Pediatric and adult HIV/AIDS treatment: still worlds apart.

Born with HIV infection in 1992, Jane Queen's prospects for life were bleak. Riddled by chronic, recurrent infections, Jane's blood platelets were low, predisposing her to easy bruising and bleeding. She contracted chickenpox twice, once requiring hospitalization. Only a miracle could restore her health.

Jane's miracle arrived in the summer of 1996 when she became one of the first children in the world to receive highly active antiretroviral therapy (HAART), powerful combinations of HIV medications that can near totally suppress the ability of the virus to reproduce within the body. Jane's miraculous road to health was detailed in an October, 1999 Houston Chronicle feature story by Leigh Hopper, entitled "Worlds Apart." Jane and thousands of other HIV-infected American children whose lives were slowly being extinguished in 1996 are thriving today.

Sadly, nearly a decade after Jane's miracle appeared, 2 million children living with HIV/AIDS in the developing world still are waiting for their miracles. Earlier this year, UNICEF estimated that no more than 25,000 of these children (about 1%) currently receive antiretroviral treatment. For most of the rest, life will be short and painful, ravaged by terrible opportunistic infections and cancer. Ultimately, most will simply will waste away and die--half before the age of 2. About 510,000 children died from HIV/AIDS last year alone, one every minute of every hour, every day.

And yet, it doesn't have to be this way. In the face of stifling pessimism surrounding the treatment of HIV-infected children in the developing world, and in a setting of pervasive HIV-related stigma, the Botswana-Baylor College of Medicine Children's Clinical Center of Excellence in Gaborone, Botswana treats more than 1,400 HIV-infected children, more than any other center worldwide. Funded by the Bristol-Myers Squibb Foundation, the center has become a focal point in Botswana and southern Africa for health professional training and community education on pediatric HIV/AIDS. In partnership with the government of Botswana, the center has catalyzed the establishment of Africa's first-ever national HIV treatment program for children. With support from the Abbott Fund, Bristol-Myers Squibb, the US Centers for Disease Control and Prevention (CDC), and others, the programs of the Botswana-Baylor center are now being replicated across Africa--in Uganda, Lesotho, Swaziland, Malawi, and Burkina Faso--with others to follow. This global Children's Clinical Centers of Excellence Network will accelerate training of pediatric professionals and share best practices regarding pediatric HIV/AIDS care and treatment in the developing world.

We have learned a great deal over the past few years about how to deliver treatment to HIV-infected children living in some of the world's poorest places, and we sit on the cusp of a new era of hope for HIV-infected children and families in Africa and other parts of the developing world.

Pediatric HIV treatment never just happens. Political commitment to children's health is essential. Most health professionals consider pediatric HIV treatment inherently more complex than the treatment of HIV-infected adults. Excuses for not treating children are legion. Many health professionals believe that children don't respond well to treatment, making drug therapy almost futile, or that the drugs are too strong or too toxic for children, or that too little is known about dosing or monitoring treatment. These are myths. Africa currently lacks a critical mass of health professionals--people who have seen with their own eyes and experienced the miracle of a seriously ill or dying HIV-infected child restored to health by HAART. Time and again, African health professionals who train in our centers in Houston or Botswana have stated that this has been the most valuable part of their experience. Seeing is believing.

The expense of antiretroviral therapy remains a concern, particularly in the poorest countries. Fortunately, substantial resources are now being provided by the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, but more is needed. Unless HIV-infected children in the developing world are to remain therapeutic orphans forever, funders must consider setting aside resources specifically for the care and treatment of children. Manufacturers and others must work together to ensure that pediatric formulations of antiretroviral medications are made available at cost parity with comparable adult formulations. No matter the reasons, it is unacceptable that some medications used to treat HIV-infected infants or toddlers are priced substantially higher than the equivalent medications used in the same settings to treat HIV-infected adults, thereby pricing children out of access to treatment.

Scaling up the care and treatment of hundreds of thousands of HIV-infected children will take a commitment to partnerships. Governments, academic and health care institutions, community and faith-based organizations, and business communities in both the developed and developing countries all have a role to play. We are stronger and better together than apart.

In addition, treatment programs must address the critical shortage in almost every setting of professionals trained in pediatric care and treatment, with a clear recognition that children are not merely "small adults." Poaching of African health professionals by the wealthy countries and deaths of health professionals from HIV/AIDS have exacted a heavy toll on African health care. Here, American professionals clearly have a role to play as an AIDS Corps, if you will, of physicians, nurses, pharmacists, and others willing to give 1 or 2 years to treat HIV/AIDS in Africa.

It is time to re-frame discussions of HIV/AIDS care and treatment in the developing world. Rather than being paralyzed by the enormity of the problem and its many barriers, we must attack the scourge that is pediatric HIV/AIDS because it is difficult. The reward? Miracles like Jane's on a global scale: gifts of health, gifts of life, and satisfying a moral and public health imperative.

Mark W. Kline, MD, is Professor of Pediatrics at the Baylor College of Medicine and Texas Children's Hospital in Houston, where he directs the Baylor International Pediatric AIDS Initiative (bayloraids.org).