Treating children with HIV: The perennial resource challenge
The Guardian | September 12, 2013
by: Emilie Filou
Anti-retroviral medicines suppress the replication of HIV by blocking the enzymes HIV uses to replicate itself. This allows the immune system to regain its strength and combat opportunistic infections. Photograph: Krista Kennell/ZUMA/Corbis
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."
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