Health care for children
affected by HIV
IATT on Children and HIV and AIDS
Washington DC, April 2007
Siobhan Crowley
Context
• 10 million HIV infected young people
• 530 000 new HIV infections in 2006 in children <
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 > 2 mill pregnant women
living with HIV received ARV prophylaxis for
MTCT prevention (coverage 11% [8%−16%])
• Significant increase in resources for HIV
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
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.
Number of people receiving ARV therapy in low- and middleincome countries, 2002—2006
1 800
North Africa and the Middle East
Europe and Central Asia
1 600
East, South and South-East Asia
Latin America and the Caribbean
1 400
Sub-Saharan Africa
1 200
1 000
800
600
400
200
6
en d
- 200
006
mid
-2
200
5
en d
005
mid
-2
200
4
en d
004
mid
-2
200
3
en d
003
mid
-2
200
2
0
en d
People receiving ARV therapy (in thousands)
2 000
Ten low- and middle-income countries with the highest number of HIV
infected pregnant women with number of ARVs received for PMTCT, (2005
data)
Zambia
Zimbabw e
Number of HIV-infected pregnant women
who received ARVs for PMTCT
Kenya
Estimated number of HIV-infected
pregnant women
Democratic Republic of the Congo
Uganda
United Republic of Tanzania
India
Mozambique
Nigeria
South Africa
0
50 000
100 000
150 000
200 000
250 000
300 000
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
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 Cotrimoxazole receiving it (2005 data)
• Follow up of HIV exposed children very
poor
Antiretroviral therapy coverage of at least 25% among children under
15 in low - and middle-income countries, December 2006
Brazil
>95%
Thailand
>95%
95%
Botsw ana
94%
Cambodia
86%
Argentina
71%
Namibia
51%
Guatemala
Rw anda
34%
Honduras
34%
0%
20%
40%
60%
Only countries with over 1000 ART need among children are included in this graph
80%
100%
Progress on UA
•
Approximately 57% of adults receiving treatment in
countries are women, while women represent 48%
(41%–57%) 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%.
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)
Survival on ART children
Preliminary data from KIDS-ART-LINC Collaboration
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
Joint survival of mother baby pairs Tanzania
HIV negative mother n = 4130
,mother dead
child alive
0.8%
both dead
0.3%
,child dead
mother alive
9.2%
child dead,
mother alive,
15.7%
mother dead
child alive,
4.0%
both dead,
2.7%
both alive,
77.6%
both alive
89.7%
HIV positive mother n = 214
Longitudinal community based study in Mwanza TZ. Ng'weshemi et al.2002
Risk and protective factors for child
health
Community
Household
Individual
Nutrient intake
Medical care
Improved child health outcomes
Adapted from Ainsworth 2000
Adult time input
Factors worsening child health outcomes
Contextual
Health system
Poor household
Epidemic child health diseases
Recent adult death
High HIV prevalence
Higher market prices
High rates malnutrition
> Distance to market
ORS not available at HF
Little parental education
> Distance to HF
Young maternal age
Poor measles vacc coverage
Safe water
Mother HIV +ve
Age, Sex, Disability, HIV
Increased morbidity & mortality
stunting
wasting
Poor PSS outcomes
Stunting among U5 by household
assets
No
Non MaternalPaternal adult Adult
orphansorphansorphans death death
Predicted stunting of children based on assets
40.7
non poor
39.7
poor
24.4
non poor
42.9
poor
39.6
non poor
58.3
poor
38.3
non poor
59.3
poor
22.8
non poor
39.8
poor
0
10
20
30
40
% children < -2SD Height for age
Ainsworth + Semali 2000
50
60
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 > 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
• < 7 years maternal education or < 3 children at home 2 x as likely to have
incomplete vaccination
,
Health system - protective factors
for child health
•
•
•
•
•
< 5 km to health facility
High measles coverage
> Parental education
ORS available at the health facility
Mother kept alive and well
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
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
Quality, efficiency and cost of facilitybased 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 Dec;20 Suppl 1:i69-i76.
Armstrong Schellenberg JR et al Lancet. 2004;364(9445):1583-94
Bishai et al, Health Econ. 2007 Mar 26
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 (p<0.05)
• four indicators (wasting, DPT coverage,
caretakers' knowledge of danger signs and
appropriate care seeking) improved significantly
in comparison districts compared with IMCI
districts (p<0.05)
(Masanja et al,Health Policy Plan. 2005 Dec;20 Suppl 1:i77-i84)
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. 2004;20 Suppl 2:S209-19. Epub 2004 Dec 15
Chopra et al Arch Dis Child. 2005 Apr;90(4):397-401
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
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
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