HIV

At the end of 2012, more than 1.5 million children in the 22 most affected countries were in need of HIV treatment (antiretroviral therapy – ART) of these, only 34% were actually receiving it which is much lower that the proportion of adults in need of treatment receiving it.

The ARROW (Anti-Retrovirus Research for Watoto) trial was an MRC-funded large randomized controlled trail that looked at several important questions about which treatment approaches are best for HIV-infected children, and ways of increasing access to treatment in low-income settings. It was carried out in Zimbabwe and Uganda, and involved more than 1,200 children from the ages of 3 months to 17 years. These children were followed up for up to 5 years (average ~4 years).

One of the questions addressed by the study was around how children on ART are monitored. In high-income settings adults and children on ART have regular laboratory tests for treatment effectiveness and side-effects, usually every 3 or 6 months. However, these tests are expensive. Another MRC-funded trail on HIV adults in Africa, found that routine testing for side-effects did not benefit people on ART. Laboratory tests to monitor the strength of a person’s immune system had some benefit to individuals, but were not cost-effective. Spending the available money on getting more people on to treatment, rather than carrying out routine laboratory tests of those already on treatment, will lead to more lives being saved. The ARROW trial looked at this question in children and found very similar results.

These findings have major implications for treating HIV infected children in low-income settings., They mean that HIV programmes should focus their resources on getting more children onto treatment, rather than carrying out routine laboratory tests, and as for HIV-infected adults, decentralize and roll out treatment for those who live a long way from laboratory facilities.

ARROW also looked at which combination of anti-retrovial drugs should be used for children. At the time of the study most children in low-income countries were treated with three drugs. ARROW compared this approach to starting treatment with four drugs, then reducing it to 3 drugs after the first 8 months. The study found that children on 4 drugs did better while they were taking 4 drugs, but once this was reduced to 3 drugs there was no difference between those who had been on 3 drugs throughout, and those who had started on 4 drugs. It also found that children who had two different types of drugs throughout their treatment did better in terms of suppressing the virus than those who were on a maintenance phase of 3 drugs.

The Medical Research Foundation provided funding to ensure that these important research results were dessiminated rapidly to those

• who are able to influence health care practices in low-income countries and we communicated in suitable forms to national policymakers and paediatric HIV treatment implementing organisations so that it informs their decisions on how to treat children with HIV. Our dissemination funding ensured that Dr Gibbs and her colleagues were able to reach policy makers and the results from the ARROW trial influenced WHO guidelines on use of treatment for children on ART.