Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and IrelandBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7422.1019 (Published 30 October 2003) Cite this as: BMJ 2003;327:1019
All rapid responses
Editor-Gibb et al describe the dramatic impact of combination
antiretroviral (ARV) therapy on the prognosis of HIV-1 infected children
in the UK and Ireland(1). These high rates of survival mean that
increasing numbers of HIV infected adolescents will confront issues common
to this age group such as poor out patient attendance(2), problems with
adherence to treatment regimens(3) and transitional care to an adult
environment. In addition they may need to deal with the burden of parental
loss and the stigma of having a chronic disease that is sexually
The Intercollegiate Working Party on Adolescent Health supports the
development of dedicated adolescent clinics(4). In 2001, the Mortimer
Market Centre established the first adolescent-only HIV outpatient service
in the UK. Young people were closely involved in the clinic design and a
transition policy was developed together with the Family Unit at Great
Ormond Street Hospital (GOSH)(5). A multidisciplinary team of healthcare
professionals staffs the monthly clinic. It aims to create an environment
where adolescents can feel safe discussing a variety of sensitive issues
including isolation, familial bereavement, sexual debut and choices around
Over the past 2 years 15 adolescents (6 female, 9 male) have
transferred to the clinic and a further 10 are expected to transfer from
GOSH in the next 12 months. Most (87%) are Black African and born outside
the UK. At the time of transition 53% (8/15) had an AIDS defining illness
and 87% (13/15) required ARV therapy according to UK treatment guidelines.
The median duration on ARVs was 43 months (range 2-128 months). During
follow-up 54% (7/13) have had episodes of intermittent non-adherence.
Despite this 62% (8/13) currently have viral load <50 copies/ml and all
remain under active follow up. Overall, 50% (7/14) of adolescents ever
having taken ARVs have resistance to one or two classes of drugs and about
a quarter (4/15) report being sexually active.
Increasing numbers of HIV infected, multi-drug class experienced
children will be surviving into adolescence and becoming sexually active.
There is an urgent need to further develop dedicated adolescent services
to minimise loss to follow-up, encourage ARV adherence and prevent
transmission of drug resistant virus. As individual units see only small
numbers of HIV positive adolescents, it is essential to establish service
networks with comprehensive standards and guidelines to promote best
1. Gibb DM, Duong T, Tookey PA, Sharland M, Tudor-Williams, Novelli,
V et al. Decline in mortality, AIDS and hospital admissions in perinatally
HIV-1 infected children in the United Kingdom and Ireland. BMJ 2003; 327:
2. Prime KP, Sethi G, Dean GL, Fox E, de Ruiter A, Taylor CB et al.
Teenagers and HIV: what’s the problem? HIV Medicine 2001. Vol 2 (3). P11
3. Martinez J, Bell D, Camacho R, Henry-Reid LM, Bell M, Watson C et
al. Adherence to antiviral drug regimes in HIV-infected adolescent
patients engaged in care in a comprehensive adolescent young adult clinic.
J Nat Med Association 2000. 92(2):55-61.
4. Bridging the Gaps: Health Care for Adolescents. Royal College of
Paediatrics and Child Health; 2003.
5. Miles K, Prime K, Sudlow J, Kirkpatrick E, Clapson M, Penny N et
al. Bridging the gap between Paediatric and Adult HIV services. HIV
Medicine 2003. Vol 4 (3). P21.
Competing interests: No competing interests
CASE FOR DECLINING MORTALITY AMONGST HIV-1 INFECTED CHILDREN IN THE UNITED KINGDOM AND IRELAND FLAWED!
The claims by authors Gibb, Duong et al in The BMJ, Vol 327, 1st
November 2003 that their evidence shows a decline in mortality of HIV/AIDS
children in the United Kingdom and Ireland (thanks to antiretrovirals)
cannot go unchallenged. The entire article appears to be driven by a
desire to make a case exclusively for anti-retroviral drugs. In addition, the question of bias and omissions is obvious. The issue of
addressing the question of competing interests remains unanswered and
vague since all we have from the authors is “Competing interests: None
In their Method section, the authors make little or no reference to
the management of opportunistic infections – and how aggressive this might
have been in those children who survived. Second, we have no idea as to
how and where these children were delivered at birth.
Were some of these children delivered by caesarean section? This maybe
important since some authors have raised the question “Whether caesarean
delivery has a protective effect independent of zidovudine prophylaxis can
be further investigated by a large, international, individual patient data
meta-analysis of observational studies. However, a definitive answer to
the question will require a randomised clinical trial, which is the only
methods to ensure that women who undergo an elective caesarian delivery do
not differ from those with other types of delivery for any known or
unknown confounding factor.” 1 Thirdly, we note with interest that 67% of
the children were of African parentage, but we are not given the dates
when these parents entered the United Kingdom. Were there any African
children in this study from the Irish Republic? This is very doubtful,
since the Irish Republic hardly has a significant immigrant population. Linked to this reference to African children in the UK is the question of
nutrition since clearly their nutritional status must have improved by
virtue of being in the United Kingdom. Aids experts accept the role of
nutrition in improving the immune status of individuals.
Fourthly, a reference to social class may have been relevant. Why was
this not done? In the UK the Registrar General has a fairly comprehensive
social classification system and a reference to this might have been
It is accepted that in drug trials, the randomised control trial
remains the Gold Standard. In this article there is no reference at all
to this and as such the results drawn from the study are questionable. In
this issue of The BMJ, the declining number of randomised trials is
alluded to – in particular those trials that are not sponsored by drug
companies. “The number of randomised controlled trials supported by the
main non-commercial funding sources is declining. Chalmers and colleagues
(p1017) surveyed 1464 randomised controlled trials in the United Kingdom.”
2 In conclusion therefore we are of the view that the claims made by DM
Gibb, T Duong et al that there is a decline in mortality amongst HIV-1
infected children in the United Kingdom and Ireland is grossly flawed and
1. Mandelbrot L, Le Chenadec J et al (1998) Perinatal HIV-1 transmission –
Journal of the American Medical Association 280:55-60.
2. Chalmers I, Rounding C, Lock K. Descriptive survey of non-commercial
randomised controlled trials in the Untied Kingdom 1980 – 2002. BMJ Vol
Prof. SWP Mhlongo MBBS, MSc, LRCP, MRCS (London), MRCGP(UK)
Chief Specialist / Chief Family Practitioner,
Department of Family Medicine & Primary Health Care,
Dr. PMH Maduna
MBChB (Natal); M Prax Med (Medunsa)
Principal Specialist, Family Medicine & Primary Health Care
Competing interests: No competing interests