Antiretroviral Therapy in Children Less Than 24 Months of Age at Pediatric HIV Centers in Tanzania: 12-Month Clinical Outcomes and Survival.

BACKGROUND: Without antiretroviral therapy (ART), approximately one-half of HIV-infected infants will die by two years. In 2010, the World Health Organization (WHO) recommended that all HIV-infected infants < 24 months be initiated on ART regardless of their clinical/immunologic status. However, there remains little published data detailing cohorts of infants on ART in Sub-Saharan Africa. This study describes baseline characteristics and 12 month outcomes of a cohort of HIV-infected children < 24 months of age at pediatric HIV centers in Mwanza and Mbeya, Tanzania. MATERIALS AND METHODS: Retrospective chart review. INCLUSION CRITERIA: children < 24 months of age, initiated on ART at Baylor Children s Foundation Tanzania clinics, between March-December 2011. RESULTS: Baseline: Ninety-three children were initiated on ART at a median age of 13.4 months. Sixty-seven percent had severe immunosuppression and 31.5% had severe malnutrition. OUTCOME: Seventy-three patients were still in care at 12 month follow-up, there were four (4.3%) deaths, five (5.4%) patients transferred, and 11 (11.8%) loss to follow-up. Average CD4% was 32.7 (p < 0.001). Ninety percent of patients were WHO treatment stage I (p < 0.001). Eighty-six percent had normal nutritional status (p < 0.001). CONCLUSION: Our cohort of HIV infected children < 24 months initiated on ART did well clinically at 12 month outcomes despite being severely immunocompromised and malnourished at baseline. Nevirapine based regimens had good 12 month clinical outcomes, regardless of maternal exposure. Loss to follow-up rate was high for our cohort, demonstrating the need to develop strong mechanisms to counteract this.

Beyond prevention of mother-to-child transmission: keeping HIV-exposed and HIV-positive children healthy and alive.

In 2011, Joint United Nations Programme on HIV/AIDS announced a plan to eliminate new HIV infections among children by 2015. This increased focus on the elimination of maternal to child transmission (MTCT) is most welcome but is insufficient, as access to prevention of MTCT (PMTCT) programming is neither uniform nor universal. A new and more expansive agenda must be articulated to ensure that those infants and children who will never feel the impact of the current elimination agenda are reached and linked to appropriate care and treatment. This agenda must addresses challenges around both reducing vertical transmission through PMTCT and ensuring access to appropriate HIV testing, care, and treatment for all affected children who were never able to access PMTCT programming. Option B+, or universal test and treat for HIV-infected pregnant women is an excellent start, but it may be time to rethink our current approaches to delivering PMTCT services. New strategies will reduce vertical transmission to less than 1% for those mother-infant pairs who can access them allowing for the contemplation of not just PMTCT, but actual elimination of MTCT. But expanded thinking is needed to ensure elimination of pediatric HIV.

HIV-exposed infants: rethinking care for a lifelong condition.

Each year over a million infants are born to HIV-infected mothers. With scale up of prevention of mother-to-child transmission (PMTCT) interventions, only 210 000 of the 1.3 million infants born to mothers with HIV/AIDS in 2012 became infected. Current programmatic efforts directed at infants born to HIV-infected mothers are primarily focused on decreasing their risk of infection, but an emphasis on maternal interventions has meant follow-up of exposed infants has been poor. Programs are struggling to retain this population in care until the end of exposure, typically at the cessation of breastfeeding, between 12 and 24 months of age. But HIV exposure is a life-long condition that continues to impact the health and well being of a child long after exposure has ended. A better understanding of the impact of HIV on exposed infants is needed and new programs and interventions must take into consideration the long-term health needs of this growing population. The introduction of lifelong treatment for all HIV-infected pregnant women is an opportunity to rethink how we provide services adapted for the long-term retention of mother-infant pairs.