South African study shows good ART outcomes for children in primary health clinic

Over 80% of children who began antiretroviral treatment remained in care with 90% of those still in care showing complete viral suppression after two years in a primary health care setting in a very poor township in Johannesburg, South Africa, reported Pippa MacDonald at the Fifth International AIDS Society Conference on Pathogenesis, Treatment and Prevention held in Cape Town, South Africa in July.

Preliminary findings were presented at the Second Botswana International HIV Conference in Gaborone, Botswana in September 2008.

Of the 2.1 million children infected with HIV worldwide 90% reside in sub-Saharan African, of which 280,000 are in South Africa.

Challenges to the provision of paediatric antiretroviral treatment in South Africa are many and include: the co-morbidities of tuberculosis and malnutrition; complex drug regimens and a corresponding lack of paediatric formulations; a complex social context, for example, being an orphan, an adolescent, living in poverty and/or receiving parallel treatment by traditional healers. Late initiation contributes to the high mortality rates as well as stunted growth and development in this population.

The Phatsima Khanya (Place of Bright Lights) Children’s HIV Clinic is a health care clinic located in Alexandra Township, Johannesburg. Alexandra is very poor. Crime is rampant with high unemployment and severe overcrowding. Malnutrition and illiteracy are common. All combined make for difficult living conditions.

The clinic began in April 2005 and became a national roll-out site in February 2006. The clinic is a comprehensive care, management and treatment (CCMT) site. All services are free-of-charge. A family-centred approach is taken and the clinic operates as part of a general adult HIV clinic. HIV testing begins at 4-6 weeks of age and antiretroviral treatment is provided as necessary.

The paediatric team consists of three doctors, two nurses – one primary health care nurse and one professional nurse – and three counsellors. A dietician, social worker, pharmacist, data capturer and administrative assistants are shared with the adult CCMT clinic.

A retrospective chart review was undertaken for the four year period from April 2005 to April 2009. The study population included all infants, children and adolescents up to the age of 14 who began antiretroviral treatment.

A total of 337 children began ART with a median age of 5 years 7 months. Seventy-five per cent were on a first-line regimen consisting of lamivudine (3TC), stavudine (d4T) and efavirenz (EFV) with the remaining 25% on 3TC, d4T and lopinavir/ritonavir (LPV/r). The median baseline CD4 percentage was 12.8. Close to 85% were at WHO stages 3 and 4 (25% and 58% respectively). Eleven per cent were under one year of age, 34% aged between one and five and 41% aged between six and nine with the remaining 14% 10-14 years of age.

At the end of the study period 83% (281) were still in care. Undetectable viral loads were seen in 87% (172/199) after one year and 90% after two years on treatment. The median CD4 percentage increase was 12.7 (8.21-17.37) and 15.3 (11.0-19.8) at one and two years respectively.

At the end of the study period 193 (69%) were still on first-line treatment. The overwhelming reason for switching regimens was toxicity, as a result of stavudine, (72/88 or 82%) in the form of lipodystrophy and hyperlactataemia.

While the high orphan rate of 32% did not affect outcomes it has important consequences for the psychosocial well being of these children, noted the authors. Success in viral suppression is similar whether a mother or grandmother is the primary caregiver.

The many psychosocial challenges require a multidisciplinary team approach noted the authors. For example, to help combat severe malnutrition (baseline WAZ of -4.05) food parcels are distributed and there is a daily soup kitchen. A separate clinic exists for adolescents. The clinic does social outreach to help counter the high rate of unemployment among caregivers and poverty by providing clothing, blankets as well as educational grants.

The authors conclude that “we can confirm that ART has changed the face of the paediatric HIV epidemic in our community, but perhaps our greatest lesson learned is that ART is just one part of the total care of HIV-infected children”.