Challenges in providing HIV care to paediatric age group in India

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Challenges in providing HIV care to paediatric age group in India

 

Indian J Med Res 129, January 2009, pp 7-10

Commentary

 

Over 90 per cent of the 2 million HIV infected children worldwide, live in

developing countries1. In India , 3.8 per cent2 (approximately 100,0003) of an

estimated 2.5 million persons living with HIV/AIDS (PLHA) are children. As of

September 2008, of about

1,77,808 individuals started on antiretroviral therapy (ART) since its launch in

April 2004, about 12,116 are children and, over 42,000 are registered in pre-ART

programme (personal communication, Rewari BB).

 

Since median duration of progression from HIV to AIDS in children is two years4,

many infected children, particularly infants may not be able to access ART.

 

Paediatric HIV/AIDS Initiative of Government of India comprises Prevention of

Parent to Child Transmission (PPTCT) on one hand and co-trimoxazole (CTX)

prophylaxis to avert opportunistic infections (OI) and ART, on the other.

However, endeavours at scaling up comprehensive care for children living with

HIV/AIDS (CLHA) are met with many barriers, such as low access to treatment,

difficulty in early diagnosis, diagnosis and management of OI, implementing CTX

prophylaxis, need of specific as well as frequently changing drug dosages,

trained human resource, etc.

 

One of the greatest challenges to paediatric HIV care and treatment in India is

the low coverage of ANC and PPTCT services. Less than 20 per cent of pregnant

women5 in India access public health facilities for delivery, resulting in low

utilization rate of PPTCT

services. In fact, the reported percentage of estimated HIV-infected pregnant

women in India who received anti-retrovirals for PPTCT was only 10 per cent6.

 

As highlighted by Rajasekaran et al7 in the current issue, low access to

treatment is a culmination of multiple factors. People have to travel long

distances to reach the nearest designate ART centre for availing care and

treatment. Over 60 per cent of children in this

study had to travel more than 200 km to avail ART.

 

Absence of facilities to care and treat HIV near home, non availability of

resources at local health centres to treat HIV, inability to pay for services in

private facilities and fear of stigma and discrimination if identified in local

community, were cited as reasons for travelling such large distances. Since the

time of data collection for this study, the ART programme in India has expanded

considerably.

Although the number of ART centres in India has been substantially scaled up

from 10 in December 2004 to more than 170 as of October 2008, access to

treatment still remains a challenge as ART centres are not present in each

district, especially in low prevalence States. Moreover, many of the HIV

infected children are either orphans or have parents affected by illness due to

HIV who are unable to accompany them.

 

These difficulties eventually reflect not only on access but also on subsequent

follow up. Moreover, as reported by another study8, ART adherence is

significantly related with developmental needs of child and psychosocial issues

related to caregiver.

 

However, evidence about correlates of adherence to ART in paediatric age group

is required from India .

Early diagnosis is important for timely initiation of ART because it is

desirable to start treatment before severe immune deficiency sets in9. Infants,

if severely immuno-compromised at start of therapy, experience higher

mortality10, one of the reasons being

development of immune reconstitution inflammatorysyndrome (IRIS)11.

A study from Thailand documented that children with CD4 less than 5 per cent at

start of treatment were least likely to reach target outcome of CD4 more than 25

per cent12. On the other hand, children put early on ART while CD4 was more than

25 per cent experienced 75 per cent reduction in mortality compared with those

who received it after CD4 had fallen below 20 per cent13.

 

However, HIV diagnosis in infants is complex and is a hindrance in scaling up

paediatric HIV programme in India . The low cost antibody tests furnish false

positive results for up to 18 months of age because of the presence of maternal

antibodies.

 

Antibody testing may be probable at 9-12 months in non breast fed infants but in

a developing country like India breastfeeding is the rule rather than exception.

The available options for early diagnosis (six weeks onwards) are either real

time PCR assays to detect HIV DNA or HIV RNA14 or assays to detect p24 antigen.

However, as these are resource intensive and prohibitively costly, implementing

this technology across India is a challenge.

 

PCR testing can be done with either whole venous blood or dried blood spots

(DBS). While paediatric venepuncture is a demanding skill to come across at

peripheries, for DBS, a small stick is made on child’s foot and blood is

dripped onto a special filter paper. As storage and transportation of DBS do not

require stringent cold chain requirement, it might be an appropriate solution to

transfer specimens from periphery to centrally situated laboratories. However,

arduous manpower training is a prerequisite for use of DBS.

As experience of implementation of DBS for HIV diagnosis is limited, several

operational issues need to be considered for scale up. In addition, availability

of PCR in select centrally located laboratories leads to delay in getting

results and consequently initiation of treatment. Clinical case definitions can

be useful to suspect children infected with HIV.

Intricacies in diagnosis are complicated by hurdles in identifying some clinical

manifestations that can be non specific in these children. These will help in

identification and referral of infected child to avail necessary diagnostic

services treatment, but are not an alternative to laboratory testing15 for young

infants.

In India , tuberculosis (TB) is reported as the most common OI7,16. Respiratory

infections including Peumocystis carinii pneumonia (PCP), recurrent diarrhoea

and oral candidiasis have been reported as other important OIs. It is difficult

to identify tuberculosis in the presence of HIV infection as tuberculin skin

test has poor sensitivity when used in HIV infected children. However, clinical

suspicion can give a lead to suspect a case of TB.

Malnutrition is a common problem in CLHA with Indian studies reporting 6 per

cent7 to 56.7 per cent16,17 HIV infected children suffer from protein energy

malnutrition. The co-morbidity with malnutrition substantially influences

morbidity and mortality in these children18. Further, the dilemma in management

of CLHA with severe malnutrition is whether to start ART before or after

nutritional rehabilitation19.

 

While improvement in nutritional status unearths appearance of IRIS with

potential fatal prognosis, the potential adverse effects of ARV drugs or OIs may

themselves affect food intake, resulting limited improvements in growth and

consequently decreased adherence to therapy. These underscore the importance of

regular follow up for care including nutritional care.

 

It is thus evident that public health approach is required for improved

coverage. Basic elements of this approach are availability of standard

diagnostic procedures, simplified ARV regimens; suitability of drug formulations

for paediatric dosages; capacity

to manage co-existing conditions such as TB, malnutrition, etc; and robust drug

procurement and supply systems.

 

Access to treatment in India , however, is still a challenge. To increase access

of CLHA to ART centres it would be important to establish and strengthen a

system of linkages and two way referrals between peripheral and specialist

centres. The primary and

secondary level health care providers are proximal tothe beneficiary. Skill

building of health care workers at primary and secondary levels is required

whereby; they are able to identify suspect cases and refer them for further

investigation and care at early stages.

 

They should be able to manage the complaints of patients such as management of

TB, respiratory and gastrointestinal infections. They should encourage and

utilize the follow up visits to impart information to the mother or care giver

on common HIV related features, address psychosocial concerns, provide

counseling  on available options of infant feeding, nutritional care to manage

malnutrition and importance of adherence to ART.

As CTX prophylaxis protects the infant from PCP, toxoplasmosis and other

bacterial diseases, its availability at primary and secondary care levels and,

capability of health care personnel at that level to take decision to provide

CTX as per indication, would

further help in reducing the morbidity and mortality of children. This would

also take the burden off from higher centres who can concentrate on serious

patients.

 

These co-morbidities can be handled efficiently at primary and secondary levels,

even during pre- ART period if there is a strong two way referral system.

 

The WHO- initiated Integrated Management of Adolescent and Adult Illness (IMAI),

Integrated Management of Childhood Illness (IMCI), Integrated Management of

Pregnancy and Childbirth (IMPAC)20 are such an integrated primary care approach

that emphasises building clinical teams that are able to deliver HIV prevention,

care and treatment, along with basic primary care. IMPAC also emphasises that

Prevention of Mother to Child Transmission (PMTCT) interventions be integrated

with antenatal, delivery, post-partum, newborn and infant care. This would

ensure support for healthy pregnancy, childbirth, infant and child nutrition and

development.

 

Thus, to ensure comprehensive paediatric HIV care in India , in addition to

expansion of the availability of skilled paediatricians21 and laboratory

infrastructure for diagnosis at specialist centres, the capacity building of

health care workers at primary and secondary levels should be a priority.

 

This would immensely improve access to treatment, care and CTX prophylaxis for

CLHA in India . Appropriate guidelines for management and referral at different

levels need to be developed and distributed.

 

An integrated approach with the ongoing scale up of PPTCT in India would also be

 important to impart effective primary prevention for children since more than

95 per cent of children acquire HIV infection from mother by perinatal

transmission.

 

Partha Haldar & D.C.S. Reddy*

World Health Organization

536, A-Wing, Nirman Bhawan

Maulana Azad Road

New Delhi 110 011, India

*For correspondence:

reddyd@...

 

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