Maximising opportunities for increased antiretroviral treatment in children in an existing HIV programme in rural South Africa

Problem: Infants and young children infected with HIV as a result of mother to child transmission are not being identified or started with antiretroviral treatment (ART) in line with HIV guidelines in resource limited settings. Design: Retrospective analysis of data from a paediatric cohort before and after an intervention strategy. Setting Rural public HIV treatment programme in the province of KwaZulu-Natal, South Africa. Key measures: for improvement Increase in the number of HIV infected infants and children who start HIV treatment each year; increase in the proportion of children starting ART with less immune suppression, shown by higher CD4 counts and less advanced World Health Organization clinical stages for HIV. Strategies for change: Late 2008: training in paediatric HIV for all staff in contact with mothers and children; campaigns for increased HIV testing at immunisation and clinics; routine testing of children with tuberculosis and malnutrition for HIV, and HIV testing of all children admitted to hospital. The establishment of a family HIV clinic in late 2007. Effects of change: The number of children (1 year to ≤15 years) starting ART each year increased from 43 in 2004 to 254 in 2011; the corresponding number of infants (>1 year) starting treatment increased from 2 to 59. A trend towards increasing CD4 counts at the start of treatment was found. Lessons learnt: It is possible to improve the identification of HIV infected children and ensure a prompt start on ART where needed with relatively simple measures and limited implications for staffing and budgets.