Birth HIV testing and paediatric treatment programmes

In The Lancet HIV , Karl-Günter Technau and colleagues report on 12-month outcomes of 88 HIV-infected neonates. The infants were identified through birth HIV testing at a well resourced, academic, public maternity hospital in South Africa, an upper-middle-income country with an HIV prevalence of about 32%. Their infant birth HIV testing approach included testing high-risk HIV-exposed infants in era 1 (September, 2013 to May, 2014), testing all HIV-exposed infants in era 2 (June, 2014 to September, 2014), and testing all HIV-exposed infants with added point-of-care (POC) diagnostic PCR testing in era 3 (October, 2014 to June, 2016). The main outcomes were time to antiretroviral therapy (ART) initiation, mortality, retention in care, and viral suppression. Although data are from a single academic site, they provide insight into the effect of early infant HIV testing and ART initiation, which might be generalisable to similar settings. The findings are both encouraging and sobering, raising additional questions on how to optimise WHO's survive, thrive, and transform agenda for HIV-exposed children.https://www.thelancet.com/journals/lanhiv/issue/current2019-12-01hj2019Paediatrics and Child Healt

Infant feeding and HIV

Recent studies on antiretroviral prophylaxis during breastfeeding show that maternal HAART (alone or with 1,4 or 24 weeks infant prophylaxis) or infant prophylaxis alone (with limited maternal prophylaxis) for 6, 14 or 24 weeks reduces HIV transmission through breastmilk (postnatal transmission). Maternal postnatal regimens appear to be as efficacious as infant postnatal regimens, although one study shows a trend favouring infant nevirapine over maternal HAART (both used from 1 week to 6 months post-delivery). These new findings necessitate a review of existing PMTCT interventions, and the immediate implementation of regimens that reduce postnatal transmission - where this is feasible – to save children’s lives. In the public sector, whilst stakeholders engage in discussions about which is the best regimen to minimise postnatal transmission SSSUPPORT should be given to all HIV-positive women, as explained below, to improve infant outcomes and reduce postnatal transmission: Screen all women for HIV, Send off CD4 cell counts on all HIV-positive women, Screen all HIV-positive women for AFASS using a standardised tool (e.g. Table 3); Understand the woman’s personal and socio-cultural context; Promote exclusive or predominant breastfeeding if all AFASS criteria are not met; Promote exclusive formula feeding if all AFASS criteria are met; Organise supplies of formula milk and cotrimoxazole; Review mothers and infants in the first 3 days post-delivery, in the first two weeks postnatally and monthly thereafter, and review health and feeding practices, regardless of feeding choice, at every visit; lastly Treat all pregnant women with HAART if they meet national criteria for HAART initiation

Moving towards elimination : findings from the South Africa prevention of mother to child transmission evaluation (SAPMTCTE)

It is remarkable that we find ourselves at a point in history where we can seriously consider the possibility of virtual elimination of mother-to-child HIV transmission (MTCT). Effective antiretroviral strategies, carefully honed through randomized clinical trials, provide the means to almost entirely prevent the transmission of HIV from an HIV-infected woman to her infant during pregnancy, delivery and breastfeeding - if started timeously and sustained through the full period of risk. Massive mobilization of governments, policy-makers, health service managers, clinicians, researchers and communities have led to implementation of Prevention of Mother To Child Transmission (PMTCT) interventions on an impressive scale. South Africa, which faces the world’s highest adult HIV prevalence, has risen to the challenge, also implementing the one of the world’s largest antiretroviral drug treatment program. In so doing, South Africa has made impressive gains in mitigating the tragedy of its generalized and substantial HIV epidemic.The South African Medical Research Councilhttps://bmcinfectdis.biomedcentral.comam2020Paediatrics and Child Healt

Completeness of the Road-to-Health Booklet and Road-to-Health Card : results of cross-sectional surveillance at a provincial tertiary hospital

