Editor—The claims by Gibb et al, that their evidence shows a decline in mortality of children with HIV/AIDS in the United Kingdom and Ireland (thanks to antiretrovirals), cannot go unchallenged.1 In their methods section they make little or no reference to the management of opportunistic infections. Furthermore, we have no idea how and where these children were delivered.
Figure 1.
Risk of AIDS/death or death by year relative to 1996
Were some of these children delivered by caesarean section? This may be important since some authors have asked whether the protective effect of caesarean delivery independent of zidovudine prophylaxis can be further investigated by a large, international, individual patient data meta-analysis of observational studies. A definitive answer to the question will require a randomised clinical trial, which is the only method to ensure that women who undergo an elective caesarean delivery do not differ from those with other types of delivery for any known or unknown confounding factor.2
Sixty seven per cent of the children in the paper by Gibb et al were of African parentage, but we are not given the dates when their parents entered the United Kingdom. Nutrition in Africa is known to be poor, whereas in the United Kingdom it is better and undoubtedly the immune status of these children must have been boosted.
A worrying trend alluded to in this issue of the BMJ is the decline in the number of randomised controlled trials.3 Gibb et al make no mention of this.
Competing interests: None declared.
References
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