As in adults, the HIV treatment cascade is a critical tool for monitoring the success of efforts to bring treatment to children and minimise the risk of paediatric AIDS. Diagnosis, the first step in the cascade, presents its own specific set of challenges in children.
Virologic testing for HIV DNA at 4-6 weeks of age is recommended in all HIV-exposed infants. Point-of-care testing is most likely to ensure that the infant is not lost to follow-up and that treatment can be started promptly. Infants with HIV are at especially high risk of death during the first months of life, but up to half of infants tested for HIV in four countries never received those results, and a consequence could not receive antiretroviral treatment.
Improving access to infant diagnostic tests is essential for achieving the first 90 for children. Coverage of early infant diagnosis tests has improved dramatically in several countries since 2012, but even in some of the best-improving countries such as Zimbabwe and Mozambique, only half of HIV-exposed infants were tested in 2015, UNAIDS estimates.
“We are not putting the right resources into paediatric treatment. We have the means to end it once for and all, so why are we not prioritizing HIV treatment for children?" -- Dr Badara Samb, Director of UNAIDS Office of Special Initiatives.
Cost remains a major barrier, Dr Badara Samb, Director of UNAIDS Office of Special Initiatives told aidsmap.com.
“We needed to reduce the cost, and to make it friendlier. That’s why we have been working with a number of manufacturers to see if we can develop point-of-care diagnosis. Today, we have technology that is available through two companies that makes early infant diagnosis at the point of care possible. We have been able to reduce the price with a partnership with Roche and we are trying to push for competition to lower the price.”
Roche cut the price of its early infant diagnostic test to $9.40 per test in 2015 after negotiations with the Diagnostics Access Initiative, formed to reduce the cost of viral load testing.
A major new push to improve early infant diagnosis will begin later this year to make point-of-care testing more widely available, using WHO prequalified products (Alere HIV-1/2 Detect and Gene Xpert). As part of this, Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) is working with partners to speed up early infant diagnosis using new diagnostic kits recently prequalified by WHO in nine countries in sub-Saharan Africa. The project aims to test 320,000 children by 2019 and to provide test results within 48 hours.
If diagnosis is missed in infants, or if HIV-exposed infants are not tested at the end of the breastfeeding period, children can go for years without HIV diagnosis due to lack of healthcare provider-initiated testing.
“We’ve focused on early infant diagnosis but the yield we have achieved through that is very low and data coming from countries says we should be looking elsewhere. Provider-initiated testing has got to be part of this,” Chewe Luo of UNICEF told a meeting organised by the World Health Organization on Monday.
Provider-initiated testing needs to include opportunities to test outside medical facilities. Lesotho’s health minister Dr Molotsi Monyamane told the Paediatric strategy launch that national policy has been changed to allow lay counsellors to test children at community-based facilities, and mobile outreach services are providing under-5 and maternal-child health services that include HIV testing.
Making HIV tests a routine part of child health care would go a long way to improving HIV diagnosis for children, and community-based campaigns such as Lesotho’s `Know Your Child’s Status’ are also needed to ensure that children can be diagnosed before HIV disease progression. TB clinics are an important site for diagnosing adolescents: Francesca Celletti of the Elisabeth Glaser Pediatric AIDS Foundation reported results on the yield of positive diagnoses at different types of EGPAF-supported sites in Kenya, showing that TB clinics are vastly more likely to identify adolescents with HIV than other testing sites, underlining the importance of adolescent-friendly TB services.