Integrated approach is needed to scale up HIV care for children

September 2006

TORONTO — Increased commitment to comprehensive care for children living with HIV is needed to stem the increasing rates among this group, Ruth Nduati, MBChB, MMed, MPH, said at the XVI International AIDS Conference, held here.

“Care of the HIV infected child requires a comprehensive approach that takes into account prevention and protection of the child and provides for specific needs of the well child, sick child terminally ill child and child orphaned or living with sick parents. None of these categories are mutually exclusive and therefore an integrated approach is critical,” said Nduati, associate professor of pediatrics at the College of Health Sciences, University of Nairobi, Kenya.

Nduati highlighted the magnitude of pediatric HIV cases, reviewed predictors of disease progression in children, outlined barriers to diagnosis, such as limited laboratory infrastructure and lack of HIV testing policies, and discussed what’s needed to scale up care for children.

Children younger than 15 constitute 14% of all new global HIV infections (700,000 of 4.9 million), 18% of HIV/AIDS associated deaths a year (570,000 of 3.1 million) and 5.6% of those living with HIV (2.3 million of 40.3 million). While some geographic areas have seen testing and treatment improvements among children with HIV, other areas, specifically regions of east and south Africa, are still struggling to properly care for children.

“Pediatric HIV distinguishes itself by the increased case fatality and emerging evidence of poor response to standard therapies,” she said. “It is an increasing underlying cause of death in high HIV prevalence countries.”

Predictors of progression

“In sub-Saharan Africa, the epidemic of pediatric HIV has evolved into a chronic crisis,” she said.

Child mortality is 29 times higher in sub-Saharan Africa than that of developed countries. Leading causes of death among children affected by HIV include pneumonia, malaria, diarrhea and neonatal deaths. Malnutrition is one frequent underlying cause of death, therefore, adequate nutrition is also part of the essential package for adults and children living with HIV. Use of unsafe water and simply unavailability of water, lack of access to sanitation and treatments contribute to this mortality. Prematurity and lack of breast-feeding are two more predictors of rapid HIV progression among children.

Consistent with studies from children living with HIV in developed countries, low CD4 counts, high viral load and failure to thrive have been associated with rapid progression to HIV/AIDS-associated mortality, according to Nduati. Data indicate that risk of mortality increases if the child develops HIV within the first 4 months of life.

The mother’s clinical and vital status is a key determinant of survival and HIV progression for children, according to Nduati. Data indicate that children with HIV have an eight- to ten-fold increased risk of death compared with non-infected children, but the risk of death of children living with and without HIV in such poverished settings is approximately halved if the mother survives.

“Care of the HIV-infected child must include care of the mother and their families,” she said.

Interventions are needed to reduce the burden of HIV on children. Maternal-fetal transmission of HIV accounts for 90% of HIV infections in children younger than 15 years and without interventions, specifically antiretroviral (ARV) use, 30% to 40% of exposed children acquire the virus. Furthermore, various clinical trials have demonstrated increasing evidence of efficacy of ARV use in mothers breast-feeding infants using combination therapies.

“One of the greatest advances in HIV medicine has been the development of ARVs. HIV children respond well to both [protease inhibitors] and [nucleoside reverse transcriptase inhibitor] based ARVs,” she said. “Significant breakthroughs have also been made in development of mother-to-child transmission protocols that minimize evolution of resistance in the mother and baby. Without ARV treatment, children develop a rapidly progressive course of illness.”

Barriers to treatment

Currently 660,000 children are in need of ARVs, 600,000 of which are located in sub-Saharan Africa. Effective maternal-fetal prevention services are offered to fewer than 10% of pregnant women worldwide, and as a result, 600,000 children continue to be acquire HIV each year, according to Nduati.

“Sadly, HIV infected children are not receiving treatment,” she said. “Essentially there has been a failure to rapidly translate the success of clinical trials into a public health success story for the most affected populations of sub-Saharan Africa.”

To achieve this massive scale up of prevention, treatment and care, several interventions are required. Several studies have demonstrated that timely initiation of ARVs for pediatric patients enhances survival and improves quality of life. Initiating ARVs in the first 5 months of life is associated with reduced risk of developing encephalopathy and other opportunistic infections, Nduati said. One treatment intervention Nduati highlighted is cotrimoxazole prophylaxis. A randomized clinical trial conducted in Lusaka, Zambia, called “Children with HIV Antibiotic (CHAP) Trial,” showed the use of cotrimoxazole reduced mortality by 43% over a mean period of 19 months.

“Benefits were shown across all ages, all CD4 counts and all duration of follow up,” she said. “Cotrimoxazole is a cheap drug, widely available and on the WHO drug list and yet it is not scaled up for use among HIV-exposed children.”

In order to initiate ARV therapy early, health care providers must diagnose the patient as early as possible, necessitating for improved testing procedures and policies, even in resource-limited settings or locations hampered by poor laboratory infrastructure. Diagnostic tools to test for HIV among pediatric patients range from clinical tools to laboratory-based testing, such as algorithms, antibody tests, CD4 counts and virologic tests, according to Nduati.

Primary health care workers can use clinical algorithms to identify children with asymptomatic HIV. Clinical algorithms are included in diagnostic guidelines; however, they are associated with low sensitivity and may not identify the virus until advanced stages of disease, according to Nduati. Antibody tests are useful to identify newborns in need of ARV post exposure prophylaxis and to identify older infants in need of cotrimoxazole prophylaxis. Data show that CD4 counts have become increasingly available in resource-limited settings and have helped to increase identification of children who need treatment. Virologic testing, such as PCR and P24 antigen tests, are diagnostic tests that benefit HIV exposed infants aged up to 18 months, however, both are not readily available in resource-limited settings and PCR testing requires a high-level of laboratory infrastructure, according to Nduati.

“Technology is not the only barrier to testing,” she said, “unavailability of HIV testing policies for children and adolescents, shortage of staff, limited skills among health workers, health worker and parental fears of dealing with positive test results and exclusion of children from existing services contribute to the late diagnosis of children.”

Improving care

Nduati suggested that one key strategy of improving care for pediatric patients is active promotion of provider initiated testing when young children visit their care provider. A broad approach to care is captured in the “10-point package for comprehensive care of an exposed/infected child,” as highlighted in the Handbook for Pediatric AIDS in Africa, which recommends:

1. Early infant diagnosis
2. Growth and development monitoring
3. Routine health maintenance
4. Prophylaxis for opportunistic infections
5. Early diagnosis and treatment of infections
6. Nutrition counseling
7. HIV disease staging
8. ARV treatment for eligible children
9. Psychosocial support to the child and family
10. Referral for additional care.

“Children are facing a very serious service delivery gap. Lack of linkages and integration between services is hindering scale-up,” she said. “As a priority, all children need to be offered HIV care services at all points of contact.”

Training health care workers is also a critical component to improve treatment. The brain-drain of qualified health professionals is crippling health care provision, according to Nduati, especially for locations like sub-Sahara Africa, which requires 620,000 nurses to deliver effective HIV care and cope with other health emergencies.

“We have enough resources and knowledge to care for HIV infected and affected children,” she concluded. “Regardless of the setting, there is always something to be done for the HIV exposed and infected child.”

For more information:

• Nduati R. Children an AIDS. Advancing treatment and universal access: A report on state-of-the-art and progress. Session WEPL03. Presented at: XVI International AIDS Conference. August 13-18, 2006. Toronto.
• To view the online version of the Handbook on Pediatric AIDS in Africa visit: www.rcqhc.org.