Improving viral suppression among children and adolescents on antiretroviral therapy in Nampula province, Mozambique

BACKGROUND: Early access to optimized antiretroviral therapy (ART) regimens for children living with HIV (CLHIV) is essential to reducing morbidity and mortality. In August 2019, the pediatric ART optimization policy was implemented, including transition of children who weighed >20kg to dolutegravir (DTG)-based regimens and children <20kg with previous exposure to prevention to child transmission interventions (PMTCT) to boosted lopinavir (LPV/r)-based regimens. National stock challenges delayed the implementation of transition to LPV/r-based regimens for children <20kg regardless of their PMTCT exposure, until November 2020. In October 2019, Nampula province, in northern Mozambique, had only 37% of CLHIV who achieved viral suppression (VS). We assessed VS among children and adolescents after implementation of the pediatric ART optimization.
DESCRIPTION: ICAP supports the Nampula Provincial Health Services and 59 health facilities (HFs) to strengthen stock management and transition of CLHIV to optimized regimens using targeted tools and intensive monitoring. From October 2019 to December 2020, ICAP monitored ARV stocks at HF-level weekly and stock and consumption at provincial-level monthly. HF teams monitored transition of CLHIV to optimized regimens daily, flagging patient files prior to clinical consultation, and weekly, tracking the trends. Monthly reviews of longitudinal high viral load registers enabled identification of CLHIV with no clinical follow-up, fast-tracking patients to optimized regimens or second-line. In addition, ICAP developed a flipchart for use during clinical consultations and by peer educators and mentor mothers at waiting areas and during home visits with practical demonstrations to guide caregivers on provision of LPV/r formulations.
LESSONS LEARNED: There was a 111% increase in optimized regimens among CLHIV in Nampula between October 2019 (918/2010) and December 2020 (2819/2925). Between October 2019 and December 2020, VS increased 36% to 44% among CLHIV 1-4 years, 41% to 62% among 5-9 years, and 45% to 71% among 10-14 years.
CONCLUSIONS: Increased access to optimized regimens was associated with increased VS among all age groups. Despite these improvements, limited availability of LPV/r granules in country has impacted VS in young children. Further efforts are necessary to enhance uptake of optimized regimens among CLHIV including adequate provision of LPV/r granules for younger CLHIV.