When should children with HIV infection be started on anti-HIV medications?
The advent of effective medications for treating HIV dramatically improved the outlook for both adults and children infected with HIV who had access to treatment, but the optimal timing for starting treatment remains controversial, particularly in children. A debate article in this week's PLoS Medicine lays out the case for deferred treatment against the case for early initiation of treatment in children infected with HIV.
In laying out the case for deferred treatment, Dr Steven Welch (Consultant in Paediatric HIV and Infectious Diseases, Heartlands Hospital, Birmingham, UK) says that, "it remains rational to consider an individual child's and family's wishes and circumstances as well as the child's risk of disease progression in deciding when to start treatment." The hasty and injudicious use of antiretroviral medications in children, he argues, risks creating a cohort that has learned poor adherence habits, is infected with multi-drug-resistant viruses, and has been exposed to unnecessary cumulative drug toxicities.
Arguing the case for early initiation, Professor Di Gibb (Professor in Epidemiology and a Consultant Paediatrician at the Medical Research Council Clinical Trials Unit, London, UK), says that "deferring treatment initiation for as long as possible is no longer an option." Professor Gibb lays out several reasons why she believes that early initiation is even more important in children than in adults--for example, children with HIV grow better if they receive antiretroviral medication.
Both authors point out that there has never been a clinical trial conducted on determining when to start antiretroviral medications in children, and they conclude by saying that the time has come to conduct such a trial.
Citation: Welch SB, Gibb D (2008) When should children with HIV infection be started on antiretroviral therapy" PLoS Med 5(3): e73.
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New approach to detecting epidemic outbreaks holds promise for developing countries
A new approach to monitoring infectious disease outbreaks using statistical algorithms as well as "pre-diagnostic" data--such as medication sales, patients' symptoms, and absenteeism from work--holds promise for improving public health security in developing countries, argue researchers in this week's PLoS Medicine.
The approach, known as "syndromic surveillance," is already being used in some of the world's rich countries. The researchers, led by Jean-Paul Chretien (Department of Defense Global Emerging Infections Surveillance and Response System, Silver Spring, Maryland, USA), argue in their PLoS Medicine article that "there is cause for optimism that syndromic surveillance approaches can feasibly be adapted to developing settings."
Dr Chretien and colleagues lay out four reasons for optimism. First, they say, these approaches fit naturally with and could enhance existing strategies for outbreak detection and "situational awareness" (such as monitoring outbreak distribution and spread, and characterizing affected populations) in tropical areas. Second, many Ministries of Health already require reporting of data that have proven useful for syndromic surveillance in high-income countries, such as International Classification of Diseases codes. Third, expanding access to communication networks and technology will facilitate rapid electronic data entry, reporting, and analysis in resource-limited areas. Finally, syndromic surveillance initiatives could dovetail with other efforts to improve health information, such as the Health Metrics Network, launched in 2005, which aims to increase the availability and use of timely and accurate health information by cat alyzing the joint funding and development of core country health information systems.
"By helping to rapidly detect and characterize unusual morbidity trends," say Dr Chretien and colleagues, "syndromic surveillance holds promise as an early line of defense against new and emerging infections in developing settings."
Citation: Chretien J-P, Burkom HS, Sedyaningsih ER, Larasati RP, Lescano AG, et al. (2008) Syndromic surveillance: Adapting innovations to developing settings. PLoS Med 5(3): e72.
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