Intended for healthcare professionals

Practice Quality Improvement Report

Maximising opportunities for increased antiretroviral treatment in children in an existing HIV programme in rural South Africa

BMJ 2013; 346 doi: (Published 27 February 2013) Cite this as: BMJ 2013;346:f550
  1. Ruth M Bland, clinical research lead 12, senior clinical research fellow2,
  2. James Ndirangu, epidemiologist11,
  3. Marie-Louise Newell, director of Africa Centre 1, professor of epidemiology3
  1. 1Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa
  2. 2School of Medicine, Glasgow University, Glasgow G12 8XX, UK
  3. 3Centre for Paediatric Epidemiology and Biostatistics, University College London Institute of Child Health, London WC1E 6BT, UK
  1. Correspondence to: R Bland Africa Centre for Health and Population Studies, University of KwaZulu-Natal, PO Box 198, Mtubatuba, KwaZulu-Natal, 3935, South Africa rbland{at}
  • Accepted 24 December 2012


  • Problem Infants and young children infected with HIV as a result of mother to child transmission are not being identified or started with antiretroviral treatment (ART) in line with HIV guidelines in resource limited settings.

  • Design Retrospective analysis of data from a paediatric cohort before and after an intervention strategy.

  • Setting Rural public HIV treatment programme in the province of KwaZulu-Natal, South Africa.

  • Key measures for improvement Increase in the number of HIV infected infants and children who start HIV treatment each year; increase in the proportion of children starting ART with less immune suppression, shown by higher CD4 counts and less advanced World Health Organization clinical stages for HIV.

  • Strategies for change Late 2008: training in paediatric HIV for all staff in contact with mothers and children; campaigns for increased HIV testing at immunisation and clinics; routine testing of children with tuberculosis and malnutrition for HIV, and HIV testing of all children admitted to hospital. The establishment of a family HIV clinic in late 2007.

  • Effects of change The number of children (1 year to ≤15 years) starting ART each year increased from 43 in 2004 to 254 in 2011; the corresponding number of infants (<1 year) starting treatment increased from 2 to 59. A trend towards increasing CD4 counts at the start of treatment was found.

  • Lessons learnt It is possible to improve the identification of HIV infected children and ensure a prompt start on ART where needed with relatively simple measures and limited implications for staffing and budgets.

The setting is an HIV treatment and care programme in Hlabisa, a rural sub-district of the province of KwaZulu-Natal, South Africa. In 2011, the population of Hlabisa was about 220 000 people, of whom an estimated 37.8% (83 160) were children aged 1 year to ≤15 years and 2.4% (5280) …

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