Assembling an effective paediatric HIV treatment and prevention toolkit
Authors: Lucie Cluver, Lorraine Sherr, Ashraf Grimwood, Linda Richter, B Ryan Phelps, Gretchen Bachman, Chris Desmond, Nicole R Behnam, Geoffrey Fatti, Hoosen Coovadia
Journal: The Lancet Global Health (2014)

The world has woken up to the importance of antiretroviral treatment and HIV prevention for children and adolescents. There is a clear need to expand access to paediatric treatment and prevention by building clinical delivery mechanisms. But stand-alone clinical services are insufficient: uptake of antiretroviral therapy (ART) and adherence remain suboptimal, and adolescent HIV incidence remains high.To improve paediatric survival, several psychosocial and economic barriers to treatment and prevention must be overcome. Such barriers include depression and stigma, which inhibit treatment adherence;1Lowenthal ED Bakeera-Kitaka S Marukutira T Chapman J Goldrath K Ferrand RA Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges.Lancet Infect Dis. 2014; (published online Jan 7.)http://dx.doi.org/10.1016/S1473-3099(13)70363-3PubMed Google Scholar psychological and community barriers to the prevention of vertical transmission;2Gourlay A Birdthistle I Mburu G Iorpenda K Wringe A Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review.J Int AIDS Soc. 2013; 16: 18588Crossref PubMed Scopus (274) Google Scholar and severe poverty and child abuse, which are risk factors for transactional sex in adolescent girls.3Cluver L Orkin M Boyes M Gardner F Meinck F Transactional sex amongst AIDS-orphaned and AIDS-affected adolescents predicted by abuse and extreme poverty.J AIDS. 2011; 58: 336-343Crossref PubMed Scopus (114) Google ScholarUntil now, we have lacked substantive evidence of effective interventions to overcome these barriers. But the past 18 months have seen a body of new randomised trials and cohort studies that demonstrate the effectiveness of combination approaches.In 2013–14, new studies showed that addition of care and support interventions to clinical services maximises ART treatment outcomes. A cluster randomised trial4Lewycka S Mwansambo C Rosato M et al.Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial.Lancet. 2013; 381: 1721-1735Summary Full Text Full Text PDF PubMed Scopus (122) Google Scholar in Malawi found that women's support groups reduced perinatal mortality (odds ratio 0·67, 95% CI 0·50–0·88), neonatal mortality (0·59, 0·40–0·86), infant mortality (0·72, 0·56–0·94), and maternal mortality (0·26, 0·10–0·70). In a multicentre cohort study in South Africa,5Grimwood A Fatti G Mothibi E Malahlela M Shea J Eley B Community adherence support improves programme retention in children on antiretroviral treatment: a multicentre cohort study in South Africa.J Int AIDS Soc. 2012; 15: 17381Crossref PubMed Scopus (60) Google Scholar, 6Fatti G Shaikh N Eley B Grimwood A Improved virological suppression in children on antiretroviral treatment receiving community-based adherence support: a multicentre cohort study from South Africa.AIDS Care. 2014; 26: 448-453Crossref PubMed Scopus (37) Google Scholar psychosocial support reduced paediatric mortality (adjusted hazard ratio 0·39, 95% CI 0·15–1·04), increased virological suppression (odds ratio 1·60, 1·35–1·89), and increased retention in ART services (adjusted hazard ratio 0·57, 0·35–0·94). Also in South Africa, two randomised trials7Richter L Rotheram-Borus MJ Van Heerden A et al.Pregnant women living with HIV (WLH) supported at clinics by peer WLH: a cluster randomized controlled trial.AIDS Behav. 2014; 18: 706-715Crossref PubMed Scopus (58) Google Scholar, 8Tomlinson M Doherty T Ijumba P et al.Goodstart: a cluster randomised effectiveness trial of an integrated, community-based package for maternal and newborn care, with prevention of mother-to-child transmission of HIV in a South African township.Trop Med Int Health. 2014; 19: 256-266Crossref PubMed Scopus (67) Google Scholar of maternal peer mentoring increased height-for-weight Z-scores of HIV-infected and exposed infants (odds ratios 3·32 and 0·09, respectively). The trials also tested augmentation of clinical prevention of parent-to-child transmission (PPTCT). The first trial improved adherence to infant ART (odds ratio 1·72, 95% CI 1·04–2·86), maternal ART (odds ratio 0·44, 0·26–0·74), and single feeding method after birth (1·72, 1·08–2·75).7Richter L Rotheram-Borus MJ Van Heerden A et al.Pregnant women living with HIV (WLH) supported at clinics by peer WLH: a cluster randomized controlled trial.AIDS Behav. 2014; 18: 706-715Crossref PubMed Scopus (58) Google Scholar The second increased exclusive breastfeeding (relative risk 1·92, 1·59–2·33).8Tomlinson M Doherty T Ijumba P et al.Goodstart: a cluster randomised effectiveness trial of an integrated, community-based package for maternal and newborn care, with prevention of mother-to-child transmission of HIV in a South African township.Trop Med Int Health. 2014; 19: 256-266Crossref PubMed Scopus (67) Google ScholarNew evidence shows that interventions to mitigate socioeconomic adversity have HIV-prevention effects. In 2012, a cluster randomised trial in Malawi9Baird SJ Garfein RS McIntosh CT Ozler B Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial.Lancet. 2012; 379: 1320-1329Summary Full Text Full Text PDF PubMed Scopus (414) Google Scholar showed that cash transfer provision reduced HIV incidence (odds ratio 0·36, 95% CI 0·14–0·91). In 2013, national child-focused government grants in South Africa reduced adolescent girls' transactional sex (0·49, 0·26–0·93) and age-disparate sex (0·29, 0·13–0·67).10Cluver L Boyes M Orkin M Molwena T Sherr L Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study.Lancet Glob Health. 2013; 1: e362-e370Summary Full Text Full Text PDF Scopus (150) Google Scholar A propensity-matched study in South Africa and a cluster randomised trial in Kenya in 2014 both showed delayed sexual debut among adolescents receiving grants.11Department of Social DevelopmentSASSAUNICEFThe South African Child Support Grant impact assessment: evidence from a survey of children, adolescents and their households. UNICEF South Africa, Pretoria2012Google Scholar, 12Handa S Halpern CT Pettifor A Thirumurthy H The government of Kenya's cash transfer program reduces the risk of sexual debut among young people age 15–25.PloS One. 2014; 9: e85473Crossref PubMed Scopus (101) Google Scholar A further study tested augmentation of grants with social support from parents or teachers: "cash plus care" was more effective than cash alone, reducing HIV-risk behaviour incidence for boys (0·50, 0·31–0·82) and girls (0·55, 0·35–0·85).13Cluver L, Orkin M, Boyes M, Sherr L. Cash plus care: social protection cumulatively mitigates HIV-risk behaviour among adolescents in South Africa. AIDS (in press).Google ScholarThe evidence suggests that insufficient programming for psychosocial care and economic support of AIDS-affected children is detrimental to successful treatment and prevention. A strength of our HIV community has been its swift use of new evidence to improve clinical outcomes. To close the treatment gap for children and adolescents, we must be equally swift in using the latest evidence on care and support. Only when effective treatment and prevention are combined with psychosocial care and economic support will we close the gap and progress towards an AIDS-free generation.We declare that we have no competing interests. The world has woken up to the importance of antiretroviral treatment and HIV prevention for children and adolescents. There is a clear need to expand access to paediatric treatment and prevention by building clinical delivery mechanisms. But stand-alone clinical services are insufficient: uptake of antiretroviral therapy (ART) and adherence remain suboptimal, and adolescent HIV incidence remains high. To improve paediatric survival, several psychosocial and economic barriers to treatment and prevention must be overcome. Such barriers include depression and stigma, which inhibit treatment adherence;1Lowenthal ED Bakeera-Kitaka S Marukutira T Chapman J Goldrath K Ferrand RA Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges.Lancet Infect Dis. 2014; (published online Jan 7.)http://dx.doi.org/10.1016/S1473-3099(13)70363-3PubMed Google Scholar psychological and community barriers to the prevention of vertical transmission;2Gourlay A Birdthistle I Mburu G Iorpenda K Wringe A Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review.J Int AIDS Soc. 2013; 16: 18588Crossref PubMed Scopus (274) Google Scholar and severe poverty and child abuse, which are risk factors for transactional sex in adolescent girls.3Cluver L Orkin M Boyes M Gardner F Meinck F Transactional sex amongst AIDS-orphaned and AIDS-affected adolescents predicted by abuse and extreme poverty.J AIDS. 2011; 58: 336-343Crossref PubMed Scopus (114) Google Scholar Until now, we have lacked substantive evidence of effective interventions to overcome these barriers. But the past 18 months have seen a body of new randomised trials and cohort studies that demonstrate the effectiveness of combination approaches. In 2013–14, new studies showed that addition of care and support interventions to clinical services maximises ART treatment outcomes. A cluster randomised trial4Lewycka S Mwansambo C Rosato M et al.Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial.Lancet. 2013; 381: 1721-1735Summary Full Text Full Text PDF PubMed Scopus (122) Google Scholar in Malawi found that women's support groups reduced perinatal mortality (odds ratio 0·67, 95% CI 0·50–0·88), neonatal mortality (0·59, 0·40–0·86), infant mortality (0·72, 0·56–0·94), and maternal mortality (0·26, 0·10–0·70). In a multicentre cohort study in South Africa,5Grimwood A Fatti G Mothibi E Malahlela M Shea J Eley B Community adherence support improves programme retention in children on antiretroviral treatment: a multicentre cohort study in South Africa.J Int AIDS Soc. 2012; 15: 17381Crossref PubMed Scopus (60) Google Scholar, 6Fatti G Shaikh N Eley B Grimwood A Improved virological suppression in children on antiretroviral treatment receiving community-based adherence support: a multicentre cohort study from South Africa.AIDS Care. 2014; 26: 448-453Crossref PubMed Scopus (37) Google Scholar psychosocial support reduced paediatric mortality (adjusted hazard ratio 0·39, 95% CI 0·15–1·04), increased virological suppression (odds ratio 1·60, 1·35–1·89), and increased retention in ART services (adjusted hazard ratio 0·57, 0·35–0·94). Also in South Africa, two randomised trials7Richter L Rotheram-Borus MJ Van Heerden A et al.Pregnant women living with HIV (WLH) supported at clinics by peer WLH: a cluster randomized controlled trial.AIDS Behav. 2014; 18: 706-715Crossref PubMed Scopus (58) Google Scholar, 8Tomlinson M Doherty T Ijumba P et al.Goodstart: a cluster randomised effectiveness trial of an integrated, community-based package for maternal and newborn care, with prevention of mother-to-child transmission of HIV in a South African township.Trop Med Int Health. 2014; 19: 256-266Crossref PubMed Scopus (67) Google Scholar of maternal peer mentoring increased height-for-weight Z-scores of HIV-infected and exposed infants (odds ratios 3·32 and 0·09, respectively). The trials also tested augmentation of clinical prevention of parent-to-child transmission (PPTCT). The first trial improved adherence to infant ART (odds ratio 1·72, 95% CI 1·04–2·86), maternal ART (odds ratio 0·44, 0·26–0·74), and single feeding method after birth (1·72, 1·08–2·75).7Richter L Rotheram-Borus MJ Van Heerden A et al.Pregnant women living with HIV (WLH) supported at clinics by peer WLH: a cluster randomized controlled trial.AIDS Behav. 2014; 18: 706-715Crossref PubMed Scopus (58) Google Scholar The second increased exclusive breastfeeding (relative risk 1·92, 1·59–2·33).8Tomlinson M Doherty T Ijumba P et al.Goodstart: a cluster randomised effectiveness trial of an integrated, community-based package for maternal and newborn care, with prevention of mother-to-child transmission of HIV in a South African township.Trop Med Int Health. 2014; 19: 256-266Crossref PubMed Scopus (67) Google Scholar New evidence shows that interventions to mitigate socioeconomic adversity have HIV-prevention effects. In 2012, a cluster randomised trial in Malawi9Baird SJ Garfein RS McIntosh CT Ozler B Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial.Lancet. 2012; 379: 1320-1329Summary Full Text Full Text PDF PubMed Scopus (414) Google Scholar showed that cash transfer provision reduced HIV incidence (odds ratio 0·36, 95% CI 0·14–0·91). In 2013, national child-focused government grants in South Africa reduced adolescent girls' transactional sex (0·49, 0·26–0·93) and age-disparate sex (0·29, 0·13–0·67).10Cluver L Boyes M Orkin M Molwena T Sherr L Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study.Lancet Glob Health. 2013; 1: e362-e370Summary Full Text Full Text PDF Scopus (150) Google Scholar A propensity-matched study in South Africa and a cluster randomised trial in Kenya in 2014 both showed delayed sexual debut among adolescents receiving grants.11Department of Social DevelopmentSASSAUNICEFThe South African Child Support Grant impact assessment: evidence from a survey of children, adolescents and their households. UNICEF South Africa, Pretoria2012Google Scholar, 12Handa S Halpern CT Pettifor A Thirumurthy H The government of Kenya's cash transfer program reduces the risk of sexual debut among young people age 15–25.PloS One. 2014; 9: e85473Crossref PubMed Scopus (101) Google Scholar A further study tested augmentation of grants with social support from parents or teachers: "cash plus care" was more effective than cash alone, reducing HIV-risk behaviour incidence for boys (0·50, 0·31–0·82) and girls (0·55, 0·35–0·85).13Cluver L, Orkin M, Boyes M, Sherr L. Cash plus care: social protection cumulatively mitigates HIV-risk behaviour among adolescents in South Africa. AIDS (in press).Google Scholar The evidence suggests that insufficient programming for psychosocial care and economic support of AIDS-affected children is detrimental to successful treatment and prevention. A strength of our HIV community has been its swift use of new evidence to improve clinical outcomes. To close the treatment gap for children and adolescents, we must be equally swift in using the latest evidence on care and support. Only when effective treatment and prevention are combined with psychosocial care and economic support will we close the gap and progress towards an AIDS-free generation. We declare that we have no competing interests.