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      Early Initiation of Antiretroviral Therapy Among Young Children: A Long Way to Go

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          Abstract

          To the Editors: The article by Koller et al1 is a welcome effort to document trends and determinants of immunodeficiency among children living with HIV starting combination antiretroviral therapy (cART) in low-, middle-, and high-income countries and highlights the very modest improvements in the stage at which children begin cART. The article raises several questions which would benefit from further consideration. Interpreting the findings in this article would be enhanced if there was more information about the sites within each country that contributed data such as how many sites, what level of care were they (clinic or hospital), public or private, nongovernmental or research-based service settings, and rural or urban areas. Without this level of detail on the sites, it is difficult to determine whether these results represent “best case” scenarios, and consequently the situation in “non-international epidemiologic databases to evaluate AIDS (IeDEA)” sites is likely to be much worse. According to the IeDEA Web site (http://www.iedea-sa.org), the main criterion for clinics to participate in the IeDEA collaboration is that a clinic treats people with HIV and prospectively and electronically collects clinical data. In low- and middle-income country (LMIC) settings, this inclusion criterion would likely have limited the sample of facilities to those receiving some donor or research support. Routine health information systems in many LMIC countries have been characterized as weak,2,3 and it is unlikely that electronic data would be the norm for national health management information systems in these settings.3,4 Using the group of upper-middle income countries as an example, 83% of the sample comes from 1 country, South Africa, where all except 1 IeDEA site is situated in the metropolitan areas of Cape Town and Johannesburg, the exception being a clinic in Hlabisa, KwaZulu-Natal, which is a rural demographic surveillance site. The finding that around 63% of children in these research sites in South Africa started cART with severe immunodeficiency is concerning because the situation is likely to be considerably worse in general public health facilities without additional research support and without electronic prospective tracking systems. Similarly, 82% of the sample for the lower middle-income countries comes from Zambia, and within Zambia from 1 nongovernmental organization (Centre for Infectious Disease Research in Zambia), situated in Lusaka. Although the findings are important in improving our knowledge of the progress with access to pediatric cART, having clear information on the source of the data is also critical to improve the utility of the findings for national governments and health managers. We agree with the conclusion of Koller et al1 that early diagnosis of HIV in children must remain a global public health priority, and we have shown it is still a major missed opportunity in South Africa.5 We highlight, though, an important issue affecting initiation of cART among children, which is not discussed in this article, the notion of pediatric HIV disease and treatment as a neglected disease.6 Although there is evidence of a worldwide decline in vertical HIV transmission, a high number of children still become infected with HIV.7 In a country such as South Africa where there have been significant declines in perinatal HIV transmission,8 The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 16,000 (95% confidence interval: 14,000 to 19,000) children 0–14 years were newly infected in 2013.7 Given the complexity of pediatric HIV treatment, it is not surprising that there is late initiation of cART during the first years of life. Treatment options are still overlooked, particularly for the youngest children who are unable to take tablet formulations. Unlike for adults where fixed-dose combinations of ARVs are available, children younger than 5 years have to use liquid formulations and caregivers have to measure before administering each dose twice a day.9 Drugs produced by different companies vary in bottle size and special storage needs. Some carry unpleasant tastes and risks of toxicity.10 Dosage adjustments depending on weight are needed up to 3 times in the first year of life alone. Procurement of pediatric drugs is complex and forecasting of demand is difficult with a market only a fraction of the size of the adult market. This also leads to prices twice as expensive as the adult equivalents.11 We propose that unless more child-friendly formulations are developed, late cART initiation of children is likely to continue. It is also likely that the situation will be even worse in busy nonresearch health settings in LMICs.

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          Most cited references 6

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          Challenges for Routine Health System Data Management in a Large Public Programme to Prevent Mother-to-Child HIV Transmission in South Africa

          Background Recent changes to South Africa's prevention of mother-to-child transmission of HIV (PMTCT) guidelines have raised hope that the national goal of reducing perinatal HIV transmission rates to less than 5% can be attained. While programmatic efforts to reach this target are underway, obtaining complete and accurate data from clinical sites to track progress presents a major challenge. We assessed the completeness and accuracy of routine PMTCT data submitted to the district health information system (DHIS) in three districts of Kwazulu-Natal province, South Africa. Methodology/Principal Findings We surveyed the completeness and accuracy of data reported for six key PMTCT data elements between January and December 2007 from all 316 clinics and hospitals in three districts. Through visits to randomly selected sites, we reconstructed reports for the same six PMTCT data elements from clinic registers and assessed accuracy of the monthly reports previously submitted to the DHIS. Data elements were reported only 50.3% of the time and were “accurate” (i.e. within 10% of reconstructed values) 12.8% of the time. The data element “Antenatal Clients Tested for HIV” was the most accurate data element (i.e. consistent with the reconstructed value) 19.8% of the time, while “HIV PCR testing of baby born to HIV positive mother” was the least accurate with only 5.3% of clinics meeting the definition of accuracy. Conclusions/Significance Data collected and reported in the public health system across three large, high HIV-prevalence Districts was neither complete nor accurate enough to track process performance or outcomes for PMTCT care. Systematic data evaluation can determine the magnitude of the data reporting failure and guide site-specific improvements in data management. Solutions are currently being developed and tested to improve data quality.
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            First population-level effectiveness evaluation of a national programme to prevent HIV transmission from mother to child, South Africa

