CD4 count was noteworthy: at 6 months, children showed an average increase of 9% in their CD4 count and at 12 months, an average increase of 15.2% was evident. After the first year, 84% of 100 children (after a year only 100 children had been receiving ART for 12 months) had an undetectable viral load. While these results were encouraging, Dr France stated that what was disappointing was that only 8% of children had been disclosed to, that is, only 8% knew their own HIV-status.

Dr Gurpreet Kindra then spoke about the study at King Edward IV Hospital. 30 children, aged 2-11 years old, were started on Structured Treatment Interruption (STI) two years ago. These were all treatment naïve children. Weekly viral load and CD4 counts were done, and once viral remission was achieved, children were randomised into 2 arms - continuous or intermittent therapy. Children in the intermittent therapy arm (9 children were eligible out of the 15) stopped treatment when their viral loads because undetectable. They resumed therapy when the viral load went up 1 log. After 3 months if the viral load was undetectable, children went off ART again. Unfortunately the study had to be stopped because treatment interruption was being based only on CD4 count.

Results showed that viral rebounds occurred rapidly on structured treatment interruption, and that viral load in both groups (both children on continuous treatment and those in the STI group) decreased over time. But prolonged interruptions may lead to deterioration of the immune system, thereby negating the benefits of STI. In addition, Dr Kindra pointed out that CD4-driven treatment interruption is clearly inferior if the threshold is less than 250 cells/ul.

Note: This overview serves to inform readers about presentations given at the HIVAN/ECI HIV/AIDS Public Health Journal Club on the first or second Friday of every month, at the Nelson R Mandela School of Medicine. It should be read in conjunction with the PowerPoint presentation slides and/or MS Word documents provided on the righthand side of this page.