Estimating Prevalence of Pediatric HIV in Sub-Saharan Africa

Gaps in diagnosis and treatment of pediatric HIV testing across 7 sub-Saharan African countries should be addressed, according to a paper published in The Lancet: HIV.

Investigators from CUNY Graduate School of Public Health and Health Policy in New York conducted an analysis of Population-Based HIV Impact Assessment surveys from 2015 to 2017 and used HIV rapid test data in order to measure the HIV prevalence among children in 7 countries: Eswatini, Lesotho, Malawi, Namibia, Tanzania, Zambia, and Zimbabwe. The surveys used are nationally representative, the study authors said, and measure HIV outcomes. Dried blood spots were also used to detect antiretroviral medication, the study authors added.

World Health Organization guidelines have suggested the “immediate treatment initiation at diagnosis for children living with HIV, regardless of age, to improve survival and development,” the study authors explained.

Using their data, the investigators categorized the more than 42,000 children aged 1 to 14 years based on those with previous or unknown HIV test results and without detectable antiretroviral medication blood concentrations (called the previously undiagnosed group) and those children who tested positive, who were considered previously diagnosed, they said. The study authors determined that 594 children were living with HIV, and said that 61 percent were previously diagnosed and the rest of the children had not been previously diagnosed.

The study authors extrapolated their data to estimate that 425,000 children are living with HIV.

The highest estimated weighted prevalence of HIV among children was found in Eswatini (2.7 percent) and was lowest in Tanzania (0.4 percent), the study authors determined. They also observed that in all of the countries they studied except Tanzania and Zambia, HIV prevalence was higher among children aged 10 to 14 years than compared to children aged younger than 10 years. The median age of children living with HIV was 6 years, they said.

Additionally, the study authors wrote that about two-thirds of children living with HIV had been previously tested for HIV before the survey was conducted. Most of those children (80 percent) reported having HIV-positive results, with the rest having negative, indeterminate, or no results received. A majority of the children’s mothers were alive, and 72 percent of those mothers tested HIV-positive in the survey. The study authors estimated that about 10 percent of mothers were diagnosed before pregnancy, 20 percent were diagnosed during pregnancy with an HIV-positive child, and about 40 percent were diagnosed after the child was born. An additional 20 percent were identified in the survey, the study authors said.

Among the group of children that had been previously diagnosed, a majority (88 percent) had detected antiretroviral medication blood concentrations, and half of the children had viral load suppression, the study authors learned. The investigators also observed that for all the children living with HIV, whether they had been previously or newly diagnosed, about half had detectable antiretroviral medication blood concentrations and a third had viral load suppression.

“It is crucial to identify children living with HIV who are undiagnosed and ensure that they are initiated on ART because of the high mortality among children living with HIV who are not on treatment,” the study authors wrote. Barriers to this testing include finding children who were missed in programs designed to test for the prevention of mother-to-child transmission (PMTCT), a lack of perceived need to test older children, and issues related to disclosure and consent, the study authors noted.

“To close the pediatric treatment gap, urgent efforts are needed to accelerate HIV testing in these settings,” they concluded.