30 Years of Pediatric HIV/AIDS Treatment: A Time of Breakthroughs, Innovation

Abstract

Stanford T. Shulman, MD, moderator: We now will discuss the human immunodefi ciency virus and AIDS. Ram Yogev, MD, is an international leader in HIV, specifi cally pediatric HIV. Ram Yogev, MD: This disease was fi rst noticed in 1981 in the United States, which is only 30 years ago. Interestingly, there is evidence that the disease originated in Africa. There is also a possibility that it had been identifi ed in the United States back in the 1960s, although we didn’t know too much about it at that time. It fi rst appeared in homosexual men and then in IV drug users, and unfortunately, that brought a lot of stigma to it. Many physicians were even reluctant to take care of these patients, and they even suggested that they should not be allowed in the hospital. The real breakthrough in this disease in pediatrics was about 5 or 6 years after it was discovered. The fi rst treatment was approved, which was azidothymidine (AZT). This drug was originally investigated for the treatment of cancer. However, it was not effective for cancer, and it was put on the shelf. Luckily enough, someone remembered it, and began suggesting its use. That really led to major changes to our approach to treatment. One of the biggest successes of all the funding in research is the study, conducted by the Pediatric AIDS Clinical Trials Group (PACTG), sponsored by the NIAIA/NIH, at several study sites, which showed that AZT reduces the risk of HIV transmission from infected mother to the children.1 The study showed that treatment with AZT alone can reduce mother-to-child transmission of the disease by two-thirds. Recently, a few states (eg, New York, Connecticut, Illinois) made it mandatory to test if the newborn is infected, and they reported close to 100% lack of transmission from mother to child. The next breakthrough was in the 1990s, when more drugs came to the market. These drugs attack the virus and when it enters the cell, or the way it comes out of the nucleus and when it replicates itself. The fi rst protease inhibitor was a major breakthrough. The availability of the family of protease inhibitors led to three different drugs from at least two different families, called HAART (Highly Active Antiretroviral Therapy). HAART made the difference between an acute disease, which in children had a 60% mortality rate by 6 years of age, to a life expectancy of 40 or 50 years. Obviously, there are side effects of these drugs. We have problems with patient adherence, but the future for those patients looks very bright compared with what it was 20 years ago. Dr. Shulman: Dr. Yogev wrote an editorial, which starts out by saying that when he started his career in treating patients with HIV, he attended their funerals.2 Now, he’s able to attend their grade school, high school, and college graduations. I think that encapsulates the incredible progress made in the treatment of pediatric HIV infection. Dr. Yogev: That editorial was written because there were small studies suggesting that at least in pediatrics, if we start treatment in the fi rst 3 months of life, we’re changing the course of the disease so much that the patients are losing their antibodies.3,4 A study published about 2 years ago showed that within 1 year you can see the difference in the outcomes of patients who started treatment before 3 to 4 months of age and those who started it later.5 Sharon B. Murphy, MD: I’m prompted to refl ect that, coincident with your recollections of the epiA note from the editors: To commemorate the 40th anniversary of Pediatric Annals, the publishing staff invited the Editorial Advisory Board and some experts to discuss important advances in the fi eld of pediatrics over the past 40 years. Excerpts from this discussion, held in March 2011, will be published in the next several issues of Pediatric Annals. roundtable • roundtable • • roundtable • roundtable roundtable