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Background: The context of HIV prevention and treatment for children in South Africa has significantly improved and there is a recent shift toward birth early infant diagnosis and early infant antiretroviral therapy (ART). We describe the characteristic and outcomes of children initiating ART in the context of changing paediatric HIV testing and treatment guidelines in South Africa.
Methods: A retrospective cohort analysis was conducted using data from the IeDEA-SA collaboration. HIV-infected children initiating combination ART at < 3 months old, from 2006-2016 were included. We described changes in characteristics of children starting ART and mortality, loss to follow-up (LTFU) and transfer out by 12 months on ART.
Results: Among 1380 infants, the median age at ART initiation was 62 days (interquartile range (IQR) 37-79); median time on ART was 13.6 months (IQR 4.0-34.5). The median age at ART start decreased from 67 days (IQR 53-81) in 2006-2009 to 48 days (IQR 9-74) in 2013+ (p< 0.001). There was a decline in median log viral load at ART initiation from 5.9 (IQR 5.4- 6.4) in 2006-2009 to 5.4 (IQR 3.9-6.3) in 2013+ (p< 0.001). The median absolute CD4 count (cells/µL) increased progressively from 888 (IQR 380-1703) in 2006-2009 to 1526 (IQR 659-2231) in 2013+ (p< 0.001). Among infants with data on WHO disease staging (n=865), 84% (n=299) started ART with WHO disease stage 3/4 in 2006-2009 compared to 39% (n=279) in 2013+ (p< 0.001). After 1 year on ART, 11% (median age 68 days (IQR 55-75)) and 4% (median age 60 days (IQR 25-83)) of children died in 2006-2009 and 2013+ respectively (p< 0.001). LTFU increased from 7% in 2006-2009 to 21% in 2013+ (p=0.002) and transfer out declined from 20% in 2006-2009 to 12% in 2013+ (p< 0.001).
Conclusions: Children are starting ART earlier, with less progressive disease and associated declines in mortality; however mortality and LTFU in infants starting ART remains unacceptably high. In view of the scale up of birth PCR testing in South Africa, a significant proportion of children still start ART with advanced disease, highlighting the need for a focused approach to early infant HIV testing and follow-up on ART.