Very Young Children in HIV Treatment More Likely to Die

Children younger than age 5 years with HIV who received antiretroviral treatment (ART) died globally at percentages two to nine times higher than older children, a CDC study found.

Among children receiving ART for HIV through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), 4.9% of those under age 1 and 2.5% of those ages 1 to 4 years died over a 2-year span, reported Nickolas Agathis, MD, of the CDC’s Global Health Center in Atlanta, and colleagues.

Compared with similarly treated patients ages 5 and older, those mortality rates were four to nine times higher for infants and two- to five-fold higher for 1- to 4-year-olds.

“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,” the authors wrote in Morbidity and Mortality Weekly Report (MMWR).

It’s known that children under age 5 with HIV who are not receiving ART have disproportionately high mortality. Children under age 5 are also less likely to receive an HIV diagnosis than older people. Less well documented is mortality among young children who do receive treatment.

In the study, interruptions in treatment were more common and HIV viral load suppression less common for children age 4 and younger, which “might suggest that mortality is disproportionately underreported in this age group, because patients with interruptions in treatment or who are lost to follow-up might have died,” the group wrote.

The researchers suggested strategies for improving care for young children with HIV, including:

• Diagnosing children as early as possible and connecting them to ART treatment (especially dolutegravir [Tivicay]-based treatments)
• Ensuring care continues though family-centered approaches
• Preventing, identifying, and managing advanced HIV and complications like tuberculosis and malnutrition
• Ensuring access to immunizations, nutritional supplementation, and antimalarial treatments for children under 5

“These strategies … 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 wrote.

Researchers collected data from PEPFAR treatment sites in 25 countries and three regions, through which approximately 18 million people with HIV receive ART. Among them, 11,980 were less than age 1 and 105,510 were ages 1-4 years in the 2-year analysis period from October 2020 through September 2022, during which quarterly site monitoring, evaluation, and reporting data were analyzed.

Treatment interruptions were defined as no clinical encounter in the 28 days since the last scheduled clinical contact. Viral load suppression was defined by HIV RNA under 1,000 copies/mL among those with a viral load result documented in the previous 12 months.

Of children under age 5, 4% had interruptions in treatment compared with 2% of children ages 5-14 years and 3% of those ages 15-49. Viral load suppression rates were 78% and 73% for infants under age 1 and children ages 1-4, respectively, compared with 66% for children ages 5-14 years and 85% in those ages 15-49.

The authors added that in low-resource settings, including where PEPFAR supports HIV programs, general mortality for children under age 5 is high, and factors that contribute to it also exacerbate HIV mortality rates. They cited a study from Kenya that found mortality in children both with and without HIV was affected by pneumonia, malnutrition, and malaria.

Limitations included likely underreporting of deaths and treatment interruptions in the PEPFAR data, as well as variations between the PEPFAR sites in this underreporting such as site-level factors that affect data completeness. Findings might not be generalizable to children with HIV treated in non-PEPFAR-supported sites.

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