In the 20 sub-Saharan African countries with the highest pediatric HIV burden, the proportion of HIV-positive children receiving ART rose from 24% in 2012 to 44% in 2016 as countries adopted new WHO guidelines on treatment, according to a newly published CDC analysis.
That left approximately 750,000 HIV-positive children in these high-burden countries without treatment in 2016 — showing that, although progress has been made in starting and maintaining children on ART, a large coverage gap still exists, researchers said.
“Robust pediatric HIV testing and comprehensive ART programs are needed to ensure that all children with HIV infection are identified and initiated on ART as early as possible,” Amanda Burrage, MD, Epidemic Intelligence Service officer in the CDC’s Division of Global HIV and Tuberculosis, and colleagues wrote in MMWR. “Further evaluation might identify challenges to implementation of ART guidelines and help rapidly address this gap in pediatric ART coverage to further reduce morbidity and mortality among children with HIV infection.”
WHO guidelines published in 2016 expanded the recommended age for pediatric ART initiation to include all HIV-positive children aged younger than 15 years after previous guidelines recommended initiation in children aged younger than 2 years in 2010 and younger than 5 years in 2013. According to Burrage and colleagues, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) has supported ART for children since 2003, and PEPFAR-supported countries have adjusted their national guidelines for pediatric HIV treatment to align with that of WHO. To understand the lag between the development of these national guidelines and implementation of ART, the researchers said they assessed national guidelines in the 20 PEPFAR-supported countries in sub-Saharan Africa with the highest pediatric HIV burden and analyzed UNAIDS data on the number of HIV-positive children aged younger than 15 years who are on ART.
According to their research, by 2015, all 20 countries had adopted the 2013 WHO guidelines recommending ART for all children aged younger than 5 years. By 2016, 13 of the 20 countries had adopted the 2016 guidelines expanding the recommendation to include all children aged younger than 15 years.
Meanwhile, although overall ART coverage in children increased in all but one of the countries from 2012 to 2016, it remained below 50% in at least 11 and was as low as 5% in South Sudan, Burrage and colleagues reported. They noted several obstacles to expanding coverage, including delays in implementation of the latest guidelines, challenges to secure funding and medicine and the need to train medical staff.
“Although prompt adoption and implementation of expanded ART eligibility is required for improved pediatric ART coverage, attention to other key components of the HIV treatment cascade is critical,” Burrage and colleagues wrote. “Identification of all children with HIV infection is fundamental; therefore, active case finding is essential to identify undiagnosed children with HIV infection included in the UNAIDS estimates.
“Prompt linkage to care (ideally, with availability and initiation of same-day ART) is also required to initiate ART for patients with newly diagnosed HIV infection. Lastly, community-based retention and adherence support are necessary to help maintain children with HIV infection on ART; patient tracking might help initiate ART for previously ineligible children or those lost to follow-up.” – by Gerard Gallagher
Burrage A, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.mm6719a4.
Disclosures: The authors report no relevant financial disclosures.