Treating children with HIV: the perennial resource challenge
In June this year, the WHO published
new guidelines on the prescription of
anti-retroviral therapy (ART) for the
treatment of HIV positive patients.
One of the major changes was a
recommendation to prescribe ART to
all children under five, whatever
their CD4 count (a measure of the
strength of the immune system). Yet
only 28% of children who were
eligible for treatment under the
previous guidelines received
treatment, so can the new guidelines
help break down the barriers to
access to treatment?
Most health professionals think so,
simply by virtue of not requiring a
CD4 count before putting a child on
treatment. Allan Mayi, senior
technical adviser at the Elizabeth
Glaser Pediatric Aids Foundation
(EGPAF) in Turkana, Kenya, says that
health workers often struggle to
interpret CD4 count results, which
can take weeks. There are only three
CD4 machines in Turkana County, an
area the size of Ireland, a situation
that is commonplace in developing
countries. Removing this requirement
will be a relief, he says. "I wish the
recommendation were for all
children, not just those under five."
But extending ART to millions more
children presents challenges, chief
among them identifying HIV positive
children. Dr Jennifer Cohn, medical
director of the MSF access campaign,
says that the use of early infant
diagnosis (EID) must become much
more systematic in Preventing
Mother to Child Transmission
(PMTCT) programmes. "Babies have a
spike in early morbidity around 8-10
weeks, yet the first EID is around six
weeks and results might not come
back until they are about 10 weeks.
That's too late," she says. "We need to
have EID in week one, along with the
BCG [tuberculosis] vaccine. This offers
an opportunity to test babies while
they are interacting with the
healthcare system."
Point-of-care EID tools that can be
used in lower-level healthcare
facilities should hit the market in
2014 and encourage testing to be
done earlier and more frequently.
Cohn says that health professionals
must start thinking now about how
they will combine the use of point-of-
care EID with other health
interventions such as vaccination or
nutrition clinics to catch children
who slipped through the PMTCT net.
Mayi says that skills and training will
also be an issue. In high burden
countries like Kenya and South
Africa, ART can be initiated by
nurses, midwives and health workers
in dispensaries or local clinics. These
professionals will need greater
supervision as their workload
increases, says Mayi, which has
logistical implications.
Dr Laura Guay, vice president for
research at the EGPAF, says that many
health workers will also need
additional training and mentoring
before they can confidently initiate
treatment on infants or toddlers.
Drugs are another concern. Their
availability isn't an issue since they
are heavily supported by
international donors but Guay says
that a second generation of paediatric
drugs is desperately needed. The
current formulation, liquid-based,
tastes nasty and babies often spit it
out. There are other problems too:
it's difficult to administer in
combination with other drugs and the
infant formulation requires a cold
chain. A new formulation using
sprinkles in pre-packaged sachets
(tablets aren't suitable for growing
children's constantly changing
weight) is currently in the pipeline
and its adoption won't come soon.
In the long-term, another problem
looms: that of dealing with a growing
cohort of HIV positive teenagers. The
success of PMTCT programmes should
make the problem moot, but in the
meantime, the increasing availability
of ART and its efficacy means more
children growing into healthy
adolescents and adults.
The first major challenge as children
turn into adolescents is disclosure of
their HIV status. Mayi says that many
children still reach adolescence
without knowing their status because
of social stigma. Current best practice
recommends that a child should be
told of his or her status around the
age of seven or eight, but in many
cases, parents put it off. "Staff are
trained to do assisted disclosure and
help parents tell their child, but we
need to do more communication and
behavioural interventions," says
Mayi.
For HIV positive adolescents, the
issues of sexuality and discipline are
particularly pertinent: they must
learn to adhere to their drug regimen
despite their irregular hours; and they
must add the minefield of disclosure
to partners while negotiating their
own sexuality.
Yet, despite these crucial needs,
adolescents are not well catered for.
"There are teen clinics but they are
few and far between compared to
how many people are infected," says
Guay. One such clinic is Themba
Lethu - run by Right To Care , a non-
profit organisation - at the Helen
Joseph hospital in Johannesburg,
South Africa. The clinic caters to
teens and young adults aged 11 to 19
and it has set up a support group, run
by teenagers.
"The best way to get adolescents to
adhere to their regimen is to let them
talk to each other," says Dr Kay
Mahomed, the HIV consultant who
works with the peer group. "They will
not listen to older people, be they
parents or doctors."
Mahomed says the group has been
incredibly successful, with older
adolescents becoming role models for
younger teens. She has been
advocating for adolescent clinics to
be deployed in smaller facilities too.
Some of these teenagers have now
gone on to have families. "You just
have to empower them to make the
right decisions."
