A Matter of Life and Death

Children with AIDS are dying needlessly because of a lack of suitable and adapted medicines, according to Medecins Sans Frontieres, the medical humanitarian organisation. A day before the opening of a paediatric AIDS summit organised by the World Health Organization and UNICEF in Geneva, MSF highlights experience that shows treating children with HIV/AIDS is much more expensive and difficult than treating adults.

Simplified ways to treat HIV/AIDS in adults have become available to patients in developing countries within the past year. Most adult patients in developing countries now take either a triple fixed-dose combination treatment - one pill twice a day - or one double combination plus a third drug. But neither the triple nor double combinations are available in dosages for children. When childhood doses are available, they come at a premium. It can cost over six times more to treat a child than to treat an adult - US$1,300 versus US$200 per year (for a 14-kg patient taking three different syrups).

"Since companies do not make easy-to-use triple drug combinations for children, I do what most doctors are doing: I try to show caregivers such as grandparents how to crush and break adult tablets, hoping that the children will get the doses they need," said Dr Koen Frederix, a paediatrician working for MSF in Malawi. "Small children can't swallow tablets so they have to use different syrups in different quantities, which complicates treatment."

There is only a weak global market in paediatric AIDS drug formulations: in wealthy countries relatively few children are being born with HIV, while developing countries are often simply too poor. Consequently, drug companies have little interest in developing or marketing paediatric formulations adapted to poor countries, such as fixed-dose combinations or breakable or chewable tablets.

The only hope on the horizon is that some companies may choose to develop fixed-dose combinations or adapted formulations for children. Some ongoing studies are looking at once-daily tablets for children. However, without the lure of a lucrative market, companies are not allocating enough resources to make quick progress.

MSF urges the WHO, UNICEF and national governments to document the extent of this crisis and to lead the charge to overcome the lack of a market for AIDS drugs for children.

"As the UN's children's agency, UNICEF should sound the alarm," said Daniel Berman, HIV/AIDS coordinator for MSF's Campaign for Access to Essential Medicines. "This week the experts will meet to identify the gaps. But to really make an impact, international organizations and national programmes will need to work proactively with governments and drug companies to overcome the lack of commercial interest in AIDS drugs for children."

MSF began treating children with ARVs in December 2000. By mid-2004, about 5% of MSF patients on antiretroviral treatment were children under 13. MSF is committed to doing better for children but the efforts of our doctors have been frustrated by the lack of proper tools.

MSF teams have created innovative tools to support health care providers in prescribing ARVs and supporting adherence in children, such as health diaries, treatment calendars, and fairy tales about "Devimmon", a witch that is a metaphor for HIV, in an effort to help children understand and adhere to treatment.

The estimated worldwide number of children with HIV/AIDS was over 2.5 million in 2003. In the same year, 700,000 children under the age of 15 were newly infected with HIV/AIDS, 88.6% of whom live in sub-Saharan Africa. Approximately 50% of children with HIV/AIDS die before the age of two.



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