Despite Positive Results, Treatment Gaps in Pediatric HIV Care Remain in the “Treat All” Era

In 2015, the World Health Organization (WHO) revised global HIV guidelines and endorsed a “Treat All” approach, which removed CD4-based clinical staging criteria for antiretroviral therapy (ART) initiation and expanded ART eligibility for children.

While the “Treat All” approach called for increased equity in HIV treatment, an article published in Pediatrics showed that ART coverage continues to lag in children. The authors also said comprehensive approaches that address structural issues, such as family-based services and intensified case-finding, are needed to close pediatric HIV treatment gaps.

The researchers abstracted country-level estimates of ART coverage and AIDS mortality over an 11-year period, specifically looking at the proportion of children under 15 years old on ART and the number of deaths per 100,000 population. They also collected information on the year when "Treat All" was implemented in national guidelines for 91 of the 173 countries with available estimates. The authors used multivariable 2-way fixed effects negative binomial regression to analyze the data, and calculated adjusted incidence rate ratios (adj IRR) with 95% CI to assess the potential impact of "Treat All" expansion on pediatric ART coverage and AIDS mortality.

Of note, 89% of the 91 countries adopted “Treat All” into national HIV treatment guidelines by 2018, and only 1 country had not yet formally adopted the approach by 2020.

The authors found that, between 2010 and 2020, pediatric ART coverage tripled, jumping from 16% to 54%. However, pediatric coverage still consistently lagged behind adult ART coverage, which jumped from 26% in 2010 to 74% in 2020. Meanwhile, AIDS-related deaths dropped by more than half, going from 240,000 to 99,000 over the decade.

Following the plan’s implementation, increases in pediatric ART coverage continued increasing from the pre- to post-implementation period, but the rate of increase declined by 6% post-implementation (adj IRR, 0.94; 95% CI, 0.91-0.98). Similarly, pediatric AIDS mortality continued declining from the pre- to post-implementation period, but the rate of decline decreased by 8% (adj IRR, 1.08; 95% CI, 1.05-1.11).

Although pediatric ART coverage increased across all regions, the most significant increases were observed in the following regions:

• Asia-Pacific (23% to 81%, P < .005)
• East and Southern Africa (18% to 57%, P < .001)
• Middle East and North Africa (8% to 47%, P < .001)
• West and Central Africa (7% to 35%, P < .001)

The most significant reductions in pediatric ART coverage expansion were found in East and Southern Africa (adj IRR, 0.91; 95% CI, 0.87-0.95) and West and Central Africa (adj IRR, 0.93; 95% CI, 0.87-0.99).

Meanwhile, the steepest declines in pediatric AIDS mortality reductions were observed in Asia-Pacific (adj IRR, 1.26; 95% CI, 1.07-1.49), the Caribbean (adj IRR, 1.04; 95% CI, 1.01-1.06), and East and Southern Africa (adj IRR, 1.10; 95% CI, 1.08-1.14).

With all this data taken into account, the authors said that significant advancements have been achieved in expanding ART coverage and lowering mortality rates among children living with HIV. However, additional strategies beyond the current "Treat All" approach are necessary to achieve effective control of the HIV epidemic in both children and adults. This is particularly crucial in regions with high HIV burdens and inadequate outcomes for pediatric HIV, such as West and Central Africa.

“Despite significant increases in pediatric treatment coverage and decreases in AIDS mortality over the last decade, our findings suggest that complementary approaches to 'Treat All' must be scaled up to accelerate momentum toward global HIV treatment equity for children,” the authors concluded. “Early infant diagnosis, targeted case-finding strategies (ie, integration with adult index testing efforts), and prioritization of family-based service delivery models are key to closing the pediatric HIV treatment gaps in the 'Treat All' era.”

Reference

Rosen JG, Muraleetharan O, Walker A, Srivastava M. Pediatric antiretroviral therapy coverage and AIDS deaths in the "treat all" era. Pediatrics. Published online May 17, 2023. doi:10.1542/peds.2022-059013