Health care for children affected by HIV

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Health care for children affected by HIV
IATT on Children and HIV and AIDS Washington DC,
April 2007 Siobhan Crowley
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Context

• 10 million HIV infected young people
• 530 000 new HIV infections in 2006 in children lt
  15 years
• 90 of children infected through mother-to-child
  transmission.
• Vast majority of pregnant women in need of PMTCT
  services are not receiving them
• In 2005, 220 000 of the gt 2 mill pregnant women
  living with HIV received ARV prophylaxis for MTCT
  prevention (coverage 11 8-16)
• Significant increase in resources for HIV

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HIV and child health

• Child health outcomes affected by health of
  mother and family maternal illness death
  worsening child outcomes
• Increasing orphanhood attributable to HIV
• Slow steady progress in access to ART

4
International commitments

• Millennium Development goals
• Reduce by two thirds the mortality rate among
  children under five
• (MDG 4)
• Reduce by three quarters the maternal mortality
  ratio
• (MDG 5)
• Halt and begin to reverse the spread of HIV/AIDS,
  halt and begin to reverse the incidence of
  malaria and other major diseases
• (MDG 6)
• UNGASS declaration of commitment (2001)
• strengthen health-care systems
• develop national strategies to provide
  psychosocial care for individuals, families and
  communities affected by HIV/AIDS
• implement care strategies to strengthen families
  and communities to provide treatment for all
  people living with HIV/AIDS
• Universal access (2005 G8 Summit at
  Gleneagles) and (June 2006 UNGASS) work towards
  the goal of universal access to comprehensive
  prevention programmes, treatment, care and
  support by 2010.

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Number of people receiving ARV therapy in low-
and middle-income countries, 20022006
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Ten low- and middle-income countries with the
highest number of HIV infected pregnant women
with number of ARVs received for PMTCT, (2005
data)
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Estimated number of children under 15 years
receiving antiretroviral therapy, children
needing antiretroviral therapy, and percentage
coverage in low- and middle income countries
according to region, December 2006
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Children and ART

• 780 000 were estimated to be in need of
  antiretroviral therapy, 680,000 in Africa.
• 115 500 children had access to treatment by the
  end of 2006, coverage rate of about 15 (12-19)
• Proxy for care - only 4 eligible for
  Co-trimoxazole receiving it (2005 data)
• Follow up of HIV exposed children very poor

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Only countries with over 1000 ART need among
children are included in this graph
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Progress on UA

• Approximately 57 of adults receiving treatment
  in countries are women, while women represent 48
  (4157) of adults living with HIV/AIDS.
• Ratio of men to women receiving treatment is in
  line with regional HIV prevalence sex ratios
• Little data on other 'care' provided
• 50 increase in the number of children receiving
  ART during the last year
• South Africa, children in need ART estimated to
  be 86000 has coverage of 21, the no of children
  receiving treatment having increased by 50
  between Dec 2005 and Sept 2006
• For
• Nigeria 100 000 children in need of ART treatment
  but only 3 were estimated to be receiving it by
  Sept 2006.
• India coverage is only between 3 -19.
• Zimbabwe coverage is estimated to be about 6.

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HIV treatment outcomes in children

• KIDS ART linc data confirm good treatment
  outcomes in children
• Kenya (Nyandiko et al 2006)
• Adherence and CD4 response to ART no different
  for orphan children
• At 1 year follow up Mortality 7.1 vs. 6.6 for
  orphans vs non orphans
• Short term outcomes same for orphan vs. non
  orphan (70 wks)

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Survival on ART children
Preliminary data from KIDS-ART-LINC Collaboration
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Mortality in children affected infected

• Mwanza study (Ng'weshemi et al, Measure 2002)
• Infant mortality in children with HIV ve mother
  158/1000 compared to 79/1000 for HIV negative
  mothers
• By age 5 mortality risk was 270 for HIV exposed
  child, 138 for non exposed child (HR 2.2), and
  386 for those whose mother ill or died during
  infancy
• Effect of maternal death independent of HIV
  status (HR 4.6)
• Fraction of infant mortality attributable to
  maternal HIV was 8.1, where ANC prevalence 4.3
• Other studies report mortality 3-10 X higher for
  children exposed to HIV

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Joint survival of mother baby pairs - Tanzania
HIV negative mother n 4130
HIV positive mother n 214
Longitudinal community based study in Mwanza TZ.
Ng'weshemi et al.2002
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Risk and protective factors for child health
Community
Household
Individual
Adult time input
Medical care
Improved child health outcomes
Adapted from Ainsworth 2000
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Factors worsening child health outcomes
Age, Sex, Disability, HIV
Increased morbidity mortality stunting wasting
Poor PSS outcomes
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Stunting among U5 by household assets
Ainsworth Semali 2000
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Health well being of orphans /- HIV

