The cost of laboratory analysis of CD4 lymphocyte count and viral-load assessment (conventional procedures in industrialised countries) is more expensive than the cost of antiretroviral drugs in some resource-poor settings. Lynne Mofenson from the US National Institutes of Health, and colleagues assessed the prognostic value of five measures (total lymphocyte count, immune complex-dissociated p24 antigen, white blood cell count, packed-cell volume, and blood albumin) for death in 376 HIV-1-infected children. The investigators found that total lymphocyte count and albumin independently predicted the risk of death in HIV-1-infected children of all ages.
Lynne Mofenson comments: "Use of one or more of these assays could serve as relatively inexpensive means to establish when to initiate antiretroviral therapy in children in settings where CD4 and RNA assays are not available. Total lymphocyte count remained predictive even when CD4 and RNA values were known."
In an accompanying Commentary (p1597), François Dabis from INSERM, France,concludes: "The urgency now is to start HAART in as many African HIV-infected children as possible because the disease burden is unacceptable. Children born to HIV-infected mothers who fail one of the interventions for peripartum mother-to-child transmission of HIV are an obvious target, assuming early diagnosis of paediatric HIV is widely implemented with the same low-cost technologies. Older children in the same families should also be offered diagnosis and treatment. Children's clinics could be another portal of entry for proposing HIV screening and starting treatment to more children. Finally, we should not forget that many HIV-infected children are particularly vulnerable and in need of treatment are orphaned. Reducing the proportion of infants infected by HIV by 20% by 2005 is not an easy target set by WHO, and requires that all solutions are implemented at the same time. Antiretroviral therapy of children is now clearly one of them for Africa."
Contact: Robert Bock, Public Information and Communications Branch, National Institute of Child Health and Human Development, National Institutes of Health;
Building 31 Room 2A32, MSC2425, Bethesda, MD 20892 USA;
Dr François Dabis, INSERM U593, Institut de Santé Publique, Epidémiologie et Développement, Université Victor Segalen;
33076 Bordeaux Cedex, France;
Lancet 2003; 362: 1597, 1625-27