key: cord-0982243-jd3f3exb
authors: Spencer, David C.
title: Southern African Journal of HIV Medicine August 2021
date: 2021-10-15
journal: South Afr J HIV Med
DOI: 10.4102/sajhivmed.v22i1.1309
sha: 298552fc0db0a3db8dc9ba772c5840c8f8db9848
doc_id: 982243
cord_uid: jd3f3exb

nan

The UNAIDS 2025-2030 targets include the following: ≥ 95% of those living with HIV to know their HIV status, ≥ 95% of this group to have started and remain on antiretroviral therapy (ART) and ≥ 95% of those on treatment to have persistently undetectable viral loads by 2025-2030.

'Know your epidemic, know your response' (Wilson et al. 2008, Further reading) . Our authors argue that a new commitment and new targets are needed for the current decade. A total of 20.7 million, or 54%, of the globe's 38 million people living with HIV live in ESA. Most (87%; range: 15% -98%) are aware of their diagnosis, 83% (37% -98%) are on ART, and 90% (68% -97%) of these have suppressed viral loads. Interpret the numbers with caution: ranges and confidence intervals are wide, the background data is incomplete, and many clinics and individuals are likely to have been missed. The problems include the following:

• Retention in care. Africa's men are still too easily lost from care. • Infrastructure. There are too few high-throughput labs and insufficient point-of-care tests and testing. • The neglected. How well represented are our key populations and are these being adequately reached? Our men who have sex with men, those who inject drugs, female sex workers, the truck drivers, the migrants, mobile miners, the serodiscordant couples, pregnant women and their infants? Why are these so often missed?

The authors question whether these key groups are on the 2030 roadmap. To this, they add the 'acutely infected' -a highrisk transmission group. How well are these groups being recognised and targeted in ESA? The authors draw attention to multiple gaps -multiple opportunities -throughout ESA. This is an important article. It asks pertinent questions and gives some answers:

• Promote and expand local prevention research (and implementation The article provides the reader with numbers. Between 2010 and 2019, South Africa's total HIV-infected population increased from 5.9 to 7.64 million. In the same period, the overall HIV incidence rate fell by 55%. South Africa's children are falling behind. The achieved overall targets in children were 79-47-34! While peripartum and pregnancy-related mother-to-child transmission in South Africa is now uncommon, breastfeeding-related transmission (4.3%) continues. And children infected in infancy still slip through the net to reappear, treatment naïve, in late childhood or adolescence. The second half of the article discusses advances in the management of children living with HIV in South Africa. Medication, adherence and 'responsible care' are nonetheless persistent points of worry, as are health systems. The authors cite the 7-year delay between registration of

Incomplete immune reconstitution in HIV/AIDS patients on antiretroviral therapy: Challenges of immune non-responders

Virologic failure following persistent low-level viremia in a cohort of HIV-positive patients: Results from 12 years of observation

South African HIV clinicians' society guidelines for antiretroviral therapy in adults: 2020 update

The authors follow the trajectory of the CD4+ cell count post-ART initiation in a large anonymised electronic South African patient database, the Three Interlinked Electronic Registers project, or TIER.Net. Records are from 2004-2021 and describe 1 178 190 persons in the South African public sector on ART in two urban (Gauteng) and two rural (Limpopo) settings. Overall, baseline CD4+ cell counts were low: 50% had CD4+ counts of < 200 cells/µL. By 2017, this percentage had improved to 37.2%. However, only 46.5% of CD4 counts captured on TIER.Net were repeated. Of these, 14.3% PLWH (n = 78 494) remained with CD4 counts of < 200 cells/µL. Indeed, 20% (n = 18 566) of those on ≥ 4 years of ART and with viral suppression, viz. a viral load (VL) of < 1000 copies/mL, were immune-non-responders or immune-discordant responders (Further reading: Yang et al. 2020; Laprise et al. 2013) . The latter were likely to be on second-line ART (adjusted odds ratio [aOR], 1.79), older, viz. 35-45 years and particularly, > 45 years (aOR, 1.15 and 1.50, respectively), male (aOR, 2.28) and to have confirmed tuberculosis (aOR, 2.49). Baseline CD4 cell counts of > 350 cells/µL were protective of long-term immune deficiency (aOR: 0.35)!

an essential fixed-dose paediatric generic-combination antiretroviral by the Food and Drug Administration in the United States and registration in South Africa.The good news in this report is in the new drug formulations for the very young: a dispersible, scored combination of abacavir/lamivudine (120/60 mg) for children weighing from 3 kg to 25 kg and a dispersible, scored 10 mg dolutegravir tablet to treat children from 4 weeks of age or weighing > 3 kg. These await approval by the South African Health Products Agency (SAHPRA). Future innovations? The long-acting injectables (8-weekly cabotegravir/ rilpivirine) for children and adolescents aged 12-18 years. Will these be the answer to the current unimpressive viral suppression rates?What about the larger context of children's health on our subcontinent? Consider that in the first year of the COVID-19 epidemic, 23 000 teenage (10-19 years) pregnancies occurred in South Africa's Gauteng province, of which 934 were in girls aged 10-14 years (Further reading: Bengu 2021). Genderbased violence takes many forms. This is one. The subtext of this article is exactly that society's children, particularly those living with HIV, deserve better. Children lag behind. The childhood gap in the diagnosis of HIV, treatment and viral suppression must be closed before 2030.

• Bhengu L. Gauteng records more than 23 000 teen pregnancies in one year, some moms as young as 10. News24 , 2021 August 17. This is an article that should be read and its message ruminated on.