Newsletter GRANDIR | La lettre d’information sur le VIH pédiatrique en Afrique

Over 200 young people were tested for HIV over the course of three days: this is the result of a campaign conducted by REVS+, an organization in Bobo-Dioulasso, Burkina Faso.

The campaign took place during July 16, 17 and 18, 2007. "All of this happened because of an observation: many children don't get tested until very late and by the time they come to our organization they are often already quite sick," explained Bernadette Paré, coordinator of orphan and vulnerable children programs at REVS+. "So we had the idea to organize large scale testing, in conjunction with the paediatric department of the Sanou Souro hospital."

The campaign required three months of preparation. Goal: to encourage members of the organization to have their children tested for free but also to sensitize young people participating in REVS+ support groups.
Speaking directly to children and adolescents was the strength of this campaign. "Because of their parents' reluctances, they are often tested without knowing why and many concerns run through their minds; it's better not to hide the truth from them," said Fatoumata Koné, a REVS+ HIV counsellor in the pediatric department of the hospital.

For the pre-test counseling, "we used the brochure entitled, Brenda has a Dragon in her Blood to help explain HIV to the younger children, including how it is transmitted and also to reassure and inform them about treatments," emphasized Lazare Sawadogo, assistant to the OVC care and support programs. A hitch: they had to adapt the story since the traditional fairy tales that are a part of these children's lives don't have dragons in them! For those who are interested in reading this fairy tale to children, please be aware that children may be frightened by the metaphor with dragons! Use this book with discretion.

A total of 223 children and adolescents (between the ages of 21 months and 18 years) were tested for HIV at REVS+. Six of them (from 6 to 14 years old) tested positive and pediatric treatment and follow up were set up with the organization. 33 adults were tested and two of them tested positive. There was one organizational problem: a system of anonymous coding was used but in order to keep track of people with positive results, people where requested to give their names. This upset several young people who strongly desired confidentiality.

This first campaign gained parents' trust and since they were familiar with the organization, they accepted more easily the idea of having their children tested for HIV. It also facilitated prevention counselling on a large scale. REVS+ hopes to repeat this experience each year in order to raise awareness with even more children and parents.

The fourth IAS Conference (International Aids Society) was held in Sydney in July 2007 and the third South African Conference on HIV was held in Durban in June 2007. Four important issues relevant to the care and treatment of children were discussed:

• The Importance of starting HAART early with children:
  
  A study conducted in South Africa (CHER), could have an important impact on the recommendations in the months and years to come concerning the initiation of HAART with children. This study showed the effects on children who receive treatment early: by three months of age, even before they meet any of the immunological criteria of severe immunosuppression. The study showed they fared much better (with 75% reduced mortality) than children whose treatment was deferred based on their meeting these criteria. These results reinforce the urgent need for early diagnosis (by PCR).



• Triple-therapy during breastfeeding and mother to child transmission:
  
  The studies that we talked about in Growing Up Info n° 11 were also discussed (MITRA+ and AMATA). They both showed encouraging results with very low transmission rates. This takes on even more importance in situations where the conditions for feeding with infant formula cannot be met. (AFASS).



• A good clinical response but an inadequate viral response in children treated in resource-limited countries (a rural area of Uganda):
  
  MSF (Doctors without Borders) exhibited a poster which presented a good clinical response (weight gain and other indicators) but an inadequate virological response after 24 months of follow-up (only 59% of the viral loads measured were < 400 copies/ml), in children who received ART in the form of AZT/3TC/NVP in oral solution for the youngest (weighing < 10 Kg) or in the form of the triple adult fixed dose combination (d4T/3TC/NVP) halved or whole depending on weight. These results most likely illustrate:
  • Lower long-term adherence in children whose treatment consists of several separate medicines,
  • A dosage that is not entirely appropriate if given in fractions of an adult FDC.
  It is therefore important to use pediatric fixed dose combinations (See Growing Up Info n° 12), which will soon be available in most Africa countries, so as to optimize adherence and the dosages based on weight.



• Flawed pediatric and post-PMTCT follow-up leads to higher infant mortality:
  
  An audit of Durban, South Africa hospitals studied to what extent children in PMTCT programs who had died were on ART or on the verge of starting ART. This audit revealed serious flaws in the services provided including poor documentation of PMTCT measures in medical files and no record of clinical classification (WHO clinical stage) in over half of the cases. More than 60% of children who had been prescribed ART were not taking them at the time of their death. This study showed that despite the accessibility of drugs, the problem is now applying the recommendations and disseminating knowledge. . Lack of continuity between the services provided (PTMCT and pediatric follow-up) is also a problem that needs to be resolved. PMTCT services and pediatric services have to work consistently in conjunction with one another in order to assure the continuum of care; especially since the first 6 months of life is a decisive period (PTMCT, early diagnosis, administering CTX, early ART, high mortality rate if not on treatments).

Arsène Adonon, a nurse at ADIS center in Cotonou (from the NGO “RACINES”) sent in this case study. It is something that actually happened and caused a lot of discussion among the healthcare team at the ADIS center. How would you have handled it?

“A boy around 7 years old is referred to the ADIS center in Cotonou by the national pneumo-phtisiology clinic. He arrives accompanied by a person claiming to be his aunt who brings them his HIV+ test result as well as a CD4 count of 123.

As the admittance interview at the ADIS center progresses, it is discovered that the woman who has brought him there is not actually the child’s relative. The woman and the child’s mother were hospital roommates and before she died, the child’s mother asked the woman to take care of her child.

What should the ADIS staff do in this situation?”