Dr Moherndran Archary's research has helped shape South African health policy, most notably the rollout of better HIV treatments for children and babies. Spotlight's Biénne Huisman chatted to him about the state of HIV treatment for kids and some exciting prospects on the horizon.
"There would be multiple deaths every night," says Dr Moherndran Archary, referring to Durban's former King Edward VIII Hospital. "We had multiple children in the ward who were wasting away. And there was no treatment, nothing to make their lives better," he recalls, with emotion.
In the early 2000s, as the initial HIV epidemic swept through South Africa and KwaZulu-Natal, Archary trained under the late HIV mother-to-child transmission icon, Professor Hoosen Coovadia.
Over the next two decades, at the forefront of South Africa's HIV response for children, Archary worked as a paediatric doctor while helping run several global trials to test treatment efficacy for youngsters living with HIV, all the while advocating for pharmaceutical companies and governments to prioritise young patients.
And things have indeed changed a lot over the last 20 years.
As appears to be his nature, Archary is quick to point out the most recent "good news" - which is that the antiretroviral medicine dolutegravir is now finally available for children in South Africa, as stipulated in the National Department of Health's 2023 ART Clinical Guidelines for the Management of HIV.
This, he says, brings "many welcome improvements" for infants and children living with HIV, such as two new dolutegravir formulations: a 10 mg daily tablet for babies four weeks and older, who weigh at least 3 kg; and a single fixed-dose daily tablet of abacavir, lamivudine and dolutegravir, for children weighing 25 kg or more. Spotlight previously reported on the benefits of these new child-friendly treatments.
And now, he says there are even better drugs on the horizon.
His voice rising with enthusiasm, Archary says: "We are in the early days. Some of the studies I lead are looking at these new formulations for children."
Long-acting treatments for kids
At present, he is part of the team running a new trial testing the efficacy of the world's first long-acting HIV treatment injection for children - a move near to his heart as he endeavours to "relieve children and adolescents from the burden of taking daily oral medicine".
The trial called LATA (Long-Acting Treatment in Adolescents) will see adolescents living with HIV - aged between 12 and 19 years old - in South Africa, Kenya, Uganda and Zimbabwe, receive injections containing long-acting formulations of the antiretrovirals cabotegravir and rilpivirine, every eight weeks for two years. Led by University College London, in the United Kingdom, the trial will test whether the injections work as well as antiretrovirals taken in tablet form. The researchers started recruiting participants for the study last year.
Archary points out a recently concluded study called CARES (Cabotegravir and Rilpivirine Long-Acting in Africa) which "for the first time found that long-acting injectables can be administered and maintain high levels of viral suppression in adults in three different countries across Africa (South Africa, Kenya and Uganda)," he says.
Pending the outcomes of LATA, he intends to advocate for the long-acting benefits seen in the CARES study to be extended to children living with HIV.
"We need advocacy to ensure that low income countries can access these drugs at a price that makes it competitive," he says. "If you don't speak up; if you don't advocate for children, they often get left behind."
Paediatric HIV has long been considered a neglected disease in less affluent countries. In 2018, Médecins Sans Frontières (MSF) accused pharmaceutical companies of "failing children" due to a lack of financial incentive to prioritise this "small market" mainly found in poor parts of the world.
'Gap of 12 to 20 years'
In March, Archary moderated a session called HIV Across the Life Continuum: Pregnant People, Infants, Children, and Adolescents, at the Conference on Retroviruses and Opportunistic Infections (CROI) in Denver, in the United States. During a break at the conference, he told Spotlight that there often is a gap of between 12 to 20 years, between the registration of HIV medicine for adults, and registration of that same medicine for children.
"Much of the work I do is to narrow this gap," he says. "To create access to optimal treatment regimens for children, soon after it's available for adults; so that they're not being left behind."
Referencing the latest figures released by UNAIDS, Archary paints a picture of South Africa's paediatric HIV landscape, showing lagging treatment for youngsters living with the disease, even compared to neighbouring countries in sub-Saharan Africa. In 2022, an estimated 230 000 children in South Africa under 15 were living with HIV - of whom 83% had been diagnosed, 54% were on treatment, and 37% were virally suppressed. (Viral suppression indicates the efficiency of ARV treatment in an individual - with a high viral load suggesting that a person is not taking their medication consistently, or that the treatment is not working.)
Apart from slow access to drugs for youngsters, Archary lists factors contributing to low viral suppression in children in South Africa. Reasons, he says, include that treatment consisted of complicated multi-dose medication regimens and that medicines tasted bad. "[O]ld formulations had an extremely bitter taste, parents had to fight with children to get it down," he says. Another reason relates to social factors such as disrupted routines in multi-caregiver homes where grandparents, other relatives or neighbours, take turns to look after children.
Presented in the CROI session moderated by Archary, were findings of a global trial called ODYSSEY, which demonstrated the "superior efficacy" of dolutegravir in youngsters. Participants aged from three months to 18 years old, from several countries including South Africa took part in the trial.
The researchers also looked at the effects of dolutegravir on mental health, analysing "psychiatric events and suicidal ideation" in the group. Archary says a slightly higher occurrence of suicidal thoughts in the dolutegravir sample (as compared to the standard-of-care group) did not reach statistical significance, while nevertheless highlighting the mental health challenges faced by youngsters living with HIV.
Supporting young people
Archary's research through the African Health Research Institute (AHRI) looks to create interventions to support young people living with HIV in transitioning from supervised ARV treatment regimens to unsupervised treatment as an adult. To this end, they enrolled adolescents living with HIV to use moderated WhatsApp-based communication, referred to as InTSHA (Interactive Transition Support for Adolescents Living With HIV using Social Media).
He explains: "One of the clear messages we got from adolescents is that they don't only want to talk about HIV; they want to speak about career development, how to navigate relationships, sexual and reproductive health. So we've developed a several module-driven activity that's delivered through a WhatsApp group."
InTSHA uses encrypted, closed group chats delivered via WhatsApp to develop peer support and improve communication between adolescents, their caregivers and health care providers. "The final InTSHA intervention involves 10 modules conducted weekly through moderated WhatsApp group chats with adolescents and separately with their caregivers," according to a study conducted to evaluate the initiative.
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Archary adds: "We have groups of between eight and 10 adolescents with a peer navigator; in the pilot study it was a social scientist. On the WhatsApp group, they're not identified as an individual; but by whatever emoji they choose. Then the discussions happens over time, usually after hours or during weekends."
What drives Archary?
Archary grew up in Durban, the middle child of three boys - and has two sons himself. "Neither of them are in medicine," he says, smiling. His one son is studying in architecture at University of KwaZulu-Natal (UKZN), the other in commerce at the University of Cape Town. Archary enjoys the outdoors and running. "[I]t helps to numb the mind, so you don't need to think, you can be on autopilot".
He is an Honorary Associate Professor at the Paediatric Infectious diseases Unit at the Victoria Mxenge Hospital - affiliated to UKZN. Earlier this month, Durban's King Edward VIII Hospital was renamed Victoria Mxenge Hospital at an event to celebrate international nurses day on May 12. Mxenge was a nurse and apartheid activist.
At medical school at UKZN, Archary says he was drawn to paediatrics early on. "I felt most drawn to and most comfortable relating to children," he says.
"The gratifying thing with children is, when you make them better, within a day they are running around, playing in the ward. And again, living through the worst of the HIV pandemic, I think that really drove me into infectious diseases and wanting to work on improving outcomes for children living with HIV, trying to find the best ways to treat them."
