Challenges to Pediatric HIV Care and Treatment in South Africa

Harriet Shezi Children's Clinic, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.
The Journal of Infectious Diseases (Impact Factor: 6). 01/2008; 196 Suppl 3(Suppl 3):S474-81. DOI: 10.1086/521116
Source: PubMed


It is estimated that almost 300,000 children in South Africa have human immunodeficiency virus (HIV) infection. The disease is responsible for reversing decreases in child mortality. Few data exist evaluating the outcomes of the prevention of mother-to-child transmission of HIV (PMTCT) program, although PMTCT coverage appears to be low. Hospitals are still witnessing large numbers of admissions of HIV-infected children. Postnatal transmission of HIV is high, reflecting poor education of and support for women in their infant feeding choices. Too few infants and children are entering care through early diagnosis, which should be widely available. Cotrimoxazole prophylaxis coverage is inadequate, contributing to high morbidity and mortality in infants. The number of children receiving antiretroviral therapy (ART) is increasing steadily. However, significant inequalities in access to ART exist between and within provinces. Challenges for pediatric ART include a lack of sufficiently trained health care personnel and inadequate facilities, as well as the complexity of drug regimens and formulations. The compartmentalization of the ART rollout program hinders PMTCT and makes it difficult for children to be identified and referred into appropriate services. This article delineates the challenges to pediatric HIV care in South Africa and provides some practical recommendations to improve it.

