We have come a long way in the past few years in the management of HIV. An ambitious 90:90:90 treatment target was implemented to end the AIDS pandemic.

This well known target aimed to have 90% of people living with HIV to know their status by 2020, 90% of those diagnosed with HIV to be on treatment and lastly 90% of those on treatment to be virologically suppressed. This goal might not have been reached but it is definitely achievable.

Unfortunately, thousands of women and children are still contracting this disease. The reason for this is multifactorial. As we all know HIV stigma and discrimination is rife in certain communities. This results in patients not seeking the help that they need for themselves and their children despite being aware of the diagnosis. Often, we are faced with couples in practice where partners have not disclosed their status’ out of fear of the other person’s reaction. Another reason is poor access to screening and healthcare and loss to follow up during pregnancy.

In an ideal world, HIV positive women of childbearing age should be diagnosed and virological suppression achieved before pregnancy. Antenatal care in the pregnant HIV positive mom is a crucial time to prevent transmission to the unborn baby. Ensuring that mom is healthy and compliant on her ARVs will suppress her viral load and protect baby. During the pregnancy, a feeding plan and preventative treatment for baby after delivery should already be discussed so that mom knows what to expect.

Post delivery the mother and baby must have  a general practitioner/ paediatrician to follow up with to ensure continued care for both her and baby. This is usually ideal at the same point of care. During the first 18 months of life, baby needs to be screened for HIV with an age appropriate test on a regular basis. These intervals will be determined by whether baby is breastfeeding or formula fed. Mom will also need regular screening for disease control, especially if she is breastfeeding. Yes!!!! HIV positive moms can safely breastfeed their infants.

Should the infant contract the virus, it is critical that they are diagnosed and started on treatment without delay because without early treatment the complication and mortality rate is high. These infants usually need extra close monitoring by a medical and nutritional team to ensure the best outcome. Their medication dosages need regular adjustments according to their weight.

Even if treatment is initiated correctly we know that many children develop virological failure at some point in time.Virological failure is when a patient on treatment has a detectable viral load and disease progression. Below are some reasons why babies, toddlers and adolescents develop virological failure.

1. Incorrect medication dosages
   • The young infant is usually initiated on 3 separate syrups which needs to be adjusted according to their weight as mentioned above. If this is not done precisely and the child is under-dosed their viral load will not be suppressed
   • If caregivers do not have a good understanding of these dosages they could get it wrong

2. Complicated treatment regimes
   • Adults have a variety of fixed dose combinations available to them where children need to take multiple different meds
   • Fortunately there are exciting new treatments coming soon to offer fixed dose combinations to children too

3. Unpalatable medication
   • Some of the syrups taste so bad it is almost impossible to get the child to take it despite the best efforts to mask the taste
   • Once again there are new treatments that are well tolerated by kids

4. Non-disclosure
   • Many parents do not tell their children why they are taking medication out of fear that they might say something to their teacher or friends at school
   • These children believe they have allergies or asthma
   • Unfortunately children  and adolescents have access to internet and sooner or later realise why they are really taking medication
   • When they feel betrayed they often rebel against treatment, especially the teenagers

5. Normal development
   • It is normal for a child/adolescent to push the boundaries and this often results in them defaulting their treatment behind their parent’s back
   • It is imperative to support them through this developmental phase and get them on board with their own treatment

6. Drug interactions
   • Sadly a lot of virological failure is due to interactions with other medications
   • Prescribers should have a sound knowledge of how to adjust ARV dosages when given together with certain drugs such as TB medication

From the above information it is clear that HIV positive young women and children need special support with their treatment throughout all the phases of life and a doctor to help them navigate through each challenge they come across.

Dr Nadine Stewart has her Diploma in HIV Care and Management and would love to help you on your health journey!

 

– Dr Nadine Stewart