HIV-infected children require early initiation of antiretroviral therapy (ART) to ensure good
outcomes. The aim was to investigate missed opportunities in childhood HIV diagnosis leading
to delayed ART initiation.
Baseline data was reviewed of all children aged <15 years referred over a one-year period for
ART initiation to the Kalafong Hospital HIV services in Gauteng, South Africa. Of the 250
children, one quarter (24.5%) were of school-going age, 34.5% in the preschool group, 18%
between 6-12 months old and 23% below six months of age (median age=1.5 years [IQR 0.5-
4.8]). Most children (82%) presented with advanced/severe HIV disease, particularly those aged
6-12 months (95%). Malnutrition was prominent and referrals were mostly from hospital
inpatient services (61%).
A structured caregiver interview was conducted in a subgroup, with detailed review of medical
records and HIV results. The majority (≥89%) of the 65 interviewed caregivers reported good
access to routine healthcare, except for postnatal care (26%). Maternal HIV-testing was mostly
done during the 2nd & 3rd pregnancy trimesters (69%). Maternal non-disclosure of HIV status
was common (63%) and 83% of mothers reported a lack of psychosocial support. Routine infant
HIV-testing was not done in 66%, and inadequate reporting on patient-held records (Road-to-
Health Cards/Booklets) occurred frequently (74%). Children with symptomatic HIV disease
were not investigated at primary healthcare in 53%, and in 68% of families the siblings were not
tested. One-third of children (35%) had a previous HIV diagnosis, with 77% of caregivers aware
of these prior results, while 50% acknowledged failing to attend ART-services despite referral.
In conclusion, a clear strategy on paediatric HIV case finding, especially at primary healthcare, is
vital. Multiple barriers need to be overcome in the HIV care pathway to reach high uptake of
services, of which especially maternal reasons for not attending paediatric ART services need