“Children are dying of diseases that are preventable and treatable with tools that are simple i.e. IMCI; prevention of HIV infection of young women; prevention of transmission of HIV from mother-to-child; and cotrimoxazole prophylaxis.” Saving Children: 200568
Ultimately, the best way to reduce HIV’s impact on pneumonia is to control it through preventive interventions starting as far upstream as possible, by scaling up family-based prevention and provider-initiated testing and counselling in general and ANC HIV testing and prevention counselling in particular. But other evidence-based preventive activities must be scaled up as well. General MNCH strengthening is essential: stakeholders, policy makers, funders and researchers should consider the possibility that, with these preventive interventions in place, providing the best care possible for all children may lead to the best possible outcomes in children with HIV and pneumonia.
Antenatal HIV testing, and HIV prevention or treatment for the mother
Having a child die of HIV-related pneumonia is the last way that one should have to find out about one’s own HIV status. Provider-initiated testing and counselling and other HIV testing outreach services must be universally available to reach all pregnant women.
Women should receive targeted care and support with ART, when indicated for their own health, if positive, and if HIV-negative, targeting counselling services to prevent HIV transmission to women during the ante and post natal periods (when women are at an especially high risk for HIV acquisition). For instance, data from last year’s International AIDS Society Meeting in Sydney showed an 8% incidence of recent seroconversion (within the previous six months) among pregnant women attending clinics in Botswana.69 Follow-up testing of mothers at vaccination visits in South Africa also suggest this.70 Engaging her male partner(s) in testing and counselling may be important for the success of prevention efforts.
PMTCT
HIV-positive women should receive the best available regimen to prevent mother to child transmission, preferably ART, and preferably for as long as the mother breastfeeds. The continuing low uptake of PMTCT simply isn’t acceptable and ultimately impacts on the quality of care that every child receives.
Accurate child health cards
Documentation of maternal HIV status (with indicators such as HIV-positive, last test date negative, refused test) or the child’s HIV status on the caregiver-held child health cards may be essential for the well being of all children in HIV-endemic settings. If included in the initial assessment, having a child health card available documenting current HIV exposure status (treating untested as HIV-exposed) could allow the implementation of more aggressive community case management of pneumonia to be attempted in high HIV burden settings. However, in order to not disclose a child or mother’s HIV status, community care workers would have to be trained to respect HIV confidentiality.
Another alternative would be training HIV community care workers/home based care teams in the implementation of the spectrum of community-based MNCH interventions (malaria, TB screening, etc) to offer families with HIV an alternate entry point to care.
Universal access to cotrimoxazole prophylaxis
WHO and UNICEF recommend cotrimoxazole prophylaxis for all HIV-positive children, as well as for infants born to HIV-infected mothers, in order to prevent pneumonia (and other infections) and UNICEF has made it a target to provide cotrimoxazole (and/or antiretroviral treatment) by 2010 to 80 per cent of children in need. And yet, in the most recent update on the campaign, Children and AIDS Second Stocktaking Report, which came out last month, only a small number of countries are reporting on rolling out cotrimoxazole.71
“Out of an estimated 4 million children in need of cotrimoxazole prophylaxis (HIV-exposed and HIV-infected), only 4% are currently receiving this intervention,” wrote Zachariah et al in a review of the major barriers preventing the scale-up of cotrimoxazole prophylaxis.72 Of course, one of the chief reasons for this is the lack of coverage of PMTCT programmes and their appalling lack of follow-up.
Among the numerous specific actions proposed to tackle these challenges, the authors suggest that cotrimoxazole be made as an essential component of routine maternal and child-health services at all levels of the health system. One option, “the universal option” is cotrimoxazole prophylaxis for all infants and children born to mothers confirmed or suspected of living with HIV. This strategy may only be considered in settings with a high prevalence of HIV, high infant mortality caused by infectious diseases, or limited health infrastructure.
If suspected includes a mother who has refused the offer of HIV testing, this option may indeed be universal enough.
Given that there is usually good participation in at least the first vaccination visit around 6 weeks, MNCH programmes in high HIV burden countries could offer mothers another chance to test (including those who were negative at or prior to delivery), and provide cotrimoxazole for the child to all of those without an HIV-negative test result. The timing is crucial, because although cotrimoxazole reduces the risk of malaria and a variety of bacterial infection in children, and the risk of PCP is in infants, the peak incidence of PCP is between 2 and 6 months, so the window of opportunity is narrow.
Universal access to ART for HIV-positive children
Ultimately the burden of pneumonia in infants with HIV could be relieved by treating all children with antiretrovirals, but this will require a scale-up of infant HIV testing. Infant HIV testing was discussed in detail in edition 100 of HATIP.
A table presented by Dr Zar illustrates how ART can dramatically reduce the incidence of respiratory infections in children (although it doesn’t account for other changes in care such as prophylaxis and the conjugate pneumococcal vaccine).
Incidence of respiratory infections in children on HAART vs. pre-HAART
OI category |
Post-HAART73 |
Pre-HAART74 |
|
IR per 100 Child yrs |
95%CI |
IR per 100
Child yrs |
95%CI |
Bacterial pneumonia |
2.2 |
1.8-2.6 |
11.1 |
10.3-12.0 |
Bacteraemia |
0.4 |
0.2-0.5 |
3.3 |
2.9-3.8 |
Dissem. Myco av./ MOTT |
0.1 |
0.1-0.3 |
1.8 |
1.5-2.1 |
PCP |
0.1 |
0.04-0.2 |
1.3 |
1.1-1.6 |
Universal access to immunisation
“Vaccines against the two leading bacterial causes of child pneumonia deaths, Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (pneumococcus), can further improve child survival by preventing about 1,075,000 child deaths per year,” Madhi et al wrote in a review of the vaccines in the recent WHO Bulletin.75
Although the vaccines are less effective in children with HIV not on ART (65% and 54%, respectively), compared with children without HIV (83% and 90%, respectively), “because of a 20–40 times increased risk of illness from these bacteria, HIV-infected children still derive a significant protective effect and the absolute burden of invasive disease and pneumonia prevented by the vaccines exceeds that of HIV non-infected children”
Newer conjugate vaccines may offer even broader protection — though they will be more expensive.
HIV funding partners might want to consider helping out, because making certain that all children are vaccinated is in the best interest of children (and adults) with HIV since the reduction in infectious bacterial illness could improve herd immunity, as discussed previously.
Addressing other risk factors of pneumonia
A number of other factors also increase the risk of pneumonia in children.
“Environmental factors, such as living in crowded homes and exposure to parental smoking or indoor air pollution, may also have a role to play in increasing children’s susceptibility to pneumonia and its severe consequences,” according to the Pneumonia, Forgotten Killer of Children report. In fact, a recent randomised controlled trial in Guatemala reported that decreasing indoor air pollution by installing stoves with a chimney achieved a marked reduction in cases of severe pneumonia.76
Lack of exclusive breastfeeding and poor nutrition are risk factors for pneumonia, and there is evidence that providing zinc in settings where zinc deficiency is common may reduce the risk of pneumonia.77
Handwashing and hygiene in the home may be particularly important where people are living with HIV.78
Infection control continues to be neglected in healthcare facility settings, leading to the spread of pneumonia and potentially polymicrobial mixes in hospitalised children with HIV. (An upcoming HATIP will investigate how hospitals in resource-limited settings are unsafe.)