Factors associated with improved access to treatment and care for children with HIV in Africa identified in 5-country study

Nutritional support, early infant diagnosis (EID), linkages with associations of people living with HIV and on-site prevention of mother-to-child transmission (PMTCT) services were associated with favourable paediatric enrolment and a high proportion of children under two years of age on ART. This is according to a four-year retrospective review of over 200 clinical sites within the Elizabeth Glaser Pediatric AIDS Foundation’s (EGPAF) large multi-country HIV care and treatment programme in Africa, published in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

Home-based care (treatment, adherence counselling and psychological support provided by a healthcare worker in the home) was associated with low paediatric attrition rates (aOR 2.9, 95% CI: 1.4-5.8).

These findings showing the link between certain services and favourable programme outcomes for children suggest areas of clinical activities that might be expanded or strengthened so leading to improved paediatric HIV service utilisation among similar resource-poor country populations, Georgette Adjorlolo-Johnson and colleagues report.

However, the percentage of children enrolled in HIV care services was far below the international target of 15% of all HIV-positive people in care, highlighting the “need for more aggressive strategies to increase enrolment of children in such settings”, the authors add.

Ninety per cent of all HIV-infected children live in sub-Saharan Africa. Early access to antiretroviral treatment is critical to their survival. Without treatment, approximately 50% will die before their second birthday. Conversely, studies have shown that treatment within the first twelve weeks of life results in significant reductions in early death, with a greater than 90% chance of surviving to adulthood.

Poor access to early infant diagnosis (EID) using DNA polymerase chain reaction (PCR) testing, limited paediatric antiretroviral drug formulations, weak healthcare infrastructure and socio-cultural factors are some of the barriers to receiving paediatric HIV treatment services.

Additionally, overall paediatric attrition rates in clinical settings providing HIV treatment across all HIV programmes in Africa are unacceptably high, ranging from 10% to over 50% at two years of age, mostly because of loss to follow-up or AIDS-related death.

EGPAF has been providing technical support to implement HIV care and treatment and PMTCT services through Project HEART ('Help expand antiretroviral therapy)', a PEPFAR-funded initiative through the Centers for Disease Control and Prevention (CDC) since 2004. The programme was rolled out in a wide variety of healthcare facilities in Ivory Coast, Mozambique, Tanzania, South Africa and Zambia.

A retrospective review was conducted at all sites providing HIV treatment services within Project HEART from 2004 until 2008. Information describing HIV care and treatment site characteristics was collected through a standard questionnaire.

Favourable paediatric programme outcomes for each site were defined as having more than 100 children in care (including those on ART); at least 8% of all patients in care being under 15 years of age; at least 10% of children on ART in 2008 under two years of age, or having a total attrition rate under 10% for children on ART.

The authors compared proportions of sites with favourable outcomes among those with and without selected characteristics. Selected site characteristics included:

• General – urban or rural, level of care and type of facility.

• Access to essential services – EID by DNA PCR testing, provision of cotrimoxazole prophylaxis and nutritional support.

• Level of staff available and trained in HIV.

• Linkages with PLHIV associations.

• On-site PMTCT services.

• Provision of home-based care service.

Over the four-year period a total of 33,331 children were enrolled, of whom 18,255 were on ART across 220 sites.

Favourable enrolment of children was more likely at sites offering EID (aOR 3.3: 95% CI: 1.5-7.1) or nutritional services (aOR 8.9, 95% CI: 2.8-28.4) and those linked to PLHIV associations (aOR 4.2, 95% CI: 1.8-9.5).

However, only 58% of sites had EID services or links with PLHIV associations, suggesting expansion of these services and linkages would be beneficial.

Malnutrition and failure to thrive are common among children with HIV and AIDS so provision of nutritional services may explain favourable enrolment. Yet no link was seen with infants on ART, perhaps because of the lack of EID and a corresponding delayed diagnosis, the authors note.

A direct causal relationship between provision of nutritional support services and paediatric enrolment is unclear as the review was retrospective, they add.

High enrolment of infants and children was associated with on-site PMTCT services or linkage to PLHIV associations, supporting current strategies to integrate paediatric HIV treatment and PMTCT services and the involvement of people living with HIV in HIV programmes.

Having a nurse specifically trained in HIV care was not significantly associated with paediatric enrolment, but was associated with a high percentage of new children on ART under two years of age.

While home-based care was linked to low attrition rates of children from the programme, consistent with other findings, nutritional support was not. This may be because of advanced HIV disease and high attrition because of death, the authors note.

Sites with computerised patient tracking systems also had high attrition rates. The authors suggest this may reflect the difference in the quality of data collection and reporting systems with a paper-based monitoring system. In the latter, loss to follow-up is are often under-reported so attrition rates may be underestimated.

The sites were limited to Project HEART-supported clinics rather than a random sample of HIV treatment sites in the respective countries so they may not be representative of these countries. Nonetheless, the authors believe any bias is limited, as the sites represent a wide range of health facilities offering different types and levels of care in diverse geographic settings.

The authors conclude these findings suggest that:

• Increasing systematic access to EID may increase starting treatment early in infants diagnosed with HIV;

• Integrating nutritional support of any kind with HIV services could improve enrolment and retention of HIV-positive children with malnutrition in urgent need of ART;

• Integration of PMTCT with paediatric HIV care services and strengthening linkages with PLHIV associations might improve enrolment of younger children; and

• Developing or strengthening home-based care services could be a way to improve retention of paediatric patients in HIV care and treatment programmes in resource-poor settings.

Adjorlolo-Johnson G et al. Scaling up pediatric treatment and care in Africa: clinical site characteristics associated with favourable service utilization. Advance online edition J Acquir Immun Defic Syndr, doi: 10.1097/QAI.0b013e3182706401, 2012.