December 17, 2012

December 17, 2012
Improving Outcomes in HIV-exposed Children

Welcome to another day in my life. Today is Monday and I hope you had a beary safe and great weekend. It was another busy weekend for Dab the AIDS Bear doing more of our holiday parties for children living with HIV and AIDS.

Every year, I ask Santa for the same thing... a cure! But barring a cure, how to we get to where we have an AIDS free generation and improve outcomes in HIV-exposed children?

In the past, there has been considerable focus on the efficacy of particular antiretroviral regimens for the prevention of vertical transmission, but in recent years there has been a growing recognition that prevention of HIV infection and AIDS in children is a complex process, or 'cascade' as the sequence of services outlined above shows.       Studies and programmatic experience in some countries seem to suggest that despite improvements in the performance of some of these services, continuing sequential losses along other parts of the 'PMTCT cascade' mean that very few mother-infant pairs receive all the interventions, and very few HIV-infected infants are actually diagnosed and make it on to treatment. In addition, the focus of infant diagnosis on mother-infant pairs tends to ignore both children cared for by other family members and those who arrive at health facilities other than the HIV clinic, sick and in need of evaluation for possible HIV infection.

There are many reasons why programmes don’t perform as well as they should, but one seems particularly intractable in low-resourced settings, particularly in remote areas with poor infrastructure: the poor access to reliable HIV laboratory services that serve as the gateway to antiretroviral treatment (ART) in most countries’ HIV programmes. There have been multiple reports that have described how poor access to these lab services in these settings is a barrier to care.

As long as eligibility for antiretroviral therapy (ART) is determined on the basis of the result of a lab test, and if either that lab test, or the results, cannot be readily and reliably accessed in every part of the country, it may not matter how well a clinic’s PMTCT program is doing, or even whether the healthcare system overall is doing an outstanding job in addressing the performance and uptake of the most of the individual components of PMTCT.

These gaps are likely to become more apparent as programmes continue to scale up and decentralise to primary healthcare facilities in remote rural settings.       One solution might be to no longer require CD4 counts for mothers to initiate treatment, which Malawi is doing for the mothers at least, by adopting what is called ‘Option B+’—providing ART for life to any pregnant women who tests positive for HIV. However, although a strong case can be made that it will be cost-saving in the end, the up-front costs of Option B+ may not be judged affordable in all settings, and in any case it does not take care of either the diagnostic or the treatment needs of the child.

Another approach, and the topic of several symposia at AIDS 2012, would be to speed up the development and implementation of new point-of-care (POC) diagnostic tests that could be easily and affordably performed in less well-resourced facilities, possibly even in the patient’s home, with results provided in under an hour. This strategy got a big boost at the conference, with an announcement that UNITAID had committed US$140 million for projects implemented by the Clinton Health Access Initiative (CHAI), UNICEF and Médecins Sans Frontières (MSF) to increase access to affordable point-of-care HIV diagnostics adapted for use in resource-poor settings.

So hopefully one day my Christmas wish will come true. But until then I will keep the hope alive in my heart while we continue doing our yearly holiday parties for children living with HIV and AIDS.

Until we meet again; here's wishing you health, hope, happiness and just enough.

big bear hug,

Daddy Dab