Main Category: HIV / AIDS News
Article Date: 08 Jun 2007 - 2:00 PDT

Directly observed antiretroviral therapy is a promising strategy to
ensure that HIV-infected children in developing countries take life-
saving medications, new research from The Warren Alpert Medical
School of Brown University shows.

The study was conducted in collaboration with Maryknoll, the
international Catholic charity that runs a program for AIDS orphans
in Phnom Penh, Cambodia's capital city. The study is the first to
test the benefits of directly observed treatment in children living
in developing countries. Findings are published in the June issue of
the American Journal of Public Health.

"Results of this study tell us that directly observed treatment for
children with HIV is an important strategy to consider in resource-
limited settings" said David Pugatch, M.D., director of the pediatric
and adolescent HIV program at Hasbro Children's Hospital and an
assistant professor of pediatrics at The Alpert Medical School.

"With the cost of AIDS drugs dropping, antiretroviral treatments are
increasingly becoming available in Asia, Africa and Latin America,"
Pugatch said, "yet there is little evidence of what is the best way
to deliver these drugs to children living in these countries. We
found that directly observed therapy is an effective and economical
way to go."

Without antiretroviral treatment, half of all HIV-infected children
die by age 2. With therapy, however, many children survive to
adulthood. That's why the World Health Organization is calling for
worldwide universal access to antiretroviral therapy by 2010.

But what's the best way to deliver these drugs to children in
developing countries, places with often limited access to basic tests
and trained professionals" Pugatch and his Brown colleagues, who have
helped combat AIDS in Cambodia for years, decided to find out.

They evaluated the outcomes of HIV-infected children receiving
directly observed therapy, a method that calls for health care
workers to either watch patients take every drug dose or deliver
those doses themselves. This method, widely used to combat
tuberculosis, is aimed at ensuring that people take their
medications. That adherence will keep patients healthy and reduce the
likelihood of drug resistance.

Researchers evaluated HIV-infected children living in orphanages or
with extended family in Phnom Penh. Researchers assessed 117 late-
stage HIV-infected children ages 1 to 13.

Because treatment started so late, 22 children died of AIDS within
the first six months. The remaining 95 children were treated for at
least six months or as many as 18 months. Trained childcare workers
administered the generic drugs, in liquid or pill form, twice daily.

The results: The number of immunity-boosting T helper cells in the
blood of children more than tripled. Children gained significant
amounts of weight. Drug toxicities were uncommon and easily managed.
And the price was right: Staff costs for the program were about $5
per child per month, or 15 percent more than the price of the
medications. Calculated another way, it cost $400 per child per year
to buy the drugs and another $60 to pay the professionals who
administered them.

"For just a little extra money, we could be sure that children had
100 percent adherence to their medications," Pugatch said. "We know
that a high degree of adherence reduces the chances of drug
resistance - which can lead to treatment failure and the need to put
kids on more expensive, second-line therapies."

The next steps researchers must take, Pugatch said, are to conduct a
randomized, controlled trial to compare directly observed therapy
with standard care as well as to conduct a rigorous cost-benefit
analysis. "We need to know what works in treating children in
resource-poor settings so we know where to put limited HIV treatment
dollars," he said.

###

Patricia Myung, M.D., a former Brown medical student and current
resident at the University of California-Irvine, is lead author of
the article. Brown medical student Mark Brady was part of the
research team, along with Mark Lurie, assistant professor of
community health, and Joseph Harwell, M.D., assistant professor of
medicine and pediatrics and attending physician at The Miriam
Hospital. Former Maryknoll program directors Phok Many and John
Tucker also conducted the research.

The International Health Institute at Brown University and the Brown-
Tufts Fogarty AIDS International Training and Research Program funded
the work.

Contact: Wendy Lawton
Brown University