Strides Toward Early Infant Diagnosis for HIV Elimination in South Africa

Landiwe, a young South African mother, was diagnosed with human immunodeficiency virus (HIV) in 2017 while she was pregnant. Her baby was born HIV-positive, putting her tender life at risk.  

Each year globally, an estimated 1,3 million women and girls living with HIV become pregnant.¹ Without intervention, the rate of transmission from HIV-positive mothers to their babies during pregnancy, labor, delivery, or breastfeeding (vertical transmission) is 15-45%.¹

Globally, 1,5 million children (0-14 years) were living with HIV in 2022.² This is a small proportion of the 39 million total people living with HIV,² but infants and children suffer worse outcomes because their immune systems are not fully developed. Thus, prevention, testing, and treatment are essential.

Progress in Preventing Mother-to-Infant Transmission

Huge advances in testing and treatment have been made in recent decades, leading to vertical transmission rates below 5% in many countries, including Ethiopia, South Africa, and Tanzania, and the elimination of vertical transmission in many others, including Armenia, Belarus, the Caribbean, Cuba, and Thailand.³

The 2023 UNAIDS Global AIDS update noted steep drops in the number of new infections among children due to effective interventions.⁴ AIDS-related deaths among children were reduced by 64% in 2010–2022,⁴ and programs to avoid vertical transmission prevented 3,4 million new HIV infections in children since 2000.⁵ These are encouraging developments in the fight against AIDS. Still, the HIV pandemic claimed the lives of approximately 84 000 children in 2022.⁴ This is still too many.

Advances in Vertical Transmission Herald New Challenges

Dr. Philip Goulder, a renowned pediatric HIV researcher and Professor of Immunology at Oxford University, agrees that mother-to-baby transmission has been decreasing thanks to advances in healthcare and treatment. He explains that as a result, babies' viral loads at birth are sometimes very low, and without immediate, sensitive testing at the point of care, they can be lost to follow-up, meaning they miss out on life-saving treatment. Dr. Goulder notes that, “if they manage to survive, several months later, they have huge viral loads, and their immune systems are damaged irrevocably.”

The same trend was observed by Dr. Nomonde Bengu, a clinician who cares for mothers and babies at the Queen Nandi Regional Hospital in South Africa. Dr. Bengu notes that “there was a concern about the rising number of positive infants at their 10-week review.” She highlights the challenge in these cases: “The question becomes whether it was a missed positive at birth because of potent antiretroviral therapy or postpartum transmission. To discern this, we think point-of-care testing would assist.”

Solutions to Identify HIV-Positive Babies Early

Dr. Goulder started a ‘Baby Cure’ study in KwaZulu-Natal, South Africa, in 2015 with the goal of further understanding HIV and the potential for HIV cure in children. Under this program, babies who are HIV-infected in utero are diagnosed using point-of-care testing at birth, and antiretroviral therapy is initiated within hours.

Dr. Bengu and her team have partnered with Dr. Goulder in this much-needed work to bring sensitive HIV testing to patients as early as possible. Dr. Bengu notes that mothers worry less once they know what they’re facing and that they can start treatment right away.

It was through the Baby Cure study that Landiwe’s HIV status was identified in 2017. Thanks to onsite point-of-care testing, her baby daughter’s status was also identified, and she started therapy immediately. With early diagnosis and therapy initiation, along with access to ongoing care, Landiwe’s daughter is an HIV success story. She celebrated her 6^th birthday in 2023 with other survivors, healthcare workers, and well-wishers at the Queen Nandi Hospital.

Toward HIV Eradication in Children

The World Health Organization (WHO) recommends point-of-care nucleic acid (e.g., PCR) testing to diagnose HIV among infants and children younger than 18 months of age.⁶ The WHO recently granted prequalification status to Cepheid’s Xpert HIV-1 Qual XC test, an improved PCR test to detect HIV-1 in infants, adolescents, and adults. “WHO prequalification aims to ensure access to key health products that meet global standards of quality, safety and efficacy/performance, in order to optimize use of health resources and improve health outcomes.”⁷

To meet the global need for timely HIV testing outside of traditional healthcare settings, the Xpert HIV-1 Qual XC test was designed for use in laboratories and at the point of care, enabling same-day results. The Baby Cure team used an earlier version of this test to provide point-of-care results for Landiwe and many others. This test adds a tool to the global community’s ongoing efforts to eradicate infant HIV so all children can live full and healthy lives.

Watch Dr. Bengu discuss the Baby Cure Trial at Queen Nandi Regional Hospital Empange, South Africa: