Paediatric HIV treatment failure: a silent epidemic.

Jonathan M Bernheimer,Nompumelelo Mantangana,Gem Patten,Nombasa Dumile,Vivian Cox,Eric Goemaere,Thembisa Makeleni

doi:10.7448/ias.18.1.20090

Jonathan M Bernheimer, Nompumelelo Mantangana + Show 5 more

Open Access

https://doi.org/10.7448/ias.18.1.20090

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Abstract

Paediatric antiretroviral treatment (ART) failure is an under-recognized issue that receives inadequate attention in the field of paediatrics and within HIV treatment programmes. With paediatric ART failure rates ranging from 19.3% to over 32% in resource limited settings, a comprehensive evaluation of the causes of failure along with approaches to address barriers to treatment adherence are urgently needed.In partnership with the local Department of Health, a pilot programme has been established by Medecins Sans Frontieres (MSF) in Khayelitsha, South Africa, to identify and support paediatric HIV patients with high viral loads and potential treatment failure. Through detailed clinical and psychosocial evaluations and adherence support with an innovative counselling model, treatment barriers are identified and addressed.Demographic and clinical characteristics from the cohort show a delayed median start date for ART, prolonged viraemia including a large number of patients who have never achieved viral load (VL) suppression, a low rate of regimen changes despite failure, and a high percentage of pre-adolescent and adolescent patients who have not gone through the disclosure process.Stemming this epidemic of paediatric treatment failure requires programmatic responses to high viral loads in children, starting with improved “case finding” of previously undiagnosed HIV-infected children and adolescents. Viral load testing needs to be prioritized over CD4 count monitoring, and flagging systems to identify high VL results should be developed in clinics. Clinicians must understand that successful treatment begins with good adherence, and that simple adherence support strategies can often dramatically improve adherence. Moreover, appropriate adherence counselling should begin not when the child fails to respond to treatment. Establishing good adherence from the beginning of treatment, and supporting ongoing adherence during the milestones in these children's lives is key to sustaining treatment success in this vulnerable HIV-infected patient population.

Highlights

While great progress has been made in the last 15 years in the field of paediatric HIV diagnosis and treatment, a growing problem has emerged that threatens to undermine much of the work that has been done
We describe below the characteristics of children enrolled in a pilot programme to support children failing antiretroviral treatment (ART) at two wellestablished primary care clinics in Khayelitsha, South Africa
Current South African Department of Health paediatric HIV guidelines recommend that clinicians consider a regimen change if the patient has experienced virologic failure Á defined as two consecutive viral load (VL) !1000 copies/mL Á despite a good adherence record

Summary

Introduction

While great progress has been made in the last 15 years in the field of paediatric HIV diagnosis and treatment, a growing problem has emerged that threatens to undermine much of the work that has been done. While few studies have fully evaluated cohorts of children with virologic failure, rates of failure in the paediatric age group are reported to range from 19.3% to over 32% in resource limited settings [1,2].

Results

Conclusion