Unmet needs persist in pediatric HIV programs: lessons from selected case studies in Uganda

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Tremendous progress has been made in the management of HIV/AIDS in sub-Saharan African adults [1]. Pediatric HIV management, however, has unmet needs in early diagnosis and antiretroviral therapy (ART) [2]. The goal of care and treatment has progressed from prevention of mother-to-child transmission (PMTCT) to elimination of mother-to-child transmission [3]. The children with HIV early ART trial in South Africa demonstrated that early ART initiation can improve survival, reducing early mortality by 76% [4]. This led to the revision of WHO ART treatment recommending ART for children aged 2 years or less irrespective of their immunological profile. Recently, WHO has updated their ART treatment guidelines [1,5–8] recommending that all people living with HIV (PLWHIV), regardless of age, should be initiated on ART [8]. If fully implemented, this recommendation will markedly improve the quality of life of PLWHIV and raises the possibility of ending the epidemic. However, this hinges on early diagnosis and treatment, reaching out to those lost to follow-up (LTFU) and a stable supply and availability of antiretroviral drugs [9]. In an ongoing study investigating the role of nutrition as a determinant of immune function and pharmacological outcome amongst HIV-infected malnourished children in Uganda, we observed that the older children had been missed by PMTCT programs. The majority presented with critical illnesses and had a mortality rate of 22.5% compared with 1% in the younger age group. We describe four ART-naïve cases as examples of the ‘forgotten children’ who have missed the opportunity of PMTCT, early infant diagnosis (EID) and early ART.

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