In 2010, in response to emerging data showing dramatic survival benefits of early ART initiation among HIV-infected infants and children, WHO issued the revised Recommendations on the Diagnosis of HIV infection in Infants and Children1. Key elements include:
- HIV virological testing to be used to diagnose HIV infection in infants and children below 18 months of age.
- All HIV-exposed infants to have HIV virological testing at 4-6 weeks of age or at the earliest opportunity thereafter.
- nfants with an initial positive virological test result to start ART without delay, and, at the same time, a second specimen to be collected to confirm the initial positive virological test result.
- Infants with signs and symptoms suggestive of HIV infection to undergo screening with HIV serological testing and if positive, follow with virologic testing to confirm infection.
- Well, HIV-exposed infants to undergo HIV serological testing at around 9 months of age (or at the time of the last immunization visit). Infants with reactive serological assays at 9 months to receive a virological test to identify HIV-infected infants who need ART.
- Children 18 months or older, with suspected HIV infection or HIV exposure, to have HIV serological testing performed according to the standard diagnostic HIV serological testing algorithm used in adults. Early diagnosis of HIV infection is essential for ensuring timely initiation of ART and reducing the high morbidity and mortality that occurs among HIV-infected children who do not receive treatment2. Using a pooled analysis of data from 12 studies in sub-Saharan Africa, Marston et al estimated that without treatment, net survival at one year would be 52% among infants infected prenatally (with 20% having demised by 90 days) and 78% among infants infected during breastfeeding3 . While disease progression is particularly rapid in the first few months of life in those infants infected parentally, early initiation of ART has been shown to significantly reduce the risk of mortality2. Infants and children who present with more advanced disease have a far worse prognosis even if ART is initiated4. It is critical for HIV-infected infants to be diagnosed as early as possible in order to begin life-saving treatment before the virus has had a chance to take its toll. Although mother-to-child transmission rates have been reduced to less than 5% in some low and middle-income countries 330,000 children were still newly infected in 2011 as only 57% of the estimated 1.5 million pregnant women living with HIV in low and middle-income countries received effective antiretroviral drugs to avoid vertical transmission to their child5 . Mothers with advanced disease, such as those with CD counts less than 350 cells/mL are at highest risk for transmitting the virus to their children but of the estimated 620,000 women who were eligible for ART for their own health in 2011, only 190,000 (31%) were initiated on ART6 . Overall PMTCT coverage rates for the 21 priority countries in sub-Saharan Africa was only at 61% during pregnancy and delivery and further decreased to 28% during breastfeeding5 . In 2010, among 65 reporting countries, only 28% of infants born to mothers living with HIV received an HIV test within the first two months of life6. While early treatment is known to dramatically decrease morbidity and mortality from HIV infection, ART coverage of HIV-infected children still remains low at 28% and in 2011 out of the estimated 3.4 million children living with HIV globally, 230,000 died from AIDS-related illnesses5. 1 WHO recommendations on the Diagnosis of HIV infection in Infants and Children. 2010 2 Violari et al. for the CHER Study Team. N Engl J Med 2008; 359:2233-2244 3 Marston et al. Net survival of parentally and postnatal infected children: a pooled analysis of individual data from sub-Saharan Africa. International Journal of Epidemiology, 2011,40:385-396 4 KIDA-ART-LINK Collaboration. Low risk of death but substantial program attrition, in pediatric HIV treatment cohorts in sub-Saharan Africa. JAIDS. 2008. 49(5):p523-31 5 Together we will end AIDS. UNAIDS. 2012 6 UNAIDS Progress Report Summary. 2011. EID coverage rates at the end of 2011 were not reported in the more recent UNAID Progress Report, 2012 EARLY INFANT DIAGNOSIS IATT Laboratory & Child Survival Working Group GSG Mid Term Review Meeting, December 6-7, 2012 | 2 Clearly there is more work to be done to identify HIV infected infants earlier and initiate lifesaving treatment. An effective EID program is the first step to ensuring the survival of this vulnerable population.