By Chris Bateman, Freelance Journalist

Only two-thirds of children in South Africa getting treatment for HIV are virally suppressed. 

Viral suppression is a measure of how well antiretroviral (ARVs) drugs reduce HIV viral load. A high HIV viral load suggests that the person is not taking their treatment constantly, or that the treatment isn’t working. 

Delays in sourcing long-acting, palatable oral ARVs for South Africa’s infants and children have been cited as a reason for the low viral load suppression. And, children need an adult caregiver to help them take the medication on a daily basis. This routine gets disrupted every time there’s a change in adult caregiving. This, in turn, leads to lower drug adherence. 

Professor Mo Archary, Paediatric Infectious Disease Specialist at King Edward VIII Hospital in Durban, says this has had a lethal impact. He cited a watershed multi-author study on the impact of the AIDS epidemic on South Africa’s children ¹ which shows that such factors caused a ten-fold increase in child mortality, and a six-fold increase in infant mortality between 1985 and 2006. Archary was speaking at the sixth HIV Clinicians Society conference in Cape Town this week.

There are an estimated 8 million people with HIV in South Africa. Five million are now living healthily on ARVs and the country’s globally leading ARV roll-out has reduced HIV to a chronic disease. But, a “staggering” three million people with HIV are still not on treatment.

An estimated 230,000 children under 15 years are living with HIV. According to a UNAIDS 2022 retrospective epidemiological analysis, South Africa’s ART coverage in children 0-14 years remained at 52% from 2020, consistently lower than in adults which rose from 74% in 2020 to 76% in 2022. Sixty percent of children not on ART were aged 5-14 years.

In response to a query by Health-e News, Archary says the most pressing problem was, “our pick-up rate (i.e., detection). People are on ARV’s but we’re not testing families and kids. We miss kids until they become symptomatic, so, (a lack of) early detection and treatment hugely affects outcomes.

“Early infant detection is not enough, there’s a need for home testing and/or self-testing to identify older children living with HIV,” he adds. 

HIV treatment for children

South Africa introduced a single ARV daily dose in a palatable strawberry flavour last year. This replaced the long-standing, bitter-tasting multiple daily doses used for decades prior.

“Some of the old formulations had an extremely bitter taste and were not easily tolerated. Parents had to fight with children to get it down,” explains Archary.

The old paediatric drug regime negatively impacted adherence, reducing paediatric viral suppression. This was compounded by social factors such as multi-parenting which is so common in low-income households where a grandmother, neighbour or relative often takes care of an infant if the mother is working (or deceased). Other contributing factors included the large pill burden, and short dosing intervals.

“Our new, simple, easy to use regimens will go a long way to improving the lives of the children and families we treat,” he says.

But there are challenges with the new regime too. Storage and transportation of the drugs is also complex. Many of the liquid protease inhibitors require cold-chain storage. This means that both the clinic and the patient need to have a refrigerator to store the medications. In resource-limited settings such as sub-Saharan Africa, where paediatric HIV is most prevalent, this is often impossible.

What gives him hope though is the accelerating success of long-acting drug combinations which will eventually have “a massive impact” on ARV adherence.

“That’s a real game-changer. It will remove the daily burden from the caregiver and child,” he adds. 

He is also looking forward to the results of several studies evaluating long-acting formulations in children. These drug formulations would allow patients to receive one injection lasting for two or more months. Such injections had already had impressive results in trials conducted in adults. He expects these formulations to be available within five to ten years. 

Plugging the gaps

A snapshot from a study of paediatric admissions at one Soweto hospital in 2000 showed that 22,5% of pregnant women had HIV, while mother to child transmission stood at 30%. The latter figure is in marked contrast to the subsequent overall decline in mother to child transmission in South Africa. 

Since the implementation of the prevention of mother to child transmission of HIV (PMTCT) programme in 2006 the rate has declined from 9.6% in 2008 to 2.7% in 2011, to 0.9% in 2016. 

In spite of the PMTCT successes, “we continue to have new HIV (adult) infections which fuel new paediatric infections. So, we need to control adult infections in order to control to get paediatric control,” he stresses.

The main problem is in preventing new HIV infections in pregnant and lactating women.

Achary says it’s crucial to support families living with HIV in order to address a multitude of problems, not least paediatric ARV adherence. The impact of HIV on children is multi-facetted and includes education, welfare, and the household. 

While South Africa is now moving rapidly towards the elimination of mother to child HIV transmission with vastly improved early infant diagnosis, (Covid temporarily setting progress back), the mortality rate remains “extremely worrying”. 

The “differentiated service delivery”, model – meaning multi-month dispensing in infants and children, has been “quite slow”, and needs streamlining, especially in virally suppressed patients.

“We need to concentrate our efforts on patients who are not virally suppressed and are doing badly. We also need to make sure children remain in care. There’s no point in spending huge amounts on early diagnostics if you’re not going to link it to care. We need to do a lot more to get infants and children onto ARV’s,” he says. – Health-e News