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Available from: Gayle Sherman, Jan 08, 2014
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    • "In Nigeria, like elsewhere,5–8 the provision of care and treatment for HIV-infected children is plagued with many challenges. Some of these challenges include: concerns about HIV disclosure to the child, orphanhood and vulnerability occasioned by HIV infection, lack of appropriate pediatric antiretroviral formulations, adherence to lifelong antiretroviral therapy (ART), shortage of skilled health personnel, and issues concerning retention of children in care and treatment programs.5–8 "
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    ABSTRACT: Background Optimal adherence to antiretroviral therapy (ART) and retention-in-care are essential in HIV management. Through a Kiddies’ Club (KC), the study aimed at assessing the impact of social leisures and psychosocial support on ART adherence and clinic attendance in a pediatric ART program. Methods This was a descriptive, longitudinal study, conducted at the Federal Medical Centre, Makurdi, Nigeria, from June 2011 to June 2012. It included 33 ART-experienced children and their caregivers. The study was supplemented with a qualitative focused group discussion, involving 12 discussants. ART adherence, clinic attendance, and clinical and immunoviralogical responses of the children to ART were noted at 6 months and at 12 months of follow-up. Results The children comprised 17 males and 16 females, with a median age of 5 years. Financial constraint was the most common reason given for losses to follow-up in quantitative (32/33, 96.9%) and qualitative (12/12, 100.0%) assessments. But, unavailability of means of transportation may still override the benefit that financial assistance can provide, as reported in the qualitative study. The baseline mean hemoglobin level (8.50 g/dL), median CD4 count (187.00 cells/mm3); median weight for height z-score (−0.395), and the median body mass index (15.40) increased significantly to respective values of 10.03 g/dL, 1,030.00 cells/mm3, −0.090, and 18.50, at 6 months (P-values: 0.000), and 10.47 g/dL, 1,203.00 cells/mm3, 0.420, and 19.20, at 12 months (P-values: 0.000). The baseline median viral load (45,678.00 copies/mL) also decreased significantly, to 200.00 copies/mL at 6 months and at 12 months (P-values: 0.000). There was no attrition from death or loss to follow-up, and adherence to ART was 100%, at 6 months and at 12 months of follow-up. Conclusion Through the KC, children were retained in care, with excellent adherence to ART, and good clinical and immunoviralogical responses to ART, even after being previously lost to follow-up.
    Full-text · Article · Aug 2014 · HIV/AIDS - Research and Palliative Care
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    • "The challenge of long-term adherence to ART in children gives rise to the potential for the emergence of drug resistance leading to treatment failure [7,8]. In resource–limited settings, there are challenges to the implementation, long-term effectiveness and sustainability of ART programmes where limited laboratory capacity to monitor treatment effectiveness and a lack of paediatric antiretroviral (ARV) formulations are notable restrictions [9]. There is some evidence that outcomes for children in rural areas of South Africa are poorer than those in urban areas [10]. "
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    ABSTRACT: Better understanding of drug resistance patterns in HIV-infected children on antiretroviral therapy (ART) is required to inform public health policies in high prevalence settings. The aim of this study was to characterise the acquired drug resistance in HIV-infected children failing first-line ART in a decentralised rural HIV programme. Plasma samples were collected from 101 paediatric patients (<=15 yrs of age) identified as failing ART. RNA was extracted from the plasma, reverse transcribed and a 1.3 kb region of the protease gene was amplified and sequenced using Sanger sequencing protocols. Sequences were edited in Geneius and drug resistance mutations were identified using the RegaDB and the Stanford, Rega and ANRS resistance algorithms. The prevalence and frequency of mutations were analysed together with selected clinical and demographic data in STATA v11. A total of 101 children were enrolled and 89 (88%) were successfully genotyped; 73 on a non-nucleoside reverse-transcriptase inhibitor (NNRTI)-based regimen and 16 on a protease inhibitor (PI)-based regimen at the time of genotyping. The majority of patients on an NNRTI regimen (80%) had both nucleoside reverse-transcriptase inhibitor (NRTI) and NNRTI resistance mutations. M184V and K103N were the most common mutations amongst children on NNRTI-based and K103N among children on PI-based regimens. 23% had one or more thymidine analogue mutation (TAM) and 6% had >=3 TAMs. Only one child on a PI-based regimen harboured a major PI resistance mutation. Whilst the patterns of resistance were largely predictable, the few complex resistance patterns seen with NNRTI-based regimens and the absence of major PI mutations in children failing PI-based regimens suggest the need for wider access to genotypic resistance testing in this setting.
    Full-text · Article · Jan 2014 · AIDS Research and Therapy
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    • "The median age of infants starting ART in 2010 was 5.6 months which is well above the median age of <2 months in the immediate arm of the CHER Study. There are a number of barriers to early ART initiation including lack of access to HIV-DNA PCR testing for diagnosis [24], [47], [48], [49], poor integration of antenatal, PMTCT, maternal and child health (MCH) and HIV services with poor infant HIV testing even among those whose mothers enrolled in PMTCT care [50], lack of expertise, experience and confidence with initiating and maintaining infants on ART and poor availability of drugs in suitable formulations for infants [4], [51]. Strategies to improve ART access for infants such as integration of PMTCT, MCH and HIV services and provider initiated testing at vaccination and other health visits [45], [52], [53], [54] need to be developed and expanded. "
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    ABSTRACT: Since 2005, increasing numbers of children have started antiretroviral therapy (ART) in sub-Saharan Africa and, in recent years, WHO and country treatment guidelines have recommended ART initiation for all infants and very young children, and at higher CD4 thresholds for older children. We examined temporal changes in patient and regimen characteristics at ART start using data from 12 cohorts in 4 countries participating in the IeDEA-SA collaboration. Data from 30,300 ART-naïve children aged <16 years at ART initiation who started therapy between 2005 and 2010 were analysed. We examined changes in median values for continuous variables using the Cuzick's test for trend over time. We also examined changes in the proportions of patients with particular disease severity characteristics (expressed as a binary variable e.g. WHO Stage III/IV vs I/II) using logistic regression. Between 2005 and 2010 the number of children starting ART each year increased and median age declined from 63 months (2006) to 56 months (2010). Both the proportion of children <1 year and ≥10 years of age increased from 12 to 19% and 18 to 22% respectively. Children had less severe disease at ART initiation in later years with significant declines in the percentage with severe immunosuppression (81 to 63%), WHO Stage III/IV disease (75 to 62%), severe anemia (12 to 7%) and weight-for-age z-score<-3 (31 to 28%). Similar results were seen when restricting to infants with significant declines in the proportion with severe immunodeficiency (98 to 82%) and Stage III/IV disease (81 to 63%). First-line regimen use followed country guidelines. Between 2005 and 2010 increasing numbers of children have initiated ART with a decline in disease severity at start of therapy. However, even in 2010, a substantial number of infants and children started ART with advanced disease. These results highlight the importance of efforts to improve access to HIV diagnostic testing and ART in children.
    Full-text · Article · Dec 2013 · PLoS ONE
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