Page 74 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 5 Opinion Paper

lower incidence of renal toxicity and decreases in bone background NTD risk. In addition, data from the International
mineral density. A pooled analysis of paediatric TAF studies Antiretroviral Pregnancy Registry (APR) showed an overall
showed high rates of virological suppression (> 90%) with no risk of NTD following peri-conception ART exposure of
13
emergence of resistance when combined with an integrase 0.03%. In the registry, there were only 248 peri-conception
5
inhibitor. In addition, results from a study using TAF/FTC/ DTG exposures with 1 NTD, limiting the ability to make
elvitegravir/cobicistat fixed drug combination (FDC) in definitive conclusions. It was noted that the majority of data
children over 6 years and 25 kg had no serious adverse events for the registry was obtained from the United States/Canada
(Grade 3/4 AEs) with high rates of viral suppression between (75%), with only 7% from Africa, and an appeal was
90% and 100%. Of note is the lack of data on using TAF with made to report peri-conception ART exposure to local
rifampin-based therapy in paediatrics; data in adults suggest pharmacovigilance structures (National Department of
twice daily administration may overcome this interaction. 6 Health, National Pharmacovigilance Centre) and international
pregnancy registries (www.APRegistry.com or https://
Novel delivery methods of ART for treatment and prevention globalbirthdefects.tghn.org). Apart from birth defects, infants
of HIV hold exciting promise for children. Long-acting exposed in utero to HIV and ART had poorer weight-for-age
subcutaneous infusions, injections and implants have shown (WAZ) and length-for-age (HAZ) z-scores compared to HIV-
promise in adults and are moving rapidly into the paediatric unexposed infants. 14
arena. Transdermal drug delivery using an adhesive patch
with micro-needles was described with data in adults Overall, the workshop highlighted major gains that have
achieving acceptable cabotegravir concentrations with once- been achieved in preventing new paediatric infections and
monthly application. This drug delivery method holds treating HIV-infected children and adolescents. However, to
7
several advantages for use in children by allowing flexibility achieve the 90:90:90 goals, new clinical- and community-
to alter doses in a growing child together with easy application based strategies are needed to find and treat patient
and removal, if required. populations that have poor health seeking behaviour and
disruptive social networks that make consistent adherence
Achieving the goals of 90:90:90 requires improved paediatric to a treatment regimen difficult.
case finding which was addressed in a plenary talk and
several oral abstract presentations. Traditional health International AIDS Society
facility-based testing does not identify HIV-infected children conference
before the onset of symptoms. Community-based screening
and index case testing were suggested as an alternative case The main IAS conference covered numerous tracks including
finding strategy for early identification. Untested children basic science, clinical science, prevention science and social,
8
often have siblings or parents that have been previously behavioural and implementation science.
tested, with failure to link other family members into care.
Effective community engagement and participation is In this article, we provide feedback on aspects of the main
necessary to facilitate case finding. In settings with high conference that related to children, adolescents and pregnant
9
burden of infections, early infant diagnosis together with women, with a focus on optimised HIV treatment and
testing during immunisation visits was cost-effective. PMTCT.
10
Getting children to start ART and maintaining viral
suppression in order to achieve the last two 90s is challenging, Optimised maternal antiretroviral treatment and
especially in HIV-infected newborns, young infants and prevention of mother-to-child transmission
adolescents. Stratifying intensity of follow-up, counselling In addition to the eagerly awaited Tsepamo data, presented
and the package of care based on virologic response to in the workshop, additional data were presented from the
therapy was found to be feasible even in rural settings. Botswana Ministry of Health and Wellness, showing a
11
Silent transfers of patients (self or poorly documented prevalence of 0.66% (95% confidence interval [CI] 0.02–3.69)
transfers) between facilities accounted for 65% of patients in women conceiving on DTG-based ART. Although only
15
that were labelled as being lost to follow-up in a cohort from one additional child enrolled in the Tsepamo trial was noted
the Western Cape province, highlighting the challenges with to develop an NTD when following all trial participants
linkage of patients. Improved data management systems up until conclusion of their pregnancies, this prevalence
12
and unique identifiers to track patients were recommended remains higher than reported in women conceiving on any
by the authors. other ART regimen and HIV-negative women. Data from
16
Brazil, where 384 women conceived on DTG, showed
Management of pregnant and lactating women no NTDs (95% CI 0–0.003). These updated findings
17
and prevention of mother-to-child transmission prompted slight wording changes within the World Health
Eagerly awaited results from the Botswana Tsepamo birth Organization (WHO) guidelines, now recommending DTG-
surveillance study on the risk of neural tube defects (NTD) based ART as the preferred regimen for all HIV-infected
in infants born to mothers receiving dolutegravir (DTG) patients, although in women of child-bearing age, an informed
peri-conception were presented indicating a reduction in decision regarding their regimen and contraception must be
the risk from that previously reported, but still above the made before deciding on a DTG- or efavirenz-based regimen. 18

http://www.sajhivmed.org.za 67 Open Access