• Tanzania (Makame et al, 2002)
• HIV orphans compared with non orphans (n 41
  matched controls)
• Unmet needs higher than non orphans and high
  reported PSS
• Kenya (Lindblake et al, Trop med Int Health
  2003. Population based study 1190)
• 7.9 lost one or both parents (6.4 lost father,
  0.8 lost mother and 0.7 both)
• No differences seen on most key health indicators
  between orphans and non orphans, except in W/HZ
  0.3 SD, lower in paternal orphans and orphans gt 1
  year
• Malawi (Crampin etal 2003)
• young orphanage children are more likely to be
  undernourished and more stunted than village
  children
• Guinea Bissau (Masmas et al 2004)
• Excess mortality associated with loss of mother
  in first 2 years of life
• Zambia (Setse et al 2006)
• HIV infection status significantly associated
  with incomplete immunization
• lt 7 years maternal education or lt 3 children at
  home 2 x as likely to have incomplete vaccination

,
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Health system - protective factors for child
health

• lt 5 km to health facility
• High measles coverage
• gt Parental education
• ORS available at the health facility
• Mother kept alive and well

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Programming approaches to CCA

• 'Back to basics' - same basics, or new basics ?
• Key interventions to improve child health
  outcomes are known
• Models for service delivery not premised on
  chronic and continual care, or 'family' as unit
  of operation

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IMCI

• Broad strategy designed to reduce childhood
  mortality, morbidity and disability in developing
  countries. It encompasses improving
• HCWs Case management skills
• health system delivery of essential interventions
  
• family and community practices

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Quality, efficiency and cost of facility-based
child health care through IMCI in Tanzania
Uganda

• Tanzania
• IMCI training is associated with significantly
  better child health care in facilities at no
  additional cost to districts. The cost per child
  visit managed correctly was lower in IMCI than in
  routine care settings
• Facility-based IMCI is good value for money
• Uganda
• investing in IMCI training at a primary facility
  level can yield a significant 44.3 improvement
  in service quality for a modest 13.5 increase in
  annual facility costs.

Bryce et al, Health Policy Plan. 2005 Dec20
Suppl 1i69-i76. Armstrong Schellenberg JR et al
Lancet. 2004364(9445)1583-94 Bishai et al,
Health Econ. 2007 Mar 26
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IMCI equity in Tanzania

• Equity differentials for six child health
  indicators (underweight, stunting, measles
  immunization, access to treated and untreated
  nets, treatment of fever with antimalarial)
  improved significantly in IMCI districts compared
  with comparison districts (plt0.05)
• four indicators (wasting, DPT coverage,
  caretakers' knowledge of danger signs and
  appropriate care seeking) improved significantly
  in comparison districts compared with IMCI
  districts (plt0.05)

(Masanja et al,Health Policy Plan. 2005 Dec20
Suppl 1i77-i84)
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IMCI Health worker performance

• Brazil
• IMCI case management training significantly
  improves health worker performance
• Nurses trained in IMCI performed as well as, and
  sometimes better than, medical officers trained
  in IMCI
• Brazil, Uganda Tanzania
• children receiving care from health workers
  trained in IMCI significantly more likely to
  receive correct prescriptions for antimicrobial
  drugs than those receiving care from workers not
  trained in IMCI
• South Africa
• IMCI trained workers showed marked improvement in
  assessment of danger signs in sick children,
  assessment of co-morbidity, rational prescribing,
  and starting treatment in the clinic.
• No change in the treatment of anaemia,
  prescribing of vit A ,or counselling of
  caregivers, no change in the knowledge of
  caregivers regarding medication or when to return
  to the health facility.
• Facilities were well stocked and supervision
  regular both before and after IMCI

Amaral et al, Cad Saude Publica. 200420 Suppl
2S209-19. Epub 2004 Dec 15 Chopra et al Arch Dis
Child. 2005 Apr90(4)397-401
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Implications for health sector

• Access to ART- enhances capacity of family to
  care protect, to plan for future, enables
  prevention, addresses stigma
• Need decentralisation improved coverage of
  immunization and essential child survival
  interventions
• Simplified, standardised and integrated
  approaches, e.g. IMCI/IMAI enable scale up
• Supportive policy and legislative environment
  necessary
• Focusing on improving access and engagement with
  poorest families most likely to improve child
  health outcomes
• Community home based structures and systems
  exist and are needed to support effective health
  service delivery e.g. community IMCI
• Need to address health needs of caregivers
• Integration of service delivery

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Health sector key responsibilities

• Make sure HIV NSP/NAP include children
  families
• Have specific targets or benchmarks for children
• Know understand the OVC framework
• Have defined and agreed definitions of
  vulnerability
• Ensure HIV policies, norms standards stipulate
  
• right to access services for children
• free HIV services for children/families
• prioritisation of service delivery for children
  families
• continuum of care
• essential package of care for children
• roles, tasks and duties of private sector not
  for profit partners,
• address stigma CCA
• Ensure coordination mechanisms for engagement of
  other sectors
• Ensure National scale up plans built on
  coordinated plans for decentralised delivery of
  the essential package of services

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For IATT CCA

• Strategic
• How to strengthen national capacity to deliver on
  protective factors and minimise risks to CH
• What additional tools or support do national
  govmts /MOH need to do this ?
• Messages back to same basics doing same
  things differently, vs. doing different things
• IATT
• Relationship to PMTCT IATT?
• Greater acceptance that MoH are part of solution
  not just the problem