Page 378 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 8 Original Research

treatment group, apart from the personal–social subscale helpful. However, we have experience in this community
(Table 5), which is the most subjective as caregiver report using the GMDS and are able to use these results for
items are used, and may reflect a change in child-rearing comparison 30,32 (Appendix 1, Table 3-A1). The confounding
practices over time with less emphasis on self-care skills. The problems of mothers with substance abuse did not seem to
CHER early treatment arms had a mean baseline VL of log have a major impact, but the limitation is probably sample size.
10
copies/mL 5.64 which is far higher than the current study
and baseline mean CD percentage of 35% which is lower than Our findings are relevant to upscaling neonatal HIV
the current study, and longer time to undetectable VL. This identification and care. 45,46 While the number of HIV+ infants
may suggest that there is a safe window period for starting is decreasing, this population remains at high risk because
ART – between birth and a median of 7.7 weeks; however, of structural and behavioural challenges in providing
these are early neurodevelopmental outcomes. Alternatively, appropriate care. As liquid Lopinavir/Ritonavir formulation
were it not for adverse in utero exposures and non-suppressed is poorly tolerated, newer formulations and other alternatives
VLs in six infants, the scores may have been higher than such as integrase inhibitors will be better accepted. Healthcare
CHER early treatment participants. The early diagnosis of planners should not downscale programmes according to
HIV+ infants within 48 h in 24% and by 7 days of age in 59% decreasing numbers, as those failing PMTCT require a higher
reflects high proportion of prenatal HIV infection, which also level of care and intensive intervention to enable benefit
negatively impacts outcomes. In the CHER trial, in utero from early ART. With the potential of early ART to limit
infection could not be assessed as infant screening began at HIV reservoir seeding, and potential to contribute to
4–6 weeks of age for HIV. functional cures, treatment programmes need to support
these vulnerable infants and their caregivers. Mentor
47
An important finding is that we identified a number of mothers as treatment supporters may decrease the burden
challenges within the context of perinatal HIV infection, of HIV care and consequences of developmental delay, and
despite good PMTCT programmes. In those perinatally could be very important when planning programmes. If
48,49
infected infants, a number of secondary effects, including these needs can be met, our findings are encouraging.
systemic illnesses and environmental affects, may negatively
impact a child’s early neurodevelopment. 39,40,41 In our sample, Conclusion
we identified three with no prenatal care, three substance Preliminary findings in this small group suggest that despite
abuse, two congenital infections (syphilis and pneumonia PMTCT failure, children infected perinatally with HIV may
of unknown aetiology), one co-infected with tuberculosis have typical neurodevelopment if starting ART at a median
and one nutritional failure. Growth in participants was age of 6 days, and similar to those starting ART at a median of
appropriate for weight and head circumference, but mean 7 weeks. Good supportive care, including for ART adherence,
length z-score was -1.1. is essential. A larger cohort that includes controls is in study
and the findings at 18 months of age will inform on the
We noted variability of ART adherence and the delay in influence of time to VL suppression and reservoir size and
attaining competence with ART dosing and adherence, also the influence of social factors and demographic factors on
with six children not yet suppressed at the time of GMDS neurodevelopmental outcomes. This may also allow for more
assessment. Management of these young children was precise study of locomotor outcomes.
challenging as caregivers were non-compliant, under-skilled
and found difficulty administering liquid formulations. Acknowledgements
Solid or dispersible formulations would certainly improve
adherence. 42,43 Our findings do not suggest neurotoxicity The authors thank the parents and babies who were willing to
from ART. be part of this study, as well as the research support team at the
Family Centre for Research with Ubuntu and Médecins Sans
This work had some limitations. As multiple factors may Frontières [Doctors Without Borders] (MSF) Khayelitsha for
influence outcomes, 29 children starting ART very early are providing excellent care; Martin Kidd for statistics help; and
too few to assess weak associations with neurodevelopmental Helen Payne, Di Gibb, Nigel Klein, Jean Maritz and Wolfgang
outcomes, including our finding of lower locomotor scores Preiser who contributed to the original study design.
compared to other subscales. More girls than boys were
enrolled in the sample; although previously described, Competing interests
44
this may be because of small sample size. We were not able The authors have declared that no competing interests exist.
to determine reliable predictors for neurodevelopmental
outcomes, or compare the outcomes of suppressed and
unsuppressed participants. This was also hindered by time to Authors’ contributions
suppression being inaccurate as VLs were only done at B.L. was the primary author of the article and was responsible
baseline 3, 6 and 12 months. We did not collect information for neurodevelopmental testing; S.N. was responsible for
on maternal health, immune status, VL or antiretroviral lymphocyte subtest testing and provided input into the
therapies. In the absence of South African normative data on article writing; E.F.M.T.D. was the clinician on study
the GMDS, a control or comparison group would have been managing infants and assisted with the article writing; M.J.B.

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