Poor virologic outcomes persist among children on ART

Suboptimal viral suppression rates among HIV-infected children in low- and middle-income countries: a meta-analysis.

Boerma RS, Boender TS, Bussink AP, Calis JC, Bertagnolio S, Rinke de Wit TF, Boele van Hensbroek M, Sigaloff KC. Clin Infect Dis. 2016 Sep 22. pii: ciw645. [Epub ahead of print]

Background: The 90-90-90 goals aim to achieve viral suppression in 90% of all HIV-infected people on antiretroviral treatment (ART), which is especially challenging in children. Global estimates of viral suppression among children in low- and middle-income countries (LMIC) are lacking. This study summarizes viral suppression rates in children on first-line ART in LMIC since the year 2000.

Methods: We searched for randomized controlled trials and observational studies and analyzed viral suppression rates among children started on ART during three time periods, based on major World Health Organization (WHO) guideline changes: early (2000-2005), intermediate (2006-2009), and current (2010 and later), using random effects meta-analysis.

Results: Seventy-two studies, reporting on 51,347 children and adolescents (<18 years), were included. After 12 months on first-line ART, viral suppression was achieved by 64.7% (95%CI 57.5-71.8) in the early, 74.2% (95%CI 70.2-78.2) in the intermediate, and 72.7% (95% 62.6-82.8) in the current time period. Rates were similar after 6 and 24 months of ART. Using an intention-to-treat analysis, 42.7% (95%CI 33.7-51.7) in the early, 45.7% (95%CI 33.2-58.3) in the intermediate, and 62.5% (95%CI 53.3-72.6) in the current period were suppressed. Long-term follow-up data were scarce.

Conclusion: Viral suppression rates among children on ART in LMIC were low and were considerably poorer than those previously found in adults in LMIC and children in high-income countries. Little progress has been made in improving viral suppression rates over the past years. Without increased efforts to improve pediatric HIV treatment, the 90-90-90 targets for children in LMIC will not be reached.

Abstract access   [1]

Editor’s notes: The authors have undertaken one of the largest meta-analyses to date of viral suppression rates among children and adolescents on first-line ART in low- and middle-income countries (LMIC). The same research group had previously conducted a meta-analysis among adults in LMIC using the same methodology. In this study, they found that viral suppression rates in children in LMIC are well below those previously found in adults in LMIC. The authors had planned to analyse viral suppression rates up to five years after initiation of first-line ART but found very few data on virologic outcomes after more than two years of follow-up. 

The paucity of data on long-term outcomes in children highlights that children have been left behind compared to adults with respect to effective ART delivery. Systems to improve retention in care and adherence to treatment for children are urgently needed. 

HIV Treatment [3]
Africa [4], Asia [5], Latin America [6]
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