BACKGROUND : Accurate record-keeping is important for continuity and quality of care. Completing a child’s Road-to-Health Booklet (RTHB), or the older, less detailed, Road-to- Health Card/Chart (RTHC), immediate interpretation thereof and appropriate action facilitates comprehensive care, which could contribute to a decline in child morbidity and mortality. OBJECTIVE : This study aimed to assess the extent to which healthcare personnel working in catchment clinics of Kalafong Provincial Tertiary Hospital (KPTH), Tshwane district, South Africa, complete HIV-related, sociodemographic, neonatal, growth and immunisation information in the RTHC and/or RTHB. METHODS : A cross-sectional, quantitative record review was conducted. Data were extracted from 318 RTHCs and/or RTHBs of children attending KPTH for paediatric care. Data extraction focused on six main areas, namely documentation of HIV-related, neonatal, sociodemographic, anthropometric, immunisation and vitamin A-related information. During data analysis, age-appropriate completeness scores were generated for each area and completeness of documentation in the RTHB and RTHC was assessed. RESULTS : Data demonstrate significantly less unrecorded HIV-related information (maternal HIV status, timing of maternal HIV testing, timing of maternal antiretroviral therapy [ART] initiation, current maternal ART use and infant feeding decisions) in RTHBs compared with RTHCs (p < 001). Despite this, 24% of all RTHBs had no record of maternal HIV status and 67% of RTHBs from documented HIV-exposed infants had no record of maternal ART duration. Neonatal information completeness was similar between RTHBs and RTHCs, but sociodemographic completeness was significantly better in RTHBs compared with RTHCs (p = 0.006). Growth (especially weight), immunisation and vitamin A completeness was > 80% and similar between RTHBs and RTHCs. Length-for-age, weight-for-length and head circumference were plotted in < 5% of RTHBs and none of the RTHCs. CONCLUSION : Although completeness of key HIV-related information was better in RTHBs compared with RTHCs, RTHB completeness was suboptimal. Healthcare personnel need reminders to utilise the RTHB optimally to improve continuity and quality of child healthcare.The South African Medical Research Councilhttp://www.sajhivmed.org.zaam2018Paediatrics and Child Healt

Call To action - Prevention of mother To child transmission of HIV

The Prevention of Mother to Child Transmission of HIV (PMTCT)programme is a critical intervention to reduce the incidence of paediatric HIV infections . It is also a key intervention to decrease infant, child and maternal mortality. The optimal implementation of a sound, evidence-based PMTCT programme is essential to meet both the HIV reduction targets in the National Strategic Plan1 and to achieve Millennium Development Goals(MDGs) 4 (reducing infant and child mortality) and 5 (reducing maternal mortalty).2 Since 2001, South Africa has been implementing a programme to prevent mother-to-child transmission of HIV. Since 2007, national PMTCT policy has evolved into a strong, enabling framework that should reduce vertical transmission significantly. This paper reviews the milestone studies that have contributed to our knowledge about drug regimens to reduce MTCT (mother-to-child transmission of HIV), reviews the latest South African PMTCT guidelines and the possible future changes. Strengthened / revised drug regimens for PMTCT are, essential but insufficient for measureable decreases in HIV transmission and improvements in maternal and childl health. The main challenge is implementation. Until the enhanced PMTCT policy is effectively operationalised, measureable achievements will remain elusive

‘We are the advocates for the babies’ - understanding interactions between patients and health care providers during the prevention of mother-to-child transmission of HIV in South Africa : a qualitative study

