Question 1: What is your opinion on the current state of care for paediatric HIV patients in the public healthcare sector?

There have been huge strides made to bring SA closer to achieving the UNAIDS 95:95:95 goal across the treatment cascade for children, however we have much work to do to achieve these fast track targets. Major successes have been the introduction of paediatric-friendly formulations including dispersible dolutegravir and the dispersible fixed dose combination (FDC) of abacavir and lamivudine.

The recent licensing of a fixed-dose combination (FDC) of abacavir with lamivudine (3TC) and dolutegravir (DTG) in South Africa will bring children as close as we probably can get to a once-daily FDC regimen for children.

In many districts across SA, over 90% of children have been transitioned to a DTG-based therapy. Our major challenge that remains is the identification and linkage to care of children with HIV and maintaining high levels of viral suppression, especially in young children and adolescents.

Question 2: Are we doing enough to train healthcare professionals to care for paediatric HIV patients, especially given the complexity of treatment regimens?

One of the major challenges with training healthcare providers is the high staff turnover, especially in underserved clinics and hospitals. Thankfully, paediatric ART has become far less complicated with the introduction of paediatric-friendly FDCs. Ideally, all healthcare workers should be trained and be comfortable with initiating ART and managing children with HIV.

Medical schools and nursing colleges need to include paediatric HIV management in their curriculum and ensure that junior staff gets exposure to managing children with HIV. With the differential care model, there is a need for nurturing a cadre of HIV experts across the country to manage children with complicated HIV disease.

Question 3: Essentially, how is mother-to-child transmission prevented using current pharmacological methods?

Vertical HIV prevention has been the poster child for the power of HIV prevention, with the number of new HIV infections falling year-on-year in this population. The challenge is maintaining parents on virologically suppressive ART regimens from contraception to the end of breastfeeding and identifying new HIV infections in parents.

The combination of maternal ART and post-exposure prophylaxis is highly effective in preventing new HIV infections in children. Unfortunately, a recurring theme we see when reviewing new paediatric HIV infections are either high maternal viral load during pregnancy or breastfeeding and where the maternal HIV status was not previously known.

Question 4: Could you comment on the use of integrase inhibitors such at dolutegravir and their observed high rates of HIV drug resistance with newborns?

There has been only one probable case of transmitted DTG resistance to a newborn. By and large, DTG is a highly efficacious and safe drug, and newborns will benefit from starting on DTG from birth. This is compared to very high known rates of non-nucleoside reverse transcriptase inhibitors (NNRTIs) resistance that is transmitted even though we use nevirapine for both prophylaxis and treatment of newborns less than a month of age. New data from the Petite and the IMPAACT studies will inform dosing of DTG from birth in the near future.

Question 5: Generally speaking, are long-acting injectables a good therapeutic option for a high-risk population such as neonates?

Long-acting injectable ART holds great promise in removing the daily challenges of administering an oral medication. Apart for infants, I would include adolescents in this high-risk category. The current approved formulations unfortunately come at a high cost and logistic challenges with integrating these modalities into routine care. I think we have embarked on the future direction of HIV and other chronic treatment.

Question 6: What is your opinion on the use of doxycycline as a post-exposure prophylactic for bacterial sexually transmitted infections (STIs) such as syphilis, chlamydia and gonorrhoea? And could you unpack the concerns about emerging drug resistance in patients treated with doxycycline?

Doxy PEP or PrEP should not be seen as a stand-alone intervention and should be considered within the context of an armamentarium of STI preventative strategies. The widespread use of long-term antibiotics especially for STI PrEP is concerning especially with our experience with reducing adherence with time.