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Characterization of the prevention and care cascade in children living with HIV in the Manhiça district, Mozambique
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[eng] INTRODUCTION Children acquire human immunodeficiency virus (HIV) infection mainly due to vertical transmission (VT) from their mothers, during pregnancy, delivery or breastfeeding (1). Without immediate access to antiretroviral treatment (ART), half of all children living with HIV die of acquired immunodeficiency syndrome (AIDS) related causes before the age of two (2). Although the number of newly infected children between 2010 to 2020 was reduced by 54% (3), there are still 1.7 [interquartile range (IQR):1.2 – 2.2] million children less than 15 years of age living with HIV worldwide and 150 000 [IQR:100 000–240 000] new infections per year (3), most of them in sub-Saharan Africa. The sequential steps of medical attention that people living with HIV experience from diagnosis to linkage to HIV medical care, receipt of ART, retention in care, to achieving sustained viral suppression, is known as the HIV care cascade (4,5). Viral suppression has been classically considered the ultimate goal because it is associated with good clinical outcomes (6). However, health related quality of life (HRQoL) goes beyond viral suppression and considers social, emotional and physical well-being, which are particularly important for children, who will endure HIV and related struggles for their entire lives (7,8). Global strategies in the fight against HIV/AIDS between 2015 and 2020 were focused on the 90-90-90 targets, which contemplated that by 2020, 90% of people living with HIV would know their HIV status, 90% of people who knew their HIV status would access ART, and 90% of people on ART would have suppressed viral load (9). In addition, a particular strategy for children, the super-accelerated “Start Free, Stay Free, AIDS Free”, was established in 2016 among the 21 African countries with the highest burden of pediatric HIV worldwide (10). The strategy included the goals of reducing the annual number of new pediatric infections to fewer than 20,000 and providing ART to 1.4 million children (aged 0-14) living with HIV in the 21 focus countries by 2020 (10). By that year, the global 90-90-90 values among children lagged behind those for adults (59-54-40 vs 82-74-67) and the total number of children receiving ART among the focus countries remained 34% below the target of 1.4 million on ART (11). In addition, the results in 2020 were uneven across countries indicating that to achieve the new global goals of “Ending inequalities and getting on track to end AIDS by 2030”, specific gaps in pediatric prevention and care need to be identified and addressed at the local level. Mozambique is one of the countries with a high burden of pediatric HIV, with 130 000 [IQR:100 000 – 170 000] children living with HIV and a VT rate of 13% (6% during pregnancy and delivery and 8% during breastfeeding) in 2020 (3,11), which placed it among the 3 countries in the world with the highest proportion of children acquiring HIV, in the same year (11). In 2013, Mozambique adopted the Option B+, which recommended lifelong ART to HIV-positive pregnant and breastfeeding women, regardless of their CD4 count and postnatal prophylaxis with 6 weeks Nevirapine (NVP) for their HIV-exposed children infants (12–15). Programmatic data showed that in 2018, poor adherence to ART was identified as a major obstacle to decreasing VT (16). Viral load (VL) monitoring is also a big challenge in the country, and only 11% of all eligible pregnant women (those with at least 3 months on ART) had a VL requested in 2018. From them, only 6% received a VL result 3 to 6 months after ART initiation treatment (16). Regarding the pediatric HIV care cascade, despite the progressive expansion of ART in the country since the adoption of test and treat strategy in 2016, treatment coverage (the second 90 target) among children living with HIV was still low, 64% in 2020 (3). For the third 90 target, it lagged even further behind with only 36% of those children on treatment achieving viral suppression, suggesting challenges for retention in HIV care (3). HYPOTHESIS: We hypothesize that, in the Manhiça district, major gaps in the pediatric HIV prevention and care cascade reside, respectively, in the prevention of VT during the postpartum period and in the retention in care of children after ART initiation. OBJECTIVE: The main objective of the research presented in this thesis is to identify the weakest steps in the pediatric HIV prevention and care cascade.
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FERNÁNDEZ LUIS, Sheila. Characterization of the prevention and care cascade in children living with HIV in the Manhiça district, Mozambique. [consulta: 15 de desembre de 2025]. [Disponible a: https://hdl.handle.net/2445/209134]