Challenges in the provision of tuberculosis preventive therapy to children in Gauteng Province, South Africa

Background. Tuberculosis preventive therapy (TPT) offered to children who come into contact with infectious adult pulmonary tuberculosis (TB) cases is an important childhood TB prevention strategy. Objectives. To document paediatric TPT coverage as per South African national TB guidelines, to measure basic knowledge of TPT in adult TB patients and healthcare workers (HCWs), and to determine challenges in TPT delivery in eligible children. Methods. We conducted a descriptive, cross-sectional study at primary healthcare clinics in South-West Tshwane, Gauteng Province, South Africa (SA). Structured interviews were conducted with adult TB patients to obtain socio-demographic data, TB and HIV history, data on child contacts and TPT knowledge. A separate questionnaire probed HCWs' knowledge of TPT. Patient folders and the clinical process flow of adult TB cases and children on TPT were also assessed. Results. We interviewed 100 adult TB patients and identified 28 child contacts who were eligible for TPT, including six children (21%, n=6/28) on TPT, all HIV-uninfected and <5 years of age. Instability in household configuration was the most common reason for eligible children not having been brought to health facilities for assessment (57%; n=4/7). Almost all adult TB patients were aware of their TB diagnosis (98%; n=98/100), but only half (48%; n=48/100) had knowledge of their TB type, and 55% (n=6/11) of the adult TB patients with drug-resistant TB were aware of the drug resistance. In addition, we interviewed 71 HCWs, and more than one-third of HCWs (37%; n=26/71) were fully knowledgeable about paediatric TPT eligibility criteria, with 63% (n=45/71) unaware that HIV-infected children of all ages qualified for TPT after exposure. Conclusions. TPT provision in eligible child TB contacts in an urban district in SA was found to be suboptimal, especially for HIVinfected children. Instability in household configuration was an important reason for suboptimal TPT provision. Training of HCWs on paediatric TPT guidelines is required, together with knowledge sharing on TPT with the TB patients

Aetiological testing compared with syndromic management for sexually transmitted infections in HIV-infected pregnant women in South Africa: a non-randomised prospective cohort study.

OBJECTIVE: To measure the frequencies of sexually transmitted infections (STIs) and adverse pregnancy outcomes among women receiving either aetiological testing or syndromic management for STIs. DESIGN: Non-randomised prospective cohort study. SETTING: Primary healthcare facilities in Tshwane, South Africa. POPULATION: HIV-infected pregnant women attending antenatal care services. METHODS: Participants were enrolled to receive aetiological testing using Xpert® CT/NG and Xpert® TV assays or standard syndromic management. Outcome data were collected at the postnatal care visit (≤30 days from delivery) and from maternity records. Enrolment gestational age-adjusted relative risk (aRR) was calculated. MAIN OUTCOME MEASURES: STI prevalence at postnatal visit, and frequency of adverse pregnancy outcomes (preterm birth, low birthweight). RESULTS: We enrolled 841 women. The prevalence of any STI at baseline was 40%; Chlamydia trachomatis 30%, Neisseria gonorrhoeae 5.6%, Trichomonas vaginalis 20%. The prevalence of STIs at postnatal care was lower among those receiving aetiological testing compared with those receiving syndromic management (14% versus 23%; aRR 0.61; 95% CI 0.35-1.05). No difference was observed between study groups for frequency of preterm birth (23% versus 23%; aRR 1.2, 95% CI 0.81-1.8) and low birth weight (15% versus 13%; aRR 1.1, 95% CI 0.66-1.7). CONCLUSIONS: Aetiological testing provides an effective intervention to reduce the high burden of STIs in pregnant women in South Africa; however, the optimal implementation strategy remains to be determined. TWEETABLE ABSTRACT: Aetiological testing effectively reduces the burden of sexually transmitted infections in pregnancy.

Monitoring diagnosis, retention in care and viral load suppression in children testing HIV polymerase chain reaction-positive in two districts in South Africa.

