Saskia Janssen

Children and adolescents living with HIV (CALHIV) remain a group requiring attention, with still unacceptable high mortality rates in certain subgroups. This session reviewed factors potentially impacting on outcomes including mortality and developmental impairment, and approaches to the optimization of management of CALHIV.

Two large retrospective, multinational cohort studies from Sub-Saharan Africa were presented. The first assessed the real-world effectiveness of dolutegravir-based antiretroviral therapy (ART) in CALHIV, and showed a rapid and sustained longitudinal viral load suppression well above 90% over a period of 2 years. Viral load suppression rates remained stable and similar among age groups and sex. The second cohort illustrated the still high mortality in CALHIV with TB-co-infection, and assessed the safety of early initiation of ART. ART initiation within 2 weeks of initiation of TB treatment was not associated with a higher mortality, suggesting that early initation of ART in CALHIV with TB is safe. The prospective EARTH-EPIICAL cohort follows children born with HIV in 3 African countries. Data from this cohort showed a still unacceptable high mortality attributable to AIDS-related morbidity, despite early initiation of ART. Factors associated with this high mortality remain to be identified. Imaging studies from a large South African birth cohort revealed a significant decreased subcortical volume (putamen and hippocampus) which associated with neurodevelopmental impairment in children exposed to HIV and ART in utero but uninfected.

Real-world data support widespread use of dolutegravir-based regimens in CALHIV. Factors impacting unfavorable outcomes in a subset remain to be evaluated. ART can probably be safely started in CALHIV with TB within the first 2 weeks of TB treatment, but more safety data is needed including hospitalizations, development of IRIS, and in complicated extrapulmonary disease. Mortality and adherence (56%) from EARTH-EPIICAL suggest significant efforts are needed in this age group. Despite adequate PMTCT HIV and/or ART still has significant impact on children born uninfected resulting in decreased sub-cortical volumes. Associated factors may include inflammation, ART exposure or socio-economic factors.