2015 37m worldwide living with HIV, vast majority in Sub-Saharan Africa. Growth is N Africa and Middle East.

20 years since introduction of ART. Still over 1 m deaths per year. Only about a third have access to ART. $250 per child per year.

West Africa seroprevalence only 1-2%, S Africa 25% of sexually active!!!

Treatment for pregnant women actually very good coverage in South and East Africa, much poorer elsewhere.

WHO now recommends treatment for everyone at diagnosis, regardless of CD4, symptoms etc!

In UK 5000 new cases per year, peaked in 2005 (8000), pretty stable now, still mostly migrant associated. Average age of HIV pos child is now 13.6!!! No neonatal cases in Scotland for years.

Majority of known patients have undetectable viral load!

Maternal transmission

Previous advice to breast feed exclusively for 6/12 then stop, now WHO say at least 10-12 months, with no recommendation on stopping. Mixed feeding is now considered acceptable. But this weighs benefits of breast feeding against low rate of transmission of under 2%.

In UK, completely discourage breast feeding, but “not a child protection issue”! Still controversial. Check with your local team!

Transition

Focus now on optimisation of health status through childhood rather than survival! Worry that significant numbers of deaths in survivors of childhood HIV.

Future

Treatment interruptions (not good outcomes in adults)?  Reduction in lab monitoring? Still new (delayed) toxicities eg portal hypertension with DDI. Depot injections!

Treatment

Kaletra + nevirapine first line. Commissioning in England influences treatment recommendations. PENTA 2016 now recommends ART for all children.

Dolutegravir has best results, side effect profile and low interactions (Integrase strand transfer inhibitors (INSTIs)).