Early diagnosis is critical to ensure good outcomes in HIV-infected children: outlining barriers to care

Abstract

HIV-infected children require early initiation of antiretroviral therapy (ART) to ensure good outcomes. The aim was to investigate missed opportunities in childhood HIV diagnosis leading to delayed ART initiation. Baseline data were reviewed of all children aged <15 years referred over a 1-year period for ART initiation to the Kalafong Hospital HIV services in Gauteng, South Africa. Of the 250 children, one-quarter (24.5%) was of school-going age, 34.5% in the preschool group, 18% between 6 and 12 months old and 23% below 6 months of age (median age = 1.5 years [interquartile range 0.5–4.8]). Most children (82%) presented with advanced/severe HIV disease, particularly those aged 6–12 months (95%). Malnutrition was prominent and referrals were mostly from hospital inpatient services (61%). A structured caregiver interview was conducted in a subgroup, with detailed review of medical records and HIV results. The majority (≥89%) of the 65 interviewed caregivers reported good access to routine healthcare, except for postnatal care (26%). Maternal HIV-testing was mostly done during the second and third pregnancy trimesters (69%). Maternal non-disclosure of HIV status was common (63%) and 83% of mothers reported a lack of psychosocial support. Routine infant HIV-testing was not done in 66%, and inadequate reporting on patient-held records (Road-to-Health Cards/Booklets) occurred frequently (74%). Children with symptomatic HIV disease were not investigated at primary healthcare in 53%, and in 68% of families the siblings were not tested. One-third of children (35%) had a previous HIV diagnosis, with 77% of caregivers aware of these prior results, while 50% acknowledged failing to attend ART services despite referral. In conclusion, a clear strategy on paediatric HIV case finding, especially at primary healthcare, is vital. Multiple barriers need to be overcome in the HIV care pathway to reach high uptake of services, of which especially maternal reasons for not attending paediatric ART services need further exploration.

Keywords:

• Children
• HIV diagnosis
• antiretroviral therapy
• barriers to care

Acknowledgements

We thank all the mothers/caregivers and the children who participated in the study, as well as the staff from the Kalafong Paediatric HIV services. We would also like to thank LAW Hahne and Pierre Meyer for the design of the clinic and study databases, respectively, and Gayle Sherman for verification of the laboratory data. The last two authors are acknowledged for their Ph.D. supervision of the first author, and Barbara English of the research office in the University of Pretoria's Faculty of Health Sciences is thanked for her copy editing of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.