BACKGROUND : HIV/AIDS has had a significant impact on maternal and child health in South Africa. It is thus of vital importance to implement interventions to prevent mother-to-child transmission of HIV (PMTCT) as early as possible during pregnancy. Negative interactions between patients and health care providers (HCPs) can be an important barrier to antenatal care, PMTCT use and PMTCT adherence. Research about respectful maternity care has focused more on the patient perspective. We therefore compared the patient and HCP perspectives and reflected on how interactions between HCPs and patients can be improved. OBJECTIVE : To obtain insights into the attitudes of HCPs in the context of HIV and PMTCTrelated care, by studying patient and HCP perceptions of their interactions, in a peri-urban hospital setting in Gauteng province, South Africa. METHODS : A qualitative study was conducted in a public tertiary-level hospital. Fourteen semistructured in-depth interviews were conducted with nurses and doctors in the antenatal clinic and postnatal ward. Thirty-one semi-structured in-depth interviews and two focus group discussions were conducted with HIV positive and negative women on the postnatal ward. RESULTS : HCPs experienced a difficult work environment due to a high workload. This was combined with frustrations when they felt that patients did not take responsibility for their own or their child’s health. They were motivated by the need to help the child. Patients experienced judging comments by HCPs especially towards younger, older and foreign women. They expressed fear to ask questions and self-blame, which in some cases delayed health care seeking. No discrimination or isolation of HIV infected patients was reported by patients and HCPs. CONCLUSION : We hypothesize that more humane working conditions for obstetric HCPs and a caring, personalised approach to patient management can improve patient-provider interactions and access to respectful care. These are critical to preventing mother-to-child transmission of HIV.The South African Medical Research Councilhttp://www.tandfonline.com/loi/zgha20am2020Paediatrics and Child Healt

Unmasking the vulnerabilities of uninfected children exposed to HIV

Although programmes to reduce vertical transmission of HIV mean fewer children are acquiring HIV, more needs to be done to understand the longer term outcomes of exposure.http://www.bmj.com/thebmjPaediatrics and Child Healt

A landscape analysis of preterm birth in South Africa : systemic gaps and solutions

Lack of accurate nationally representative preterm birth estimates limit our epidemiological understanding of this syndrome and the extent to which health services can respond appropriately.http://www.journals.co.za/content/journal/healthrPaediatrics and Child Healt

What are we doing to the children of South Africa under the guise of COVID-19 lockdown?

In response to rising numbers of cases of COVID-19, which had been declared a pandemic by the World Health Organization, the President of South Africa imposed a nationwide lockdown on 23 March 2020, effective on 27 March 2020. While some other countries seemed to panic, flounder and in some cases even turn their backs on the rising threat of COVID-19, for South Africa this was almost a Dunkirk moment. The nation showed an extraordinary degree of unity as the President implemented severe measures that have proved effective at ‘flattening the curve’.http://www.samj.org.zaam2021Paediatrics and Child Healt

A risk measurement tool for targeted HIV prevention measures amongst young pregnant and lactating women in South Africa

BACKGROUND : We aimed to develop and validate a tool to identify which pregnant/lactating young South African women (≤ 24 years) are at risk of HIV infection. METHODS : Data from three national South African Prevention of Mother-to-Child Transmission (PMTCT) evaluations were used to internally validate three HIV acquisition risk models for young postpartum women. We used univariate and multivariable logistic regression analysis to determine which risk factors were significant. Model coefficients were rounded and stratified into risk groups and the area under the receiver operating curve (AUROC) was computed. Models were developed to determine which risk factors provided the most predictive accuracy whilst remining clinically meaningful. RESULTS : Data from 9 456 adult and 4 658 young pregnant and lactating women were included in the development and validation data sets, respectively. The optimal model included the following risk factors: age (20–24 years old), informal house structure, two or more pregnancies, mothers who had knowledge of when they received their last HIV test result, no knowledge of the infant’s father’s HIV status, no knowledge of breastfeeding as a mode of MTCT and knowledge of PMTCT programme. The mean AUROC was 0.71 and 0.72 in the development and validation datasets respectively. The optimum cut off score was ≥ 27, having 84% sensitivity, 44% specificity, and identifying 44% of highrisk women eligible for PrEP. CONCLUSION : The optimal model to be used as a possible risk scoring tool to allow for early identification of those pregnant/lactating women most at-risk of HIV acquisition included both statistically as well as clinically meaningful risk factors. A field-based study is needed to test and validate the effectiveness of this targeted approach.The United Nations Children’s Emergency Fund and the National Department of Health as well as the South African National AIDS Council, the European Union (through the National Department of Health), the South African National Research Foundation, and the Global Fund also provided financial support through the SAMRC Adolescent Girls and Young Women Social Impact Bond project.http://www.biomedcentral.com/bmcpediatram2023Paediatrics and Child Healt