Question-and-Answer: HIV Services and Care in Kenya
In 2010, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) undertook research to compare provision of services and care for HIV-exposed infants in two models in Kenya: within the Maternal and Child Health Clinic (MCH), and within the HIV-dedicated clinics referred to as Comprehensive Care Clinics. The question-and-answer below with the lead researcher Dr. John Ongech sheds light on why the research – which was published in the September 2012 issue of The International Journal of AIDS – was carried out, and on the impact of the research on HIV service provision in Kenya.
1. What led you to do this research?
This research was informed by the concerns about the high number of children born to HIV-positive parent(s) (HIV-exposed infants) that were not coming back to the clinic after delivery (lost to follow up). At the time, only one out of every 10 HIV-exposed children were coming back to the facility for follow-up. Among the issues that were being considered were models of care. There was a debate as to whether HIV-dedicated Comprehensive Care Clinics were or were not convenient to mothers and children. Already, there had been discussions about providing HIV-related services in maternal child health clinics where pregnant mothers and infants have always received their services. There was a need for evidence to inform the thinking and practice, and that is why we did this research.
2. How important is the follow up of HIV-exposed children?
Half of the children infected with HIV die before their second birthdays if no followup or intervention is made. Yet the lives of these children can be saved with simple and widely available interventions for treatment to avert infections caused by compromised immunity. With HIV treatment, even HIV-positive children can live full and productive lives into adulthood. Diagnosing a child’s HIV status early helps to prevent infections, sicknesses, and fatalities, and improves his or her quality of life.
3. You compared providing HIV services and care for children within MCH settings and within the HIV comprehensive Care Clinic.
a) What were the major findings?
The MCH clinics model provides better followup to HIV-exposed children than the comprehensive care clinic model. There is increased uptake of HIV care and other treatment to avert infections in children due to compromised immunity. These include HIV testing, immunization, and growth monitoring of children in MCH settings. It is important to note that while the MCH model produced a 20 percent increase in retention compared to the comprehensive care clinic model, overall there is still a gap, as nearly 40 percent of children still don’t complete HIV services. So more work needs to be done to identify and close the gap to ensure no child exposed to HIV misses out on the services they need to survive.
b) Were you surprised by the findings?
Not really. We’d already conceptualized that MCH models would yield better results because we do not see defaulters with routine childhood immunizations, which are provided in MCH settings. Immunization retention is at 90 percent, and we thought MCH settings are “friendlier” to children, since this is the clinic they have always visited anyway, and they are seeing the same set of providers. So the findings proved our hypothesis right.
c) In all the models, overall loss to follow up for HIV-exposed children is still a challenge. Do you have ideas where and why we are losing these children?
We lose children at various levels. Many mothers visit antenatal clinics (ANC) late – 28 weeks into pregnancy – instead of the World Health Organization-recommended 14 weeks. Some only attend one ANC before delivery, and the majority still deliver at home, increasing the risk of HIV transmission, which happens during pregnancy, delivery, and while breastfeeding. After delivery, visits to the clinics occur mainly during the time of immunization which happens at six weeks, 10 weeks, 14 weeks and nine months. Other significant “outs” happen mainly between 14 weeks and nine months; after nine months, virtually all women stop coming to the clinics. HIV-exposed children need to be seen regularly to check if there are any adverse side effects of antiretroviral treatment on the baby. As the definite HIV status of the child can only be determined after 18 months, they need to be observed regularly to ensure that all growth monitoring and vaccination services happen as required.
d) Are there any risks or concerns we should pay attention to in integrating HIV services into MCH services?
We need more evidence to document the impact of integrating HIV services with MCH services. We need to know if we are clogging the system by working with nurses who are trained on MCH services to deliver HIV services. One risk would be missing out on essential MCH services (immunization, growth monitoring, malnutrition and oral rehydration therapy, among others), but if we look at the service as a package – HIV services as a part of MCH services (primary healthcare approach) as opposed to the “vertical disease” approach – the risks would be minimized.
4. How important is it for a study to be published in the International Journal of AIDS?
The International Journal of AIDS publishes high quality studies with sound methods. The review process is thorough and rigorous, and being published here means our methods were sound and all factors that could influence the results other than those that were being focused were properly controlled. In order to influence policy, one needs thorough and well-documented evidence. This study gives us confidence to influence dialogues with policymakers.
5. Do you see this research impacting the ways in which HIV services and care for children are provided in Kenya?
Since the findings of this study were released, several things have happened as a result. The MCH model has been included in the national 2012 Prevention of Mother-to-Child Transmission of HIV (PMTCT) guidelines.
In most of the facilities at the district level and below in the Western and Nyanza regions, women and children with HIV are not just seen at comprehensive care clinics, but within maternal child health clinics and the majority of the lower-level health facilities – (health centers and dispensaries within outpatient clinics). In order to address issues of stigma within the facility and at the community level, psychosocial support groups and peer counselors work with the mothers and help them overcome the many challenges of living with the virus.
Innovations such as single appointments for all services – including coinciding clinic visits with market days – help reduce the number of trips women must make, especially in those cases where facilities are located further from their homes.
Eric Kilongi is Senior Communications Officer for the Foundation, based in Africa.