            Background There is a paucity of data on the national population-level effectiveness of preventing mother-to-child transmission (PMTCT) programmes in high-HIV-prevalence, resource-limited settings. We assessed national PMTCT impact in South Africa (SA), 2010. Methods A facility-based survey was conducted using a stratified multistage, cluster sampling design. A nationally representative sample of 10 178 infants aged 4–8 weeks was recruited from 565 clinics. Data collection included caregiver interviews, record reviews and infant dried blood spots to identify HIV-exposed infants (HEI) and HIV-infected infants. During analysis, self-reported antiretroviral (ARV) use was categorised: 1a: triple ARV treatment; 1b: azidothymidine >10 weeks; 2a: azidothymidine ≤10 weeks; 2b: incomplete ARV prophylaxis; 3a: no antenatal ARV and 3b: missing ARV information. Findings were adjusted for non-response, survey design and weighted for live-birth distributions. Results Nationally, 32% of live infants were HEI; early mother-to-child transmission (MTCT) was 3.5% (95% CI 2.9% to 4.1%). In total 29.4% HEI were born to mothers on triple ARV treatment (category 1a) 55.6% on prophylaxis (1b, 2a, 2b), 9.5% received no antenatal ARV (3a) and 5.5% had missing ARV information (3b). Controlling for other factors groups, 1b and 2a had similar MTCT to 1a (Ref; adjusted OR (AOR) for 1b, 0.98, 0.52 to 1.83; and 2a, 1.31, 0.69 to 2.48). MTCT was higher in group 2b (AOR 3.68, 1.69 to 7.97). Within group 3a, early MTCT was highest among breastfeeding mothers 11.50% (4.67% to 18.33%) for exclusive breast feeding, 11.90% (7.45% to 16.35%) for mixed breast feeding, and 3.45% (0.53% to 6.35%) for no breast feeding). Antiretroviral therapy or >10 weeks prophylaxis negated this difference (MTCT 3.94%, 1.98% to 5.90%; 2.07%, 0.55% to 3.60% and 2.11%, 1.28% to 2.95%, respectively). Conclusions SA, a high-HIV-prevalence middle income country achieved <5% MTCT by 4–8 weeks post partum. The long-term impact on PMTCT on HIV-free survival needs urgent assessment.
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              Missed Opportunities for Early Infant HIV Diagnosis: Results of A National Study in South Africa

              Background: Services to diagnose early infant HIV infection should be offered at the 6-week immunization visit. Despite high 6-week immunization attendance, the coverage of early infant diagnosis (EID) is low in many sub-Saharan countries. We explored reasons for such missed opportunities at 6-week immunization visits. Methods: We used data from 2 cross-sectional surveys conducted in 2010 in South Africa. A national assessment was undertaken among randomly selected public facilities (n = 625) to ascertain procedures for EID. A subsample of these facilities (n = 565) was revisited to assess the HIV status of 4- to 8-week-old infants receiving 6-week immunization. We examined potential missed opportunities for EID. We used logistic regression to assess factors influencing maternal intention to report for EID at 6-week immunization visits. Results: EID services were available in >95% of facilities and 72% of immunization service points (ISPs). The majority (68%) of ISPs provide EID for infants with reported or documented (on infant's Road-to-Health Chart/booklet—iRtHC) HIV exposure. Only 9% of ISPs offered provider-initiated counseling and testing for infants of undocumented/unknown HIV exposure. Interviews with self-reported HIV-positive mothers at ISPs revealed that only 55% had their HIV status documented on their iRtHC and 35% intended to request EID during 6-week immunization. Maternal nonreporting for EID was associated with fear of discrimination, poor adherence to antiretrovirals, and inadequate knowledge about mother-to-child HIV transmission. Conclusions: Missed opportunities for EID were attributed to poor documentation of HIV status on iRtHC, inadequate maternal knowledge about mother-to-child HIV transmission, fear of discrimination, and the lack of provider-initiated counseling and testing service for undocumented, unknown, or undeclared HIV-exposed infants.
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                Author and article information

                Journal
                J Acquir Immune Defic Syndr
                J. Acquir. Immune Defic. Syndr
                qai
                Journal of Acquired Immune Deficiency Syndromes (1999)
                JAIDS Journal of Acquired Immune Deficiency Syndromes
                1525-4135
                1944-7884
                1 October 2015
                16 September 2015
                : 70
                : 2
                : e70-e71
                Affiliations
                [* ]Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
                []School of Public Health, University of the Western Cape, Cape Town, South Africa
                []Centre for International Health, University of Bergen, Bergen, Norway
                [§ ]School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
                QAIV15416 00023
                10.1097/QAI.0000000000000646
                4577609
                25886929
                Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

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