ICAP News - April 2010

South-to-South Partnership Bolsters Pediatric HIV Care

When Gilbert Tene first examined Joseph, the nine-month old baby was quite ill. His short life had already been marked by repeated episodes of fever, diarrhea, and coughing. He was severely malnourished, weighing no more than 12 pounds, and was struggling to sit steadily by himself. Dr. Tene, a pediatric HIV care and treatment advisor for ICAP-Rwanda, diagnosed Joseph with advanced HIV disease.

Managing HIV/AIDS in resource-limited settings presents multiple challenges, such as health worker shortages and patients’ lack of access to health facilities. But caring for an HIV-infected child is even more daunting. “Obstacles span the spectrum from difficulty in diagnosing HIV in infants to the need for special clinical skills to care for children,” said Dr. Tene. “In addition, children have special medication formulations and families must be engaged in the care of children.”

These challenges are compounded by misconceptions that caring for children with HIV is too difficult. Some feel that children are simply doomed to succumb to the disease. In addition, most HIV programs are designed to meet the needs of adults, not children.

In 2006, Elaine Abrams, MD, Senior Research Director at ICAP, and Mark Cotton, Director of the Children’s Infectious Diseases Clinical Research Unit at South Africa’s Stellenbosch University, set out to change the face of pediatric HIV care and treatment in Africa by launching a unique cross-continent collaboration called the South-to-South (S2S) Partnership. The program combines the unique strengths of ICAP and Stellenbosch in HIV program development and pediatric HIV care and treatment to train multidisciplinary teams from HIV programs across Africa.

Rather than utilize physicians from high-resource countries to provide this training, S2S taps local expertise at Stellenbosch, where a multidisciplinary pediatric HIV program already exists with highly experienced mentors. ICAP works with Ministries of Health and national HIV/AIDS programs in several African countries to identify healthcare providers who would best benefit from this type of training. Selecting staff from countries where ICAP works, including Kenya, Ethiopia, Rwanda, Mozambique, and South Africa, S2S draws participants from across the region to come together with pediatric HIV experts from Stellenbosch University and ICAP headquarters in New York.

S2S applies both didactic and hands-on clinical experiences to strengthen providers’ skills in pediatric HIV care and treatment. “We help ignite the flame for these teams to build their own pediatric programs,” explained Liezl Smit, MD, S2S Program Clinical Director. “Participants also share their own ideas and experiences, and continue to support one another after they complete the program.”

In addition to an emphasis on building capacity to implement pediatric HIV programs, Dr. Smit said S2S is distinguished for the clinical experiences that participants receive at Stellenbosch’s Tygerberg Hospital. “S2S is not just about hearing and knowing about pediatric HIV care and treatment, but doing it,” said Dr. Smit. “They see patients and learn about how to manage complicated cases. This practical component really makes a difference.”

The challenge of treating infants and children with HIV is one that wealthy countries, for the most part, do not have to face. This is because of wide access to medical specialists, HIV testing, and drugