Health care for children affected by HIV

IATT on Children and HIV and AIDSWashington 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 middle-income countries, 2002—2006

0

200

400

600

800

1 000

1 200

1 400

1 600

1 800

2 000P

eo

ple

re

ce

ivin

g A

RV

th

era

py

(in

th

ou

sa

nd

s)

North Africa and the Middle East

Europe and Central Asia

East, South and South-East Asia

Latin America and the Caribbean

Sub-Saharan Africa

Ten low- and middle-income countries with the highest number of HIV infected pregnant women with number of ARVs received for PMTCT,

(2005 data)

0 50 000 100 000 150 000 200 000 250 000 300 000

South Africa

Nigeria

Mozambique

India

United Republic of Tanzania

Uganda

Democratic Republic of the Congo

Kenya

Zimbabw e

Zambia

Number of HIV-infected pregnant womenwho received ARVs for PMTCT

Estimated number of HIV-infectedpregnant women

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 Co-trimoxazole 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

34%

34%

51%

71%

86%

94%

95%

>95%

>95%

0% 20% 40% 60% 80% 100%

Honduras

Rw anda

Guatemala

Namibia

Argentina

Cambodia

Botsw ana

Thailand

Brazil

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

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

both alive89.7%

,child dead mother alive

9.2%

,mother deadchild alive

0.8% both dead

0.3%

Longitudinal community based study in Mwanza TZ. Ng'weshemi et al.2002

mother dead child alive,

4.0%child dead,

mother alive, 15.7%

both alive, 77.6%

both dead, 2.7%

HIV negative mother n = 4130

HIV positive mother n = 214

Risk and protective factors for child health

Nutrient intake

Community

Improved child health outcomes

Adult time inputMedical care

Individual

Household

Adapted from Ainsworth 2000

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

Increased morbidity & mortalitystuntingwasting

Poor PSS outcomes

Age, Sex, Disability, HIV

Stunting among U5 by household assets

39.8

22.8

59.3

38.3

58.3

39.6

42.9

24.4

39.7

40.7

0 10 20 30 40 50 60

% children < -2SD Height for age

poor

non poor

poor

non poor

poor

non poor

poor

non poor

poor

non poor

No

no

rph

an

sMa

tern

al

orp

ha

nsP

ate

rna

lo

rph

an

s

No

ad

ult

de

ath

Ad

ult

de

ath

Predicted stunting of children based on assets

Ainsworth + Semali 2000

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 lifeZambia (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 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 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 thingsIATT• Relationship to PMTCT IATT?• Greater acceptance that MoH are part of

solution not just the problem