Success with antiretroviral treatment for children in Kigali, Rwanda: Experience with health center/nurse-based care

Médecins Sans Frontières, Kigali, Rwanda.
BMC Pediatrics (Impact Factor: 1.93). 10/2008; 8(1):39. DOI: 10.1186/1471-2431-8-39
Source: PubMed


Although a number of studies have shown good results in treating children with antiretroviral drugs (ARVs) in hospital settings, there is limited published information on results in pediatric programs that are nurse-centered and based in health centers, in particular on the psychosocial aspects of care.
Program treatment and outcome data were reported from two government-run health centers that were supported by Médecins Sans Frontières (MSF) in Kigali, Rwanda between October 2003 and June 2007. Interviews were held with health center staff and MSF program records were reviewed to describe the organization of the program. Important aspects included adequate training and supervision of nurses to manage ARV treatment. The program also emphasized family-centered care addressing the psychosocial needs of both caregivers and children to encourage early diagnosis, good adherence and follow-up.
A total of 315 children (< 15 years) were started on ARVs, at a median age of 7.2 years (range: 0.7-14.9). Sixty percent were in WHO clinical stage I/II, with a median CD4% of 14%. Eighty-nine percent (n = 281) started a stavudine-containing regimen, mainly using the adult fixed-dose combination. The median follow-up time after ARV initiation was 2 years (interquartile range 1.2-2.6). Eighty-four percent (n = 265) of children were still on treatment in the program. Thirty (9.5%) were transferred out, eight (2.6%) died and 12 (3.8%) were lost to follow-up. An important feature of the study was that viral loads were done at a median time period of 18 months after starting ARVs and were available for 87% of the children. Of the 174 samples, VL was < 400 copies/ml in 82.8% (n = 144). Two children were started on second-line ARVs. Treatment was changed due to toxicity for 26 children (8.3%), mainly related to nevirapine.
This report suggests that providing ARVs to children in a health center/nurse-based program is both feasible and very effective. Adequate numbers and training of nursing staff and an emphasis on the psychosocial needs of caregivers and children have been key elements for the successful scaling-up of ARVs at this level of the health system.


Available from: Johan van Griensven
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    • "This provides further impetus to the urgency of ensuring that children in resource-limited settings have early access to life-prolonging ART. Virological evidence is an advantage in assessing therapeutic responses [18]. In this study, the mean baseline VL decreased to below the LOQ after three months of ART. "
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    ABSTRACT: Background Antiretroviral therapy (ART) reduces HIV-related mortality and morbidity substantially in children. The clinical characteristics, immunological and virological outcomes were evaluated in HIV-infected children receiving ART. Methods Twenty-six HIV-1-infected children receiving ART in Hubei province, China, were enrolled retrospectively in this study. During the period of ART, plasma viral load, lymphocyte phenotype of CD4 and CD8 cells and clinical events were assessed. Results The median duration of ART was 41 months (18–72.3 months). In children showing clinical improvement, high viral suppression rate below log10 (2.7) copies/ml by the third months of ART was observed. The median CD4 cell counts reached to 820.5/μl by 12 months and the median ratio of CD4/CD8 increased to 0.6 by 21 months. The counts of peripheral white blood cells and red blood cells decreased in the first 12 months, while Hb concentration, MCV and MCH increased (P < 0.001). Conclusions Despite the limited small sample size, ART is an effective strategy for inhibiting HIV replication and reconstructing the immunological response in children with AIDS.
