Mother-to-child, or ‘vertical’, transmission of HIV is not just a problem for developing countries; even in countries like the US and the UK, peri-natal transmission has probably not been eliminated. But, with routine ‘opt-out’ ante-natal testing (BHIVA guidelines on HIV testing), cases are increasingly likely to involve births that have taken place overseas or before parental diagnosis (CHIVA guidelines on child testing) – cases that, for various reasons, may be difficult for health services to access (Editorial: ‘Don’t Forget the Children’ (STI)). Yet, even with such events becoming less frequent, and the increasing survival of peri-natally HIV-infected youth (PHIVY) beyond infancy, there remains the problem of managing those already infected, as they transition, in growing numbers, from childhood into adolescence and young adulthood.
Such problems are very considerable, according to Nailan & Ciaranello (N&C) – especially for adolescents (13-17yrs) and young adults (18-30yrs). This recent study offers an analysis of data of PHIVY aged 7-30 years from two cohort studies in the US, the Pediatric HIV/AIDS Cohort Study (PHACS) and the International Maternal Pediatric Adolescent AIDS Clinical Trials study (IMPAACT). As compared with the younger group (7-13 yrs), adolescents (13-18yrs) and young adults (18-30yrs) are likely to spend considerably more time with inadequate viral suppression (5% and 18% vs 2% with CD4 count <200/µL; 30% and 44% vs 22% with a viral load of ≥400 copies/mL), and to suffer correspondingly greater mortality (c.1 per 100 person-years amongst young adults) as well as HIV related events (c. 2 and 4 per 100 py. for CDC C and B category events amongst 18-30 yrs; c. 1 and 3 per 100 py. for CDC C and B category events amongst 13-18yrs). The authors attribute inadequate viral suppression, and high mortality/morbidity, to poor adherence and retention in care.
The vulnerability of PHIVY as a group to poor health outcomes is not a problem unique to the US. In the UK c.1,950 PHIVY are monitored through the Collaborative HIV Pediatric Study (CHIPS) cohort, and the data indicate comparable problems of inadequate viral suppression (around one in ten (CHIVA guidelines on transition)). In some developing countries the health problems of this group are still more evident. De Matos & dal Fabbro (STI), analysing the data for a cohort of 78 patients, aged 11-15 in 2009, from a municipality in Brazil, report five deaths, amongst other serious health events. More generally, the UNAIDS 2016 Report (The ‘life-cycle’ approach (STI/blogs) points, in the case of sub-Saharan Africa, to the recent tripling in peri-natally infected 15-19 yr olds who now account for 40% of all HIV-infected 15-19 yr olds in the region. Not only does poor adherence pose problems for PHIVY themselves; Nailan & Ciaranello also draw attention to the danger they represent for society at large, given rates of pregnancy and risky sex that appear no lower than in the general population, along with heightened transmission risk resulting from poor viral suppression, and, in some cases, emerging drug resistance.