BACKGROUND: Retention in care is associated with improved virological control and survival among HIV-infected children. However, retention of children in HIV care remains a challenge. OBJECTIVES: To describe, using routine laboratory HIV test data, the retention-in-care and virological outcomes of HIV-infected children aged <18 months in two districts in South Africa. METHODS: HIV polymerase chain reaction (PCR)-positive results of children from uMkhanyakude and Tshwane districts in KwaZulu-Natal and Gauteng provinces, respectively, tested between April 2015 and May 2016, were extracted from the National Health Laboratory Service's Corporate Data Warehouse (CDW). HIV-related tests (PCR, viral load (VL), CD4+) were documented longitudinally for each child for ≥13 months after the first positive PCR result by manually searching demographics within the CDW, supplemented by an automated patient-linking algorithm. Test sets were linked if two or more demographics (surname, name, date of birth, folder number) matched exactly. Programmatic indicators assessed included age at first positive PCR test, presumed confirmatory test rates, retention in care, and VL suppression at 6 and 12 months. RESULTS: Ninety-four and 304 children tested HIV PCR-positive in uMkhanyakude and Tshwane, respectively. The median age at diagnosis was 3.6 months (interquartile range (IQR) 1.4 - 7.1) for uMkhanyakude and 2.3 months (IQR 0.1 - 6.7) for Tshwane. In uMkhanyakude, confirmed in utero infections accounted for 18.1% of transmissions (n=17), compared with 29.6% (n=90) in Tshwane. Presumed confirmatory test rates following an initial positive PCR result were 77.7% and 71.7% for uMkhanyakude and Tshwane, respectively. Within 6 months of starting antiretroviral therapy, 43 children (58.9%) were lost to follow-up in uMkhanyakude compared with 160 (73.4%) in Tshwane. Of those retained in care at 6 months with a VL measurement, 15 (60.0%) from uMkhanyakude had a VL <1 000 copies/mL, compared with 24 (48.0%) in Tshwane. For both districts, a third of all HIV PCR-positive children were retained in care at the end of follow-up, with 29 (30.9%) in uMkhanyakude and 99 (32.5%) in Tshwane. Of these, 12 (41.4%) had a VL <1 000 copies/mL in uMkhanyakude compared with 28 (28.3%) in Tshwane. CONCLUSIONS: We demonstrate the value of routine laboratory data in monitoring diagnosis, retention and VL suppression in HIV-infected children. This approach is scalable, can be reported near real-time, is relatively inexpensive to implement, and provides a tool for improving paediatric HIV services until clinical databases can assume this role.

Monitoring diagnosis, retention in care and viral load suppression in children testing HIV polymerase chain reaction-positive in two districts in South Africa

Background. Retention in care is associated with improved virological control and survival among HIV-infected children. However, retention of children in HIV care remains a challenge.Objectives. To describe, using routine laboratory HIV test data, the retention-in-care and virological outcomes of HIV-infected children aged <18 months in two districts in South Africa.Methods. HIV polymerase chain reaction (PCR)-positive results of children from uMkhanyakude and Tshwane districts in KwaZulu-Natal and Gauteng provinces, respectively, tested between April 2015 and May 2016, were extracted from the National Health Laboratory Service's Corporate Data Warehouse (CDW). HIV-related tests (PCR, viral load (VL), CD4+) were documented longitudinally for each child for ≥13 months after the first positive PCR result by manually searching demographics within the CDW, supplemented by an automated patient-linking algorithm. Test sets were linked if two or more demographics (surname, name, date of birth, folder number) matched exactly. Programmatic indicators assessed included age at first positive PCR test, presumed confirmatory test rates, retention in care, and VL suppression at 6 and 12 months.Results. Ninety-four and 304 children tested HIV PCR-positive in uMkhanyakude and Tshwane, respectively. The median age at diagnosis was 3.6 months (interquartile range (IQR) 1.4 - 7.1) for uMkhanyakude and 2.3 months (IQR 0.1 - 6.7) for Tshwane. In uMkhanyakude, confirmed in utero infections accounted for 18.1% of transmissions (n=17), compared with 29.6% (n=90) in Tshwane. Presumed confirmatory test rates following an initial positive PCR result were 77.7% and 71.7% for uMkhanyakude and Tshwane, respectively. Within 6 months of starting antiretroviral therapy, 43 children (58.9%) were lost to follow-up in uMkhanyakude compared with 160 (73.4%) in Tshwane. Of those retained in care at 6 months with a VL measurement, 15 (60.0%) from uMkhanyakude had a VL <1 000 copies/mL, compared with 24 (48.0%) in Tshwane. For both districts, a third of all HIV PCR-positive children were retained in care at the end of follow-up, with 29 (30.9%) in uMkhanyakude and 99 (32.5%) in Tshwane. Of these, 12 (41.4%) had a VL <1 000 copies/mL in uMkhanyakude compared with 28 (28.3%) in Tshwane.Conclusions. We demonstrate the value of routine laboratory data in monitoring diagnosis, retention and VL suppression in HIV-infected children. This approach is scalable, can be reported near real-time, is relatively inexpensive to implement, and provides a tool for improving paediatric HIV services until clinical databases can assume this role

Reasons for delay in initiation of antiretroviral therapy in a population of HIV-infected South African children.

The aim of this study was to determine the reasons for delay of antiretroviral therapy (ART) in eligible HIV-infected children after the implementation of the South African National ART programme in April 2004, and to describe implemented interventions to improve ART access. This descriptive, retrospective audit included all HIV-infected children attending an ART clinic from April to December 2004, summarizing the following: (i) demographic data; (ii) HIV disease stage; (iii) CD4+ counts/percentages; (iv) ART eligibility and (v) reasons for ART delay. There were 276 study participants with a mean age of 4 years 4 months (range: 1 month-13 years). According to the South African national guidelines, 243 children were eligible for ART, but only 96 children were initiated on treatment during the study period, which was 39.5% of the eligible group and 34.8% of the total group. Important reasons for treatment delay were: (i) co-infection with tuberculosis (26.4%); (ii) lack of human resources (20.3%); (iii) socio-economic obstacles (17.3%) and (iv) incorrect disease stage classification (13.7%). Paediatric ART clinics need to co-operate closely with existing tuberculosis clinics for the effective management of tuberculosis co-infection; address socio-economic factors of HIV-affected families, especially the legal guardianship in orphans and improve their own staff capacity and the education of medical staff in HIV/AIDS management.