Timing of ART & Consistency of Utilization Is Paramount in Perinatal HIV Patients

Upwards of 4 million children have been infected with HIV via vertical transmission. In the past, a diagnosis of perinatal HIV was equitable to a death sentence; now, with the help of safe and effective antiretroviral therapy (ART), an individual with perinatal HIV infection is able to manage their condition.

In a Plenary session at the 25th Conference on Retroviruses and Opportunistic Infections (CROI), in Boston, Massachusetts, Patricia M. Flynn, MD, a professor of pediatrics and preventive medicine at the University of Tennessee’s Health Science Center, spoke about the impact ART has had on the condition, and how far the infectious disease community has come since its initial use.

The sacrifices it took to reach this point were not lost on Dr. Flynn. “Unfortunately, these successes have come too late for many.”

The perinatal transmission of HIV was first identified in the December 17, 1982, issue of the Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. By 1994, there had been over 16,000 cases reported; without effective treatment, more than 50% of the children diagnosed would die within 2 years.

With the introduction of antiretroviral regimens, the number of cases of perinatal HIV plummeted—the United Nation AIDS data reports that since 2000, 2 million perinatal HIV infections have been prevented—although worldwide there are still roughly 400 new infections of children under the age of 15 occurring daily. Furthermore, each year in the United States, 69 children are estimated to be born with HIV.

“We still have quite a bit of a way to go to totally eradicate HIV, but we’re on the way,” Dr. Flynn said. “One of the things we’ve learned is that the birth cohort—the year you were born—is probably the strongest predictor of what your outcome and survival will be.”

The reason for this, Dr. Flynn explained, is due to the availability of more effective HIV therapy and the ability to initiate that therapy earlier on. The more recent birth cohorts have reduced rates of AIDS and death, and they are more likely to be virally suppressed and have higher CD4 over time.

It is difficult to narrow down how many children are living with perinatal HIV, Dr. Flynn noted, but the Collaborative Initiative for Pediatric HIV Education and Research (CIPHER) cohort has helped. The CIPHER cohort has a database of 38,187 adolescents with HIV, born between 1982 and 2014.

“[When ART is initiated] is really key,” Dr. Flynn stressed. Of those in the CIPHER cohort, 88% had received ART, and only 38% had any viral load recorded at any time. In total, 72% had been virally suppressed at their last viral load measurement, which only adds to the proven efficacy of ART, she said.

A major issue in perinatal HIV is the transition of medication responsibilities from the caregiver to the patient—even with the medication available, adherence is a struggle. “The most common reason these patients tell us is that they forgot [to take their medication],” Dr. Flynn said. The timing of ART initiation and the consistency of its utilization paramount, she said.

Patients with perinatal HIV are similar to adults in that they face many complications due to their infection—cardiac, renal, bone, metabolic, and malignancy issues are all challenges that are exacerbated in these patients. However, perinatal HIV brings its own complications.

“One of the things that’s different about pediatrics is that aging up adolescents are unique,” Dr. Flynn said. “Both the effects of disease and therapy coincide with the critical periods of growth and development of the body, brain, and immune system.”

For that reason, she highlighted 3 key impacts of the perinatal form: growth failure, delayed puberty, and encephalopathy; all of which are not negatively affected by the treatment but rather the severity of the infection. However, earlier intervention with ART can improve these outcomes.

Perhaps most important, Dr. Flynn stressed, is the neurodevelopment, especially of the prefrontal cortex. “The effects of HIV and the timing of ART initiation can have a profound impact on neurodevelopment in children and adolescents with HIV.”

If perinatal HIV programs can continue to make an impact to improve these conditions, the future will continue to trend positively, Dr. Flynn postulated. There is much to learn from the experiences of high-income countries in the treatment of this condition, as more children in lower-income countries who present to clinics with perinatal HIV.