ART for children feasible in small rural clinics, South African study shows

Paediatric antiretroviral therapy is feasible in decentralised, nurse- and counsellor-led programmes in public health clinics in rural areas in South Africa, according to research presented at the Fourth South African AIDS Conference in Durban earlier this month.

Mortality rates in children receiving ART at public health clinics in Hlabisa, a sub-district in rural northern KwaZulu-Natal, were no different from rates seen in other African cohorts.The health infrastructure of the sub-district of Hlabisa, which has a population of 220,000, is typical of most rural health districts in South Africa and has 16 primary health care clinics, two mobile clinics and one 300-bed district-level hospital.

The ART programme, a partnership between the Department of Health (DOH) and the Africa Centre for Health and Population Studies, follows DOH national guidelines. Physicians visit the 16 clinics to initiate ART. Services are decentralised and patients are able to access free care at their nearest primary health care clinic which is managed by nurses and counsellors.

Children are less likely to receive treatment than adults, in part because HIV diagnosis is more complex in children under the age of 18 months due to the carriage of maternal antibodies that may result in a false-positive diagnosis. But children may also fail to receive treatment due to a lack of awareness of the presentation of HIV-related symptoms in children, especially infants.

In order to reveiw how well the programme was meeting the needs of children with HIV, a retrospective study was undertaken of the clinical records of all children (477) on ART in the districts from January 2004 until June 2008.

At baseline, recorded values included a mean age of 76 months and 5% of the sample were under 12 months of age. Nearly a quarter were receiving TB treatment and over 75% were classified as having WHO Stage 3 or 4 HIV disease (symptomatic illness). CD4 count and CD4 percentage, viral load, haemoglobin (anaemia) and albumin (malnutrition) levels were recorded. Most of the children were malnourished and anaemic.

Close to 90% of children who began first-line treatment over the four-year period were still alive as of July 2008. Thirty-two (6.7%) had died, 12 (2.5%) had transferred out of the programme and 18 (3.8%) were lost to follow-up. Most deaths occurred within the first 90 days across all age groups and were associated with a lower weight-for-age ratio, being anaemic, being classified as WHO Stage 3 or 4 and having a lower CD4 percentage at the start of treatment.

Unlike the deaths, loss to follow-up occurred both before and after the first 90 days of treatment and was associated with a lower CD4 percentage and stage 3 or 4 disease at the start of treatment.

After six to twelve months on treatment, 75% of children had viral load suppressed below 25 copies/ml (the limit of detection), a median increase in CD4 cell counts from 432 to 519 and in CD4 percentage from 17% to 22%.

At the conclusion of their analysis in June 2008 the researchers, concerned with the low number of children under the age of one receiving treatment, set up new procedures to ensure that HIV-positive children were not being missed.

Treatment for children at disease stage 3 or 4 was often delayed since doctor referral and subsequent ART initiation was dependent upon viral load or CD4 results.

Clinic nurses were notified that all sick HIV-exposed children, as well as those who were malnourished, could see a doctor regardless of HIV status. Nurses and counsellors received enhanced paediatric HIV training. Importance was placed on recognising TB as a WHO stage 3 condition and the eligibility of all children with HIV who had a history of TB for antiretroviral therapy.

From 1 July 2008 to 31 December 2008 a 42% increase in children receiving ART across all age groups was recorded, with an increase of almost 50% in children under one year of age.

The authors conclude: “We believe we’ve shown that paediatric ART is feasible in a devolved programme in a rural area. However there are still too few children under one year (of age) on treatment, and there is an urgent need to identify HIV-exposed children.”