Applying National Guidelines on ART - ART for Children

Authors: Louise Kuhn, PhD
Editor In Chief: Ian M. Sanne, MBBCH, FCP(SA) (More Info)

Last Reviewed: July 8, 2016 (What's New)

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Introduction

Vertically transmitted HIV—whether in utero, during labour, or postpartum through breast-feeding—is responsible for almost all HIV infections in infants and children. Other rare causes of paediatric HIV include sexual abuse or exposure to HIV through inadequately sterilised surgical instruments in healthcare facilities or transmission during traditional rituals. The last sentinel survey showed that approximately 30% of pregnant women 15-49 years of age in South Africa were infected with HIV.[ZA NDOH Sentinel Survey 2012] This represented a relatively stable prevalence for the period 2007-2012 including a low of 29.3% in 2008 to a high of 30.2% in 2010. In 2005, slightly fewer than 50% of all pregnant women were routinely tested for HIV infection but by 2009, testing was virtually universal.[Barron 2013] Surveys of prevention of mother-to-child-transmission (PMTCT) programmes have documented the decrease in transmitted infections associated with identification of HIV infection during pregnancy and implementation of PMTCT.[Goga 2010; Goga 2012] The current South Africa National Department of Health HIV guidelines recommend that all pregnant or breast-feeding HIV-infected women start immediate lifelong antiretroviral therapy (ART) at diagnosis (Management Guidelines).[ZA NDOH HIV Tx 2015]

For more information about PMTCT programmes, click here.

The major risk factor for vertical transmission is lack of or late start of ART in the mother. Advanced maternal disease as indicated by high viral load or low CD4+ cell count is also a strong risk factor for transmission especially in the absence of antiretroviral therapy.[Mofenson 1999; WHO 2007] Other risk factors have been identified that are pertinent only to transmission through certain routes. Preterm delivery is strongly associated with intrapartum transmission, particularly with prolonged rupture of membranes.[Kuhn 1999] The risk is also increased with premature birth. For breast-fed infants, exclusive breast-feeding during the first 6 months can reduce the risk of HIV transmission and also reduces the risk of breast problems, such as mastitis and cracked nipples, that can increase the risk of HIV transmission.[WHO 2007]

In 2010 approximately 3.5% of HIV-exposed infants in South Africa were HIV positive at 6 weeks postpartum,[Goga 2010] indicating a remarkable success in implementing PMTCT programmes in South Africa. The percentage dropped to 2.7% by 2011.[Goga 2012] Despite this success, the number of HIV-positive women giving birth every year in South Africa remains high and, even with this low transmission rate, an estimated 10,000 new cases of vertically transmitted infant HIV infections occur in South Africa every year.[UNAIDS AIDSinfo 2014] In addition, the large numbers of children who acquired HIV infection before the availability of effective PMTCT continue to need adequate care.

The approach to paediatric HIV disease is not limited to the management of HIV-infected infants and children, for whom the course of infection and treatment differs in some respects from adults. It also requires rigorous attention to essential care for infants who have been perinatally exposed to HIV, including those who do not become infected.

Untreated HIV infection in an infant is associated with a poor prognosis. Before broad access to antiretroviral therapy, fewer than one half of children with vertical HIV infection were expected to reach their fifth birthday.[Newell 2004; Brahmbhatt 2006] This statistic has dramatically improved over the ART era. In a study of all children born between January 2000 and January 2007 in the Africa Centre Demographic Surveillance Area, infant mortality (earlier than 5 years of age) declined by 49% from 69.0 in 2000 to 35.5 in 2006 deaths per 1000 person-years observed; a significant decline was observed particularly in the years 2004-2006. Mortality in children of mothers on ART was not significantly different from children of HIV-negative mothers.[Ndirangu 2014] A 2012 pooled analysis of all prevention of mother-to-child HIV transmission trials indicated that the time of HIV acquisition may affect survival of HIV-infected children.[Becquet 2012] The risk of early death is higher among children acquiring HIV infection perinatally than those acquiring HIV through breast milk, with mortality risks of 60% and 36%, respectively, by 18 months after HIV acquisition.[Becquet 2012] The high rates of mortality highlight the necessity of preventing vertical transmission to improve survival in these children.