When prevention of mother-to-child HIV transmission fails: preventing pretreatment drug resistance in African children

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In high-income and some middle-income countries, effective programs to prevent mother-to-child transmission (PMTCT) using combination antiretroviral therapy (ART) for pregnant HIV-positive women and antiretroviral prophylaxis for HIV-exposed infants have resulted in 99–100% reduction in vertical transmissions [1]. However, in Sub-Saharan Africa, the implementation of PMTCT programs has been less successful, with new pediatric infections having declined only by 21–86% between 2009 and 2015 [1]. Sub-Saharan Africa lags behind global trends because of several factors, including late or missed HIV testing, incident HIV infection in pregnant women, low uptake of or deferred treatment initiation, suboptimal ART adherence pre and postpartum, late identification and testing of HIV-exposed infants, amongst others [2–7].
The fact that children become HIV-infected despite the use of PMTCT (failing PMTCT) is not only problematic because these infections are preventable, but also because infection during antiretroviral exposure increases the risk of acquiring drug-resistant HIV variants. Consequently, despite a decrease in the overall numbers of vertical HIV infections, the proportion of children who become infected and bear drug-resistant virus early in life is very high (35–64%) in the region [8–10]. The plight of these children is dire with high risk of failure on a suboptimal standard first-line ART regimen, absence of resistance tests to inform drug choices and lack of alternative regimens in case of ART failure – all this in light of the need for lifelong effective therapy. In this opinion article, we provide arguments that increased efforts are needed to prevent HIV drug-resistance early in life in the context of ongoing PMTCT programs and limited ART options for children.

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