A new dawn for antiretroviralsBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7487.371 (Published 10 February 2005) Cite this as: BMJ 2005;330:371
All rapid responses
Interesting to contrast the confidence of Booy et als letter with F Edward Yazbak's recent post 'The Infant Mortality Rate: An Index of a Nations Health' 11 February 2005 , which registers the fact that the world's wealthiest and most vaccinated nation, the USA, still suffers relatively high infant mortality:
"I am not suggesting that infants in the United States are dying at a higher rate than those in Cuba and the Faroe Islands because we are vaccinating them so much more. I am only making the simple observation that though we are spending enormous funds on health care and we are administering all these vaccines, it certainly does NOT appear that we are increasing our infants' chances of reaching their first birthday."
Ed Yazbak also has his own observations about Bill Gates's generosity, but in this context, surely the message is that at best it is a distraction from good nutrition, good sanitation, housing etc.
Competing interests: Parent of an autistic child
Competing interests: No competing interests
OUR PERSONAL RESPONSE
Gate’s SINGLE BEST INVESTMENT
Getting ‘HIV’ vaccines to those who need them?
Booy R, Chakraborty R, Shingadia D.
Centre for Child Health, Queen Mary’s school of Medicine and Dentistry; Dept of Paediatrics, St Georges Hospital Medical School, London
The Bill and Melinda Gates Foundation announced on January 25th that it plans to provide another $750 million to support children’s immunisation programs in developing countries, a repeat of their single best investment (1). The US government will contribute $15 billion for antiretroviral drug treatment initiatives in Sub-Saharan Africa. Rebecca Sutherland (BMJ Feb 12th) highlights the hope that ARV treatment now engenders. At a time when HIV infection has become pandemic in many African countries, which is the most cost-effective way of reducing infant and child mortality, and can these large sums of money effectively benefit the individuals who need the support most urgently?
In 2002 1.4 million children died of vaccine-preventable diseases, mostly in Sub-Saharan Africa. The Foundation’s money is directed at diseases for which the cost of vaccines is low including tetanus, polio, pertussis, measles and TB, where the cost per life gained is less than $1,000 (1). However there are 600,000 new cases of HIV infection in children annually, 90% of which occur in Sub-Saharan Africa where 500,000 children died of AIDS in 2001 alone (2).
Research from Kenya published recently in the New England Journal of Medicine has thrown this issue of prioritising what diseases to prevent into high relief. In a large study over 4 years involving 20,000 children admitted to a rural hospital, life-threatening bacteraemia was noted to have occurred in a minimum of 1 in 40 children within the district by the age of 5 years; 28% of bacteraemic children died and one-quarter of deaths in hospital were secondary to bacteraemia (c.f. 22% caused by malaria, a disease rated of priority for prevention). 18% of bacteraemic children were concurrently HIV-infected. Severe malnutrition was also independently associated with bacteraemia (3). The most common cause of bacteraemia was Streptococcus pneumoniae; 60% – 70% of all cases of pneumococcal bacteraemia may have been preventable by an effective, but expensive, vaccine (4). Of 308 deaths due to bacteraemia, 103 occurred on the day of admission to hospital (so most unlikely to be preventable by medical treatment) and half of these were due to S pneumoniae.
A vaccine against S pneumoniae is not used routinely for children anywhere in Africa although vaccination against another important cause of bacteraemia, Haemophilus influenza type b has begun in 5 countries (5). Currently a Pneumococcal Vaccines Accelerated Development and Introduction Plan is underway (6), using an ‘innovative approach designed to…help assure an affordable, sustainable supply of new pneumococcal vaccines’. A virtuous circle is envisaged whereby the uncertainty of demand for vaccine is reduced e.g. through purchasing vaccines in advance so making them cheaper through economies of scale. This principle is extolled by the UK’S Chancellor, Gordon Brown, but for development of an HIV vaccine (a goal that is almost certainly unattainable for another 10 years) as part of a new ‘Marshall Plan’.
Although the principle of an ounce of protection is worth more than a pound of cure is implicit in Brown’s plan, another key part of it is to increase investment in treatment of AIDS, Tuberculosis and Malaria. The cost of treatment per patient with AIDS considerably dwarfs the cost of the afore-mentioned pneumococcal vaccine; it is a ready immunoprophylactic answer to deadly infections of far more immediate relevance than the elusive AIDS vaccine. This brings us back to the issue of Gates’ single best investment. Perhaps the pneumococcal and H. influenza vaccines should be regarded as our best ‘HIV’ vaccine for the moment?
There is already a huge financial commitment to rolling out antiretroviral treatment for HIV/AIDS but even so, only the minority of the needy will get it. Recently, Rosen and colleagues discussed the hard choices involved in rationing treatment for HIV/AIDS. They outlined the many reasons why access to treatment is restricted including lack of testing facilities, geographic isolation and possible governmental decisions to restrict access to skilled workers who contribute more to economic health. Access of HIV-infected children to treatment is not explicitly discussed by Rosen et al nor in many ARV rollout programmes even though survival times are considerably shorter and 20% of all AIDS deaths globally occur in infants and children who acquire the virus perinatally or during infancy. Surviving children are often, stigmatized, and vulnerable orphans without advocates. Small wonder then that their needs may be overlooked (8).
Careful implementation and monitoring of ARV drugs using sustainable approaches and operational trials are urgently needed. These should be complemented by nutritional support, appropriate management and diagnosis of opportunistic infections, particularly tuberculosis, and immunoprophylaxis with efficacious vaccines. Developing suitable infrastructures that nurture these lofty goals remains a challenge to African governments and wealthy Western health-care organisations. Overcoming such political and financial barriers in resource-poor settings may prove as difficult as developing suitable prophylactic and therapeutic HIV vaccines.
1. Press release Jan 25 2005 http://www.komotv.com/news
2. UNAIDS 2001:http://www.unaids.org/epidemic_update/report/index.html
3. Berkley J A et al. Bacteraemia among children admitted to a rural hospital in Kenya New Engl J Med 2005; 352:39-47.
4. Klugman KP, Madhi SA et al. A trial of a 9-valent pneumococcal conjugate vaccine in children with and those without HIV infection N Engl J Med 2003; 349:1341-8.
5. Mulholland EK, Adegbola RA. Bacterial infections – a major cause of Death among children in Africa. N Engl J Med 2005; 352:75-7.
6. Levine OS, Cherian T, Shah R, and Batson A. PneumoADIP: an example of translational research to accelerate pneumococcal vaccination in developing countries J Health Popul Nutr. 2004; 22:268-74
7. Rosen S, Sanne I, Collier A, Simon JL. Hard Choices: rationing HIV therapy for HIV/AIDS in Africa Lancet 2005; 365: 354-56
8. Chakraborty R. Infections and other causes of death in HIV- infected children in Africa Paediatric respiratory Reviews 200; 5:132-139.
Competing interests: R.Booy has acted as a paid consultant for vaccine companies WYETH, GSK AND AVENTIS.
Competing interests: No competing interests