Preventing HIV Infection in Children

[Guest guest]

EDITORIAL: Preventing HIV Infection in Children

The New England Journal of Medicine. Volume 346:1842-1843 June 13, 2002 Number

24. http://content.nejm.org

For a child, the risk of becoming infected with the human immunodeficiency

virus (HIV) is a stark example of the difference between being born in a

rich country and being born in a poor country. In the United States, the

acquired immunodeficiency syndrome (AIDS) is a vanishing disease among

children. Throughout the world, however, the number of new HIV infections in

children continues to increase (see Figure). In 2001, an estimated 800,000

children under 15 years of age were newly infected, 2.7 million children

were living with HIV infection, and 580,000 died of AIDS, according to

UNAIDS and the World Health Organization.

Most children who are infected with HIV acquire the virus through

mother-to-child transmission. Worldwide, half these children are likely to

die before their first birthday, and most of the rest before their fifth

birthday. These infections are largely preventable with antiretroviral

therapy, careful obstetrical management, and the use of alternatives to

breast-feeding. However, these interventions are still largely unavailable

in Africa and some other parts of the world. Many women receive no prenatal

care or give birth at home or in settings where antiretroviral medicines are

not available. Counseling, testing, and treatment to prevent mother-to-child

transmission of HIV infection are possible only as part of an organized

health care system. Despite sharp price reductions, many antiretroviral

agents are still prohibitively expensive for poor countries. The World

Health Organization estimates that less than 5 percent of the 6 million

people with HIV infection or AIDS who require treatment with antiretroviral

medications have access to them.

Preventing HIV infection in children is only part of what needs to be done.

A short course of antiretroviral treatment for mother and child does nothing

to stop the progression of AIDS in an HIV-infected mother. When parents die,

they leave orphans, most of whom are not infected with HIV. In 2010, more

than 44 million children under the age of 15 years in 34 developing nations

will have lost one or both parents, according to an estimate prepared for

the U.S. Agency for International Development. AIDS and related illnesses

are projected to account for about two thirds of these parental deaths.

Thus, nearly 13 percent of the children in these countries will be orphans.

In this issue of the Journal, three articles address aspects of the problems

that HIV infection creates for children. Tuomala et al. (see pages

1863?1870) studied the safety of antiretroviral therapy during pregnancy.

They found that the use of multiple antiretroviral medications, as compared

with no therapy or treatment with one medication, was not associated with

increased rates of preterm labor, low birth weight, low Apgar scores, or

stillbirth. These findings should be reassuring, although some aspects of

the safety of antiretroviral therapy during pregnancy warrant further study.

In another article, Watts (see pages 1879?1891) reviews the management of

HIV infection in pregnant women. In the third article, (see pages

1907?1910) discusses the global problem of orphans and how best to respond

to it from local and international perspectives.

The burden of HIV infection for both infected and uninfected children

threatens to dwarf the capacity and willingness of nations to respond to it.

Nonetheless, there are hopeful signs. Some drug companies, in response to

public pressure, are discounting the prices of medications or donating them

to countries that cannot afford to buy them. South Africa has more people

infected with HIV than any other country but has lagged in providing

medications to prevent pediatric infections. In April, South Africa's

government announced that it would make medications available to a larger

number of pregnant women ? although much more needs to be done. The World

Health Organization has issued guidelines for treating HIV infection and

AIDS with combinations of medications in poor countries and has also

included 10 new antiretroviral agents on its revised list of essential

medicines.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is an independent

nongovernmental organization based in Geneva that accepts donations from

governments and other sources. The Global Fund will distribute up to $616

million over the next two years to programs in more than 40 countries.

Although these distributions are substantial they are small in comparison

with the estimates of the additional resources that are needed. UNAIDS has

calculated that a total of $7 billion to $10 billion each year is needed,

just for HIV infection and AIDS.

Further progress depends as much on the sustained commitment of governments,

the private sector, and philanthropic leaders as on clinical advances. The

United States is already the largest contributor to the Global Fund to Fight

AIDS, Tuberculosis and Malaria. Yet considerably more money and technical

support are needed for this and other efforts, both from the United States

and from other countries. Congress is pushing the Bush administration to

spend more money on global AIDS. The challenge is not only to eliminate

mother-to-child transmission of HIV but also to provide effective treatments

for mothers and fathers.

Steinbrook, M.D.

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