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Fast treatment benefits HIV-infected infants

Immediate antiretroviral treatment slows disease and delays need for potentially dangerous therapies

Mark Gould

Thursday, 22 August 2013

Young infants with HIV benefit from immediate treatment with antiretroviral therapy (ART) as it slows progression of the disease and delays the exposure to potentially dangerous long-term therapy.

Writing in The Lancet, doctors from South Africa say that although giving early ART during infancy is beneficial and lifesaving, currently treatment must be taken for life and cumulative exposure increases the likelihood of drug-related toxicity and drug resistance.

Their trials show that infants who began an immediate short course of ART could safely interrupt treatment and continue to do significantly better than infants in whom ART was deferred, and with less overall exposure to ART.

On average, infants who received deferred ART needed to begin taking life-long treatment 20 weeks after the trial started. Those given the immediate course of 40 weeks ART delayed the need for re-starting treatment by 33 weeks, and those who received the initial 96 week ART course delayed beginning long-term treatment by 70 weeks.

By the end of the trial, 24 infants (19%) given 40 weeks of early ART and 40 infants (32%) who received 96 weeks of initial ART were still well enough to remain off treatment. What is more, despite a longer period of continuous ART, the deferred treatment group had a significantly higher number of deaths, clinical events, and admissions to hospital, and was more costly than time-limited ART.

One of the study leaders, Professor Mark Cotton from Stellenbosch University, says: “this important finding indicates we may be able to temporarily stop treatment and spare infants from some of the toxic effects of continuous ART for a while, if we can monitor them carefully.”

“With ART coverage in children currently at just 28%, our findings highlight the urgency of increasing early (within the first 3 months of life) testing and treatment of HIV-infected infants,” he explains.

In 2005, the children with HIV early antiretroviral (CHER) trial, funded by the US National Institutes of Health, and with participation of the Medical Research Council Clinical Trial Unit in London, randomly assigned 377 HIV-infected infants (between 6 and 12 weeks of age) from South Africa to one of three regimens: immediate protease inhibitor (PI)-based ART and continue for 40 weeks (ART-40W); immediate PI-based ART and continue for 96 weeks (ART-96W), with subsequent treatment interruption; or defer PI-based ART until signs of illness or a weakened immune system (ART-Def; standard practice).

In 2007, interim results reported that after a median of 48 weeks, giving immediate PI-based ART reduced the risk of death and disease progression by 75% compared with deferring ART until signs of illness or a weakened immune system.

These findings led WHO to revise its treatment guidelines and recommend that ART be started immediately after HIV diagnosis in children under 1 year old rather than at a particular white blood cell count.

According co-lead author Dr Avy Violari from the University of the Witwatersrand in South Africa, “early treatment followed by a break is definitely better and more cost-effective than delaying starting infants on treatment. But we do not know if a longer initial period of treatment, or early continuous treatment, might be even better.”

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