Children and the NSP

Children and the NSP
Photo by Jon Lowenstein
(Photo by Jon Lowenstein)

It is critical that the success of the National Strategic Plan is also measured against its response to children.

There are a number of critical areas that need to be examined more closely when it comes to children. The summary points below capture some of the areas that need special and urgent attention.

Prevention of Mother-to-Child transmission (PMTCT)

New treatment drug regimens are now adopted for PMTCT. Currently regimens are Option B (triple antiretroviral therapy for all pregnant women until breastfeeding is complete) and in the Western Cape, Option B+ (immediate continuous antiretroviral therapy from pregnancy).

Researchers caution that there is poor ART adherence in pregnancy and this is confirmed by data from several African countries.

For infants, undiagnosed HIV in the mother reflects the greatest risk of vertical HIV transmission at birth.  In addition to a diagnostic PCR test at six weeks of age, more attention should be given if pregnant women have received sub-optimal treatment because they report to the clinic very late (beyond 20 weeks gestation) or if they missed any clinic appointments. Current polymerase chain reaction (PCR) testing at six weeks mainly identifies perinatal transmission – the HIV transmission that happens before or during birth. It is important for doctors to use their discretion and conduct these PCR tests at an earlier stage if some of the risk factors on the side of the mother are present.

With efavirenz part of the ART regimen for PMTCT, it is essential that data on neural tube defects in the babies be collected. Data on efavirenz safety in pregnancy is still limited. Similarly, growth data for tenofovir-exposed infants should be collected until at least two years of age.

Infant feeding

More information on maternal feeding choices should be collected now that replacement milks (formula) are no longer subsidised by the State. How many mothers elect formula feeding despite the absence of a subsidy? How many mothers undertake exclusive breastfeeding for the first six months of life and how many revert to mixed feeding? Also, how many babies are infected because of feeding practices? It is a labour intensive exercise to collect this data, but we need to do it.

ART in infants

Age of initiation is key to a good outcome: Research has shown that it is critical to initiate treatment as soon as the baby is diagnosed. Currently, the data only indicates whether the baby was initiated on treatment in the first year of life. In order to monitor whether the system is in fact diagnosing infants early, it would make sense to record their actual age when started on treatment for example at six weeks or three months.

This will help to establish where in the system improvements are required.

Plasma HIV RNA (Viral loads)

Data, which includes the actual viral load of the infants, should be collected per district and per year and reported by age group and sex.

Those patients who are part of the PMTCT programme and adolescents should be special focus areas.

2nd and 3rd Line ART

Data on numbers of patient on this regimen or in need of this regimen should be collected for planning access to resistance testing.

Adolescents (10 to 18 years of age)

The transitioning of adolescents into adult services should be monitored. The number of HIV-positive adolescents, distinguishing between those who are perinatal survivors  (infected at birth or via breastfeeding) and through sexual acquisition, should be reported and monitored by age. Outcomes for those entering and exiting the adolescent period should be reported. Thereafter, in adult programs, both perinatal survivors and those who acquired HIV sexually should have outcomes reported separately to other adult clinic attendees.

Support service for adherence

This should be measured and reported in children. We should also report on the availability of dedicated social workers and psychologists for ARV and TB programs. Poor adherence is often a symptom of complex issues in patients’ lives.

Simplification of regimen

Fixed dose combinations (FDC) reduce cost and simplify administration of ART. The availability for children should be documented as South Africa probably has the lowest FDC usages for children on the continent.