Background:  Roll-out of ART in the public sector in low resource settings makes pediatric HIV infection a manageable chronic condition.  However, there are few data demonstrating the success of these programs, particularly on virological response—a crucial outcome to predict drug resistance and long-term program sustainability. We report 4-year outcomes from a pediatric HIV outpatient service at Chris Hani Baragwanath Hospital, which included routine virological monitoring.

Methods:  Included in the analysis were 2105 HIV-infected children <15 years of age entering the program and initiating ART from April 2004 to March 2008 who had at least 1 follow-up visit. Children <3 years usually started lopinavir/ritonavir (LPV/r) + lamivudine (3TC) + stavudine (d4T) and children >3 years of age efavirenz (EFV) +3TC+d4T. Viral load, CD4 was measured pre-treatment and 6-monthly and anthropometric measurements every 3 months. All outcomes through April 2008 were included using survival longitudinal analysis.

Results:  The median age at ART initiation was 4.3 (interquartile range 1.6 to 7.5) years; 1068 (51%) were male; 602 (29%) were on TB treatment, the mean CD4 percentage was 12.8% (95% confidence interval 11.9 to 13.7%). During the first 90 days of ART, 69 children died (14.4 of 100 child-years, 95%CI 11.40 to 18.28). The mortality rate after 90 days was lower (1.99/100 child-years, 95%CI 1.55 to 2.55). Rates of loss to follow-up (6%) and transfer to other services (5%) were low. Among survivors, the proportion of children who achieved viral suppression (<400 copies/mL) increased progressively from 60.6% (95%CI 58.2 to 63.1%) by 6 months, to 85.1% (95%CI 83.1 to 86.9%) by 12 months, to reach 94.6% (95%CI 92.9 to 96.0%) by 24 months. The mean CD4 cell percentage increased to 25.0% (95%CI 24.3 to 25.7%) at 12 months, and then slowly to 31.7% (95%CI 27.6 to 35.7%) by 42 months. The mean weight-for-age z-score rose from –2.42 (95%CI –2.50 to –2.33) at ART initiation, to –0.67 (95%CI –0.87 to –0.46) at 42 months. The mean height-for-age z-score increased from –2.72 (95%CI –2.78 to –2.65) at baseline to –1.72 (95%CI –1.90 to –1.54) at 42 months.

Conclusions:  The vast majority of children achieve viral suppression even in the context of a routine service program. Mortality rates are high during the first few weeks of ART and may reflect failure to identify HIV-infected children early. Programs to strengthen early infant diagnosis combined with prompt referral to treatment programs may be able to reduce these needless deaths.