Treatment for children must become global priority, urges MSF

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Treatment for children for HIV needs to become an international priority for advocates and governments said Médecins Sans Frontières (MSF) director Daniel Berman yesterday at the Fifteenth International AIDS Conference.

He called on drug companies to pay more attention to developing paediatric formulations of antiretrovirals and international bodies such as UNICEF to pay greater attention to the treatment needs of children.

MSF is already providing antiretroviral treatment for 13,000 adults in developing countries, and, “even though we started our antiretroviral (ARV) programme without any particular intention to treat children, children [with HIV] were brought to us.”

Glossary

paediatric

Of or relating to children.

polymerase chain reaction (PCR)

A method of amplifying fragments of genetic material so that they can be detected. Some viral load tests are based on this method.

intent to treat analysis

All participants in a clinical trial are included in the final analysis, in the groups they were originally assigned to, whether or not they actually completed their course of treatment. This method provides a better estimate of the real-world effect of a treatment than an ‘on treatment’ analysis.

formulation

The physical form in which a drug is manufactured or administered. Examples of formulations include tablets, capsules, powders, and oral and injectable solutions. A drug may be available in multiple formulations.

MSF has found a number of major problems are preventing effective treatment for children in resource-limited settings, said David Clark, MSF Thailand’s Medical Coordinator.

The tests needed to detect HIV infection in children below the age of 18 months are expensive and difficult to use outside well-equipped laboratories. Until the age of 18 months the standard antibody test used to diagnose HIV infection in adults may produce a misleading result in children because the mother’s antibodies linger in the child’s body. Instead doctors use a viral load test (also known as a PCR test) to directly test for HIV’s genetic material.

However viral load tests are expensive, even after a recent price reduction negotiated with manufacturers Roche Diagnostics and Bayer. They also require specialised training and a sophisticated laboratory, so they are out of reach of many clinics in rural settings or the poorest countries.

Drugs for children are also a huge problem, explained Fernando Pascual, a pharmacist working for MSF. Many antiretrovirals are not available in paediatric formulations that can be given to small children as a liquid, and tablets are often not manufactured in small enough doses for a child’s body weight, requiring pharmacists and doctors to guess how to chop up tablets or dose according to weight.

“The market for ARVs for children in Europe and North America is very limited – there are less than 1000 new cases of HIV in children compared with 700,000 in Africa – so there is no incentive to provide new formulations,” he said.

“This is a clear case of market failure and there needs to be pressure from the international community,” added Daniel Berman.

He also highlighted the lack of differential pricing for the paediatric formulations currently available, and the lack of WHO prequalification for any paediatric formulation.

“We’ve made little progress in simplifying treatment for children. Calculating doses is difficult and time-consuming enough for doctors, let alone families, and we need tools to make this easier,“ said David Clark.

Peer support and adherence support for children are also needed if treatment is to succeed, together with engagement with caregivers who are often family members other than the child’s mother.

Mildmay International is providing HIV care for 3000 children in Uganda and 500 in Zimbabwe. Director Dr Veronica Moss told aidsmap.com, "only a few of the children we are caring for are on ARVs due to the high cost of paediatric formulations and the need for stable social support so that the child can take the medicine - their carer has to understand the need to take the medication at the right time and the need for food."