Health Systems Research Unit, South African Research Council, Cape Town, South Africa; Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa; HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa.
S Afr Med J. 2019 Dec 5;109(11b):77-82. doi: 10.7196/SAMJ.2019.v109i11b.14292.
Over the past three decades, tremendous global progress in preventing and treating paediatric HIV infection has been achieved. This paper highlights the emerging health challenges of HIV-exposed uninfected (HEU) children and the ageing population of children living with HIV (CLHIV), summarises programmatic opportunities for care, and highlights currently conducted research and remaining research priorities in high HIV-prevalence settings such as South Africa. Emerging health challenges amongst HEU children and CLHIV include preterm delivery, suboptimal growth, neurodevelopmental delay, mental health challenges, infectious disease morbidity and mortality, and acute and chronic respiratory illnesses including tuberculosis, pneumonia, bronchiectasis and lymphocytic interstitial pneumonitis. CLHIV and HEU children require three different categories of care: (i) optimal routine child health services applicable to all children; (ii) routine care currently provided to all HEU children and CLHIV, such as HIV testing or viral load monitoring, respectively, and (iii) additional care for CLHIV and HEU children who may have growth, neurodevelopmental, behavioural, cognitive or other deficits such as chronic lung disease, and require varying degrees of specialised care. However, the translation thereof into practice has been hampered by various systemic challenges, including shortages of trained healthcare staff, suboptimal use of the patient-held child's Road to Health book for screening and referral purposes, inadequate numbers and distribution of therapeutic staff, and shortages of assistive/diagnostic devices, where required. Additionally, in low-middle-income high HIV-prevalence settings, there is a lack of evidence-based solutions/models of care to optimise health amongst HEU and CLHIV. Current research priorities include understanding the mechanisms of preterm birth in women living with HIV to optimise preventive interventions; establishing pregnancy pharmacovigilance systems to understand the short-, medium- and long-term impact of in utero ART and HIV exposure; understanding the role of preconception maternal ART on HEU child infectious morbidity and long-term growth and neurodevelopmental trajectories in HEU children and CLHIV, understanding mental health outcomes and support required in HEU children and CLHIV through childhood and adolescence; monitoring HEU child morbidity and mortality compared with HIV-unexposed children; monitoring outcomes of CLHIV who initiated ART very early in life, sometimes with suboptimal ART regimens owing to medication formulation and registration issues; and testing sustainable models of care for HEU children and CLHIV including later reproductive care and support.
在过去的三十年中，在预防和治疗儿科 HIV 感染方面取得了巨大的全球进展。本文重点介绍了 HIV 暴露但未感染（HEU）儿童和感染 HIV 的儿童（CLHIV）人口老龄化带来的新出现的健康挑战，总结了护理方面的计划机会，并强调了在南非等高 HIV 流行地区目前正在进行的研究和剩余的研究重点。HEU 儿童和 CLHIV 中出现的健康挑战包括早产、生长不良、神经发育迟缓、心理健康问题、传染病发病率和死亡率，以及急性和慢性呼吸道疾病，包括结核病、肺炎、支气管扩张和淋巴细胞性间质性肺炎。CLHIV 和 HEU 儿童需要三种不同类别的护理：（i）适用于所有儿童的最佳常规儿童保健服务；（ii）目前为所有 HEU 儿童和 CLHIV 提供的常规护理，例如分别进行 HIV 检测或病毒载量监测；（iii）为可能存在生长、神经发育、行为、认知或其他缺陷（如慢性肺病）的 CLHIV 和 HEU 儿童提供额外的护理，并需要不同程度的专业护理。然而，由于各种系统挑战，包括缺乏经过培训的医疗保健人员、儿童保健手册在筛查和转介方面的使用不足、治疗人员数量和分布不足以及所需辅助/诊断设备短缺，将其转化为实践一直受到阻碍。此外，在中低收入高 HIV 流行地区，缺乏针对 HEU 和 CLHIV 优化健康的基于证据的护理解决方案/模式。当前的研究重点包括了解 HIV 感染者早产的机制，以优化预防干预措施；建立妊娠药物警戒系统，以了解宫内 ART 和 HIV 暴露的短期、中期和长期影响；了解孕前孕产妇 ART 对 HEU 儿童传染病发病率和 HEU 儿童和 CLHIV 长期生长和神经发育轨迹的影响，了解 HEU 儿童和 CLHIV 童年和青春期的心理健康结果和所需支持；监测 HEU 儿童的发病率和死亡率与 HIV 未感染者相比；监测早期开始 ART 的 CLHIV 的结局，由于药物配方和注册问题，有时 ART 方案不太理想；测试针对 HEU 儿童和 CLHIV 的可持续护理模式，包括后期生殖护理和支持。
