Pediatric HIV care: great progress through PMTCT, but increased efforts needed on testing and treatment

Dr. Helena Rabie
SHARE staff

Prevention of mother-to-child transmission of HIV (PMTCT) programs have been incredibly successful across southern Africa. However, presentations at the second day of the Southern African HIV Clinicians Society Conference highlighted important gaps in pediatric testing and treatment.

National South African data on pediatric HIV testing shows almost 100% coverage of infants at birth, but because most HIV infections among infants now occur postnatally, it is crucial subsequent testing takes place. Nevertheless, national data shows poor implementation of testing at 18 months, despite the fact that it has been in the country’s guidelines for many years. This is complicated by guidance to test children after cessation of breastfeeding – which may be different for each mother. These factors, combined with poor linkage to care, result in high rates of undiagnosed HIV-infected children, said Dr. Gayle Sherman of the Department of Pediatrics and Child Health at the University of the Witwatersrand. Polymerase chain reaction (PCR) testing is more expensive than HIV rapid testing, so children often have to “earn” a test, she added. In addition, there are increasing diagnostic challenges, as children are exposed to antiretrovirals (ARVs) in utero, through breastfeeding and by receiving infant prophylaxis – resulting in issues such as indeterminate PCR results due to inadequate test sensitivity.

Following on from this, Dr. Helena Rabie of Stellenbosch University and Tygerberg Children’s Hospital addressed the specific issues related to antiretroviral treatment (ART) regimens among children who have been diagnosed. We need doses and formulations for all ages, she said, as child size (algometric scaling) and physiology (age and gestation) change over time. In addition, ARV formulations (liquid or solid form) can have different effects. Considerations for regimen changes should include babies born prematurely, dose increases based on weight, available formulations, treatment simplification, and experiences of acute toxicity. Dr. Rabie reviewed the treatment options for children, observing that getting a pediatric ARV formulation to market can take many years, long after the same drug is available to adults. She recommended resources such as the South Africa HIV/TB Hotline (available as an app) and AIDSinfo. “We need to future-proof pediatric ART regimens and listen to our patients when planning treatment switches,” Dr. Rabie stressed. “We need to pay attention to detail to make good decisions for children on treatment, because the decisions we make today will impact them in 20 years’ time.”

Optimizing pediatric HIV formulations is an important component in ensuring children receive the best treatment available, explained Carol Ruffell of the Drugs for Neglected Diseases initiative (DNDi). She reviewed evidence from the LIVING study evaluating Lopinavir/Ritonavir (LPV/r) pellets as a new formulation for children, which recorded notable improvements in viral load suppression and immune system reconstitution regardless of prior ART regimen. The prospective, multi-country study, which was conducted in East Africa with 354 participants, included a qualitative component to assess the acceptability of the pellets, finding that the ease of administration, storage, and packaging – as well as taste (quick administration of the pellets in a food mix is best) – are important to promote treatment adherence.

While we are close to eliminating mother-to-child transmission, there’s still crucial work to be done in preventing postnatal infections among children, and providing the best care and treatment for those who are infected.