Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland

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
transmissible.

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
ARV therapy.

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
practice.

References

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:
1019-1031.

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:
None declared