    BMC Research Notes 07/2014; 7(1):419. DOI:10.1186/1756-0500-7-419
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    • "The CHBC model therefore stands to improve child survival greatly if ART is initiated early. Furthermore, patients can benefit from ancillary interventions to promote health and well-being such as food supplements, adherence counselling, and psychosocial support also effective only if retained in the programmes [34–36]. Of note, the CHBC and FBFCA models reach two different populations of HIV-infected children (Table 1). "
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    ABSTRACT: We describe factors determining retention and survival among HIV-infected children and adolescents engaged in two health care delivery models in Kampala, Uganda: one is a community home-based care (CHBC) and the other is a facility-based family-centred approach (FBFCA). This retrospective cohort study reviewed records from children aged from 0 to 18 years engaged in the two models from 2003 to 2010 focussing on retention/loss to follow-up, mortality, use of antiretroviral therapy (ART), and clinical characteristics. Kaplan Meier survival curves with log rank tests were used to describe and compare retention and survival. Overall, 1,623 children were included, 90.0% (1460/1623) from the CHBC. Children completed an average of 4.2 years of follow-up (maximum 7.7 years). Median age was 53 (IQR: 11–109) months at enrolment. In the CHBC, retention differed significantly between patients on ART and those not (log-rank test, adjusted, ). Comparing ART patients in both models, there was no significant difference in long-term survival (log-rank test, , adjusted, ), while retention was higher in the CHBC: 94.8% versus 84.7% in the FBFCA (log-rank test, , adjusted ). Irrespective of model of care, children receiving ART had better retention in care and survival.1. Background Sub-Saharan Africa (SSA) is home to the vast majority of infants, children, and adolescents living with HIV and morbidity and mortality remain high [1–3]. For example, mortality among HIV-infected children has been measured at 4.3% per year in East Africa and 8.3% in West Africa [4, 5]. A recent meta-analysis conducted in SSA reported a higher risk of early death among perinatally infected children [6]. Studies have also shown that substantial proportions of children and adolescents initiate treatment in SSA with advanced disease (46.3%–72.0%) and comorbidities such as tuberculosis (TB) (5.7%–34.0%) and malnutrition (33%–54%) that tend to be associated with early mortality and poor clinical outcomes [7–10].Significant child mortality can be averted if antiretroviral therapy (ART) is started early [11–14]. However, despite overwhelming evidence demonstrating the benefits of ART, in practice high mortality and poor retention persist among HIV-infected children and adolescents in care in the resource-limited settings of SSA. In addition to scarce resources for programmes for children, the situation is compounded by a combination of factors including late HIV diagnosis, missed opportunities to initiate ART, health care programmes not tailored to the needs of the infected child and their family, and logistic bottlenecks in implementation of care and treatment programmes [15, 16]. Initiation of ART even among children known to be eligible may be missed. For instance, in a study of ART-eligible children in The Gambia, only 32.7% started ART, 47.1% were lost to follow-up, and 13.5% died before initiating ART [17].Retention in care while awaiting ART eligibility can also be a challenge. As an illustration, retention varied from 71% to 95% and 62% to 93% at 12 and 24 months, respectively, among children and adolescents in ART programmes in several countries of SSA [18]. A prior study in Uganda showed that even with frequent CD4 monitoring, HIV-infected children experienced significant clinical events while ineligible for ART according to the 2006 WHO guidelines [19]. Another study in Uganda showed that mortality was highest among HIV-infected children under two years [20]. Given this situation, it is important to assess factors that determine survival and retention in care among HIV-infected children and adolescents in care in resource-limited settings.The present study focuses on retention and survival in two different ART delivery models for HIV-infected children and adolescents in Kampala, Uganda. One is a facility-based, family-centred approach (FBFCA) adopted by the mother to child transmission (MTCT)-Plus programme of the Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration. The other is a community home-based care (CHBC) implemented by the children’s HIV programme of the Home Care Department of Nsambya Hospital. The American Academy of Paediatrics defined family-centred care as based on the understanding that the family is the child’s primary source of strength and support [21]. Beyond that, the family provides an enabling environment for using index HIV patients to reach other infected and affected family members, build family support for therapy and chronic care, integrate other medical needs for the family, and thus enhance uptake of services for HIV and other medical conditions for the family as a unit [22]. In general, CHBC includes any form of care (physical, psychosocial, palliative, and spiritual) given to the sick and the affected in their own homes and care extended from the hospital or health facility to their homes through family participation and community involvement [23, 24].Factors that determine retention and survival of HIV-infected children and adolescents in these health care models are not well understood. The present study therefore aims at identifying factors that determine these outcomes for the CHBC of Nsambya Hospital and the FBFCA of MU-JHU. We also examine pre-ART deaths among children and adolescents in the CHBC to compare mortality rates prior to and after ART initiation and to ascertain whether children experiencing mortality prior to initiating ART had met the 2010 WHO [25] or the 2011 updated United States (US) [26] treatment guidelines for initiating ART or not.2. Methods2.1. Study Design, Setting, and PopulationThis retrospective cohort study covered eight years of records review (2003 to 2010) from two facilities implementing HIV paediatric programmes in Kampala, Uganda. They included the children’s HIV programme of the Home Care Department of Nsambya Hospital, which uses community home-based care (CHBC) and the MTCT-plus programme of MU-JHU Research Collaboration, which adopts a facility-based family-centred approach (FBFCA). Prior to the study, all children in the FBFCA had been initiated on ART; thus, the record review at the FBFCA involved only children on ART. The facilities are both private-not-for-profit but differ in service delivery approaches, including catchment areas and enrolment practices. The study population included all HIV positive infants, children, and adolescents aged 0–18 years, enrolled in both programmes over the study period. Services are generally free of charge under both models.2.2. Description of Health Care ModelsThe FBFCA of MU-JHU Collaboration was established in 2003 with funding from Columbia University. Its catchment area includes Kampala and Wakiso districts and covers approximately 20 km radius from Mulago hospital in Kampala. Enrolment into the FBFCA occurred between 2003 and 2005 and targeted all HIV-infected family members as a unit. However, HIV-infected pregnant women in PMTCT served as the starting point for identifying other infected family members such as infants, children, and spouses or partners to be enrolled into care. Eligibility of the women included being pregnant, testing HIV positive, attendance of PMTCT clinic, disclosure of HIV status to spouse or partner, willingness to be home visited, and living within 20 km radius from Mulago Hospital. The FBFCA offered comprehensive HIV care, including early infant diagnosis (EID), treatment and psychosocial support services, other medical services, and routine follow-up to eligible women and their families. All children enrolled in the study had been initiated on ART prior to the study start date, in contrast to the CHBC. The programme has a uniform design that has been implemented in many countries. Although funding ended in December 2011, the families continue to be followed in a family care approach with funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR).The CHBC also started in 2003 and it integrates facility-based care with home-based care using community involvements as important linkages to decentralize HIV services. It has a catchment area covering four districts: Kampala, Wakiso, Mukono, and Mpigi within 21 km radius from Nsambya hospital. In contrast to the FBFCA, children and adolescents in the CHBC were identified directly for participation. The components of the CHBC, details of enrolment practice, pre-ART care, and ART care packages, as well as patient tracking system, have been described in an earlier work [27]. The CHBC was funded by international donors and partners and indirectly supported by PEPFAR.Both health care models share some common elements such as providing additional support including nutritional supplements, patient education, and counselling of patients and their caregivers. Additionally, peer support groups for both adults and children have been developed to promote emotional support. Other components of psychosocial support include financial assistance for income generating activities, a music, dance, and drama group, and home visiting to track defaulting patients. Furthermore, the FBFCA trains peer-educators to provide support and help in the clinics.2.3. Clinical and Laboratory Follow-UpPatients were followed up routinely using similar appointment systems, standard guidelines, and procedures. Generally, children on ART had monthly clinic visits under both models, while visits for pre-ART patients depended on their clinical conditions and varied between one month under the CHBC and 3–6 months under the FBFCA. Initiation of ART was based on the Ugandan National ART guidelines that are adopted from the WHO guidelines [25, 28–30], which have changed over time, especially with the more recent move in 2013 to initiate treatment in all children under 5 years of age, irrespective of clinical or immune status [11]. During visits, patients were evaluated clinically using WHO clinical staging, age, weight, height, ART status, and laboratory investigations like haemoglobin levels and 6-monthly CD4 cell counts to monitor response to therapy. Adherence to clinical appointments was assessed using appointment schedules, while adherence to medication was assessed by caregivers and self-reports in addition to pill counts. Apart from ART, patients in care received universal Cotrimoxazole prophylaxis for opportunistic infections and secondary prophylaxis for cryptococcal meningitis.2.4. Study OutcomesThe main study outcomes were (a) retention in care, (b) deaths among patients on ART, and (c) pre-ART deaths (deaths before ART initiation) among patients in the CHBC programme. Death was ascertained through medical records and verbal autopsies carried out by trained community volunteers and counsellors. Retention was defined as the proportion of patients known to be alive (either by patient record review or by telephone calls or home visits) and in care at the end of the follow-up period. We defined loss to follow-up (LTFU) as 90 days or more (if on ART) and 180 days or more (if not on ART) without contact since the last clinic appointment. Attrition included deaths and LTFU. Known transfers to continue ART or care at other facilities were not considered as attrition.2.5. Statistical AnalysisWe analysed factors that determined retention and mortality among children and adolescents enrolled in the two HIV service delivery models described above. We used frequency distributions, medians, and interquartile range (IQR) to describe baseline characteristics and compared these using Chi-square and Wilcoxon Rank-Sum tests, respectively. The baseline characteristics included age groups (at enrolment), gender, CD4 cell counts, CD4 percent, growth responses (weight-for-age and height-for-age -scores), WHO disease stages, ART status, and age at ART initiation. Because of differences in baseline characteristics in the two study groups, all analyses were adjusted for age at ART initiation, CD4 percent, CD4 cell counts, proportions on ART, nutritional status, and WHO clinical staging using Cox regression. In addition, Cox regression was used to determine factors associated with attrition among patients on ART in both models and among patients in the CHBC separately, in unadjusted and adjusted analyses. Kaplan Meier curves with log rank tests were used to describe and compare retention and survival, stratified by model of care as well as by age groups. Data on CD4 cell count and CD4 percent were log transformed because of skewed distribution. Finally, we used Chi-square test to examine the number and proportions of children dying prior to ART initiation in terms of whether they met or did not meet the 2011 US or 2010 WHO guidelines for initiating ART. All statistical testing was two-sided and conducted at the 5% significance level. Data from both programmes were extracted from databases, merged, and analysed with Intercooled STATA software version 12.Ethical clearance was approved by the MildMay Institutional Review Board and Ethics Committee, and the study was registered by the Uganda National Council for Science and Technology (UNCST, ref. no. HS 1021). The relevant committees waived informed consent. The study was funded by the University of Padua and supported by Casa Accoglienza alla vita padre Angelo and PENTA Foundation.3. Results3.1. Baseline CharacteristicsOverall, 1,623 infants, children, and adolescents were included in the analyses, 90.0% (1460/1623) were in the CHBC (Table 1). There were slightly but not significantly more females compared to males. At enrolment, 47.1% in the CHBC and 38.9% in the FBFCA were over 60 months of age (). Baseline median CD4 cell counts were 393 cells/mm3 in the CHBC versus 727 cells/mm3 in FBFCA () and median CD4 percents were 5.8% in CHBC versus 17.0% in FBFCA (). By WHO clinical staging, 86.4% and 96.9% were in stages I-II in the CHBC and FBFCA, respectively, versus 13.6% and 3.1% in stages III-IV in the CHBC and FBFCA, respectively (). ART was initiated among 30.2% in the CHBC model compared to 100% in the FBFCA (). Median age at ART initiation was 91.0 months for children in the CHBC versus 45.9 months in the FBFCA (). In terms of growth response, 37.4% in the CHBC versus 16.9% in the FBFCA had weight-for-age -scores of ≤−2SD (), while 55.7% in the CHBC versus 69.7% in the FBFCA had height-for-age -scores of >−2SD ().
    04/2014; 2014:852489. DOI:10.1155/2014/852489
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    • "According to WHO, task shifting is a " process whereby specifi c tasks are moved, wherever appropriate, to health workers with shorter training… task shifting can make more effi cient use of existing human resources and ease bottlenecks in service delivery " (Chan 2008: 7). For example, in Botswana and Rwanda, task shifting to nurses was developed as a promising strategy to scale up and sustain adult and paediatric antiretroviral treatments, particularly where provider shortages threatened ART rollout (Griensven et al 2008; Monyatsi et al 2011). "
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    ABSTRACT: The massive scarcity of physicians in India, mainly in rural areas, prompted the Union Ministry of Health and Family Welfare to propose a three-and-a-half year Bachelor of Rural Health and Care degree designed exclusively to serve rural populations. The fierce opposition by powerful medical lobbies forced the proposal to fade away. This paper emphasises the importance of "task shifting" and "non-physician prescribing" in the global context and argues that non-physician healthcare providers would not only increase availability and accessibility to rural healthcare, but also provide an empowered second line of authority, adding to the checks and balances to the exploitative prestige-based hierarchy that pervades this knowledge-intensive service.
    Economic and political weekly 03/2013; XLVIII(13):112-117.
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