Thesis

Rural Realities in Paediatric HIV Service Delivery

With the few paediatric HIV programs and studies reporting from rural areas, the aim of this thesis is to evaluate HIV service delivery in rural Zambia and focus on the factors influencing the care and treatment of HIV-1 infected children.

The first part of this thesis reviews available, data on paediatric treatment programs of Sub-Saharan Africa [Part one, chapter 2]. In this chapter, we review the effectiveness of paediatric antiretroviral treatment programmes in sub-Saharan Africa and discuss the implications of these findings for the care and treatment of HIV-infected children in this region. Our review of the published literature showed that children in sub-Saharan Africa achieved comparable outcomes to those in high-income settings although they enrolled in care at older ages and more advanced stages of disease. The findings emphasised the need for low-cost diagnostic tests that allow for earlier identification of HIV infection in infants living in sub-Saharan Africa, improved access to antiretroviral treatment programmes, including expansion of care into rural areas, and the integration of antiretroviral treatment programmes with other health-care services, such as nutritional support.

Programs providing paediatric ART in sub-Saharan Africa face many challenges, many of which are exacerbated in rural areas. In the following chapters [Part two, chapters 3 and 4] we look at issues specifically related to the population in rural southern Zambia. Our observations highlight barriers to the care of HIV-infected children unique to rural settings, specifically long travel times and lack of transportation, but are encouraging in that age at clinic enrolment and immunologic outcomes in the first year of treatment did not differ substantially from published reports on the care of HIV-infected children in urban sub-Saharan Africa. These findings suggest that the barriers to the care of HIV-infected children in rural settings do not pose insurmountable obstacles to desirable treatment outcomes. Despite these barriers, children in rural Zambia had a substantial rise in CD4+ T cell counts in the first year of ART although longer follow-up is needed to indicate if these gains can be sustained.

Part three, chapters 5 and 6, reviews treatment responses in the study population in rural Zambia. HIV-infected children receiving treatment in this rural clinic experienced sustained immunologic and virologic improvements. Children with longer travel times were less likely to achieve virologic suppression, supporting the need for decentralized models of ART delivery.

It has been shown that deficits in growth observed in HIV-infected children in resource-poor settings can be reversed with antiretroviral treatment. However, many of these studies have been conducted in urban areas with older paediatric populations. Additional analyses were undertaken to evaluate growth patterns after ART initiation in this young paediatric population in rural Zambia with a high prevalence of undernutrition, and identify characteristics at ART initiation that influence growth trajectories.

In part four, issues regarding HIV service delivery are addressed. We reviewed mortality rates and clinical predictors of mortality during the period prior to ART initiation [chapter 7], underscoring the need to increase efforts to identify HIV-infected children at an earlier age and stage of disease progression.

Antiretroviral treatment options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings in sub-Saharan Africa, where the dual burden of HIV infection and tuberculosis represents a significant threat to the health of children. Using available pharmacokinetic data, an efavirenz (EFV) dosing schedule was developed for young co-infected children and implemented as the standard of care at Macha Hospital in Zambia. Treatment outcomes in children younger than 3 years of age or weighing less than 10 kg receiving either an EFV-based ART plus anti-tuberculous treatment or nevirapine-based (NVP) ART were compared, and are presented in chapter 8.

Repeatedly decentralization is mentioned as one of the strategies to scaling-up access to antiretroviral treatment, but few such programs have been evaluated. We compared outcomes for children receiving care in mobile and hospital-based HIV clinics in rural Zambia [chapter 9]. In chapter 10, we describe the feasibility and challenges in providing antiretroviral treatment to children in Sub-Saharan Africa, highlighting some of the successful practices and developments in service delivery and care.

To conclude, part five chapter 11 offers a discussion of our main findings in the context of the present literature.