On a mission to prevent HIV among children
Doctor credits screening of mothers with reduced transmission of the disease
Published 12:48 pm, Wednesday, March 20, 2013
The HIV care community was rocked in early March by the announcement that a Mississippi doctor's aggressive, early treatment of an infected baby, now 21/2, "cured" her, a pediatric first. Chronicle reporter Todd Ackerman talked to Dr. Mark Kline, architect of Baylor College of Medicine's Peace Corps-like initiative providing HIV treatment to children in Africa and Romania and one of the world's foremost pediatric AIDS experts, about the supposed breakthrough.
Q: What was your reaction to the Mississippi case?
A: I think the case was grossly overstated, the use of the word "cure" really unfortunate. I don't think we can assume that the therapy given to this baby, beginning at 30 hours, played a role in the subsequent course that's been observed. I don't think this is a cure. I think it's one of these unusual cases we see from time to time where a baby's immune system holds the virus in check.
Q: How common are such patients?
A: I have a 22-year-old patient, born with HIV, who has never had treatment because his immune system has kept the infection in check all that time. I have many other patients who have made it to 11, 12, 14 years of age without therapy, with the infection well in check. If I'd treated my 22-year-old patient with highly active antiretroviral therapy, I could have written a case report that early aggressive treatment put the infection into check and that we should do that with everyone. And that would have been wrong.
They're unusual cases. They're the exception, not the rule. But they do occur.
Q: How frequent is the transmission of the HIV virus from mother to baby?
A: Even without any treatment, it's not very frequent. Before we had anything to offer pregnant women with HIV or their babies, pre-1985, only 20 to 25 percent acquired HIV. So 75 to 80 percent of babies escape infection.
Q: Had no one ever done this before, treat a 30-hour-old baby with aggressive therapy?
A: People have done it. These doctors just put it out there. I don't have a quarrel with the decision by Dr. (Hannah) Gay, after weighing the risks and benefits, to start therapy so soon if she thought it was a particularly high-risk case. I might not have done it, but I don't particularly question it. My concern is the way they put it out there – creating a press release, appearing on NBC, ABC, CBS and CNN to say we gave the baby treatment and think it led to a cure, think this should be used for other babies. That's a real leap.
Q: And yet the case was lapped up, not just by the media, but by pediatric AIDS experts.
A: It was. I was surprised at the number of people who jumped on the bandwagon. I just wasn't one of them. I've gotten correspondence from clinicians around the world, from South Africa, Europe and other places, asking whether they should start treating every baby born to mothers with HIV with this regimen and stop therapy on babies not showing symptoms? The implications of what these doctors put out are pretty extensive.
Q: How have existing strategies changed outcomes?
A: In 1995, I was seeing three or four newly infected babies a month at Texas Children's. We now see maybe one case a year. That's a direct consequence of screening, treatment of moms and preventive therapy of babies. Nationwide, the numbers have dropped from 1,000 new cases a year to 100. We're never going to get absolutely everybody, but we could largely eliminate pediatric HIV and AIDS today if we redoubled our efforts to screen pregnant women for HIV.
Q: How about in the Third World?
A:In Botswana, where our clinic's been open 10 years, both the number of babies born with HIV and the rate of transmission have absolutely plummeted under the strategy used in the United States. New infections among babies have declined 60 percent from 2000 to 2010 and the percentage of infants born HIV infected has declined from 21 percent to 4 percent.
The World Health Organization estimates the 50 to 60 percent of pregnant women in the developing world have access to treatment. So, yes, that leaves 40 to 50 percent without access, but those are the very places where the sort of approach used in Mississippi would be completely impractical. In places where you've had so little success rolling out treatment for pregnant women, how much success are you going to have rolling out treatment for babies in the first 24 hours of life?
Q: So this supposed breakthrough isn't even worth a clinical trial?
A: I wouldn't have a particular quarrel with a trial, but I think the ethics will need to be debated very thoroughly. There's going to have to be very careful monitoring and safeguards put in place. Unlike their single case, most babies enrolled would be uninfected with HIV. You'd be exposing them to these medications and hoping they don't suffer some adverse event.