CDC Reports Higher Mortality, Treatment Interruption Rates Among Children With HIV Receiving ART vs Older Patients

Compared with older age groups, a higher proportion of children younger than 5 years old with HIV who received antiretroviral treatment (ART) died or had their treatment interrupted, according to a study published in the CDC’s Morbidity and Mortality Weekly Report (MMWR).

The researchers explained that, globally, children younger than 5 living with HIV are less likely to receive a diagnosis and ART than older patients with HIV. Consequently, children under 5 living with HIV are more likely to die, especially those who are not receiving ART.

They noted that global mortality and related clinical measures among children with HIV in comparison to older patients with HIV are not as well described. Because of this, the researchers analyzed clinical measures among children younger than 5 with HIV receiving ART compared with those aged 5 or older living with HIV and receiving ART at all clinical sites supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR).

They specifically analyzed the estimated number of persons living with HIV receiving ART, treatment interruption, mortality, proxy viral load coverage, and viral load suppression. To conduct the study, the researchers analyzed PEPFAR Monitoring, Evaluation, and Reporting data collected quarterly from all PEPFAR-supported treatment sites from October 2020 to September 2022.

Children with HIV

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Among all sites, about 17.9 million patients living with HIV received ART each quarter. During the 2-year analysis period, 11,980 of these patients were less than 1 year old, and 105,510 were between ages 1 to 4. Of patients with HIV who received ART, 586 (4.9%) of those less than 1 year old died annually, along with 2684 (2.5%) between the ages of 1 and 4. Conversely, 0.5% of 5- to 14-year-olds, 0.7% of 15- to 49-year-olds, and 1.4% of those 50 years or older died annually. Therefore, death occurred at rates 4 to 9 times higher in patients less than 1 year old and 2 to 5 times higher in children between 1 and 4 years old.

Additionally, treatment interruptions occurred more in patients younger than 5 than among those within the older age groups (<1 year and 1-4 years, 4%; 5-14 years, 2%; 15-49 years, 3%; ≥ 50 years, 2%). Also, compared with older patients, the researchers found a lower proportion of patients under age 5 to have a suppressed HIV viral load (< 1 year, 78%; 1-4 years, 73%; 5-14 years, 85%; 15-49 years, 94%; ≥ 50years, 96%).

Because of their findings, the researchers speculated the causes of these disproportionately poorer outcomes among children younger than 5. One reason they hypothesized was that many younger children with HIV are severely immunosuppressed and at high risk for poor outcomes upon HIV diagnosis and ART initiation. Additionally, general mortality for persons younger than 5, regardless of HIV status, remains high in many low-resource settings, including those with PEPFAR-supported HIV programs.

The researchers also acknowledged their study’s limitations, one being that both treatment interruption and mortality estimates from the PEPFAR Monitoring, Evaluation, and Reporting data are likely underreported; this means that the actual number of deaths and treatment interruptions among those receiving ART through PEPFAR was underestimated. Also, the study’s findings may not be generalizable to children living with HIV in non–PEPFAR-supported sites.

Despite these limitations, the researchers explained that their findings demonstrated that “prioritizing and optimizing HIV and general health services for children aged <5 years living with HIV receiving ART might help address the disproportionately poorer outcomes they experience.” They suggested enrolling high-risk children into community-based support programs, like PEPFAR’s Orphan and Vulnerable Children program, to give them access to more comprehensive services, like family-based case management and socioeconomic support, to help them and their caregivers thrive.

“These strategies, as highlighted in PEPFAR’s 2023 country and regional operational planning guidance, have the potential to prevent death, reduce the inequities experienced by children aged <5 years living with HIV, and contribute to the global measures to end AIDS among children by 2030,” the authors concluded.

Reference

Agathis NT, Faturiyele I, Agaba P, et al. Mortality among children aged <5 years living with HIV who are receiving antiretroviral treatment — U.S. president’s emergency plan for AIDS relief, 28 supported countries and regions, October 2020–September 2022. MMWR Morb Mortal Wkly Rep 2023;72:1293–1299. doi:10.15585/mmwr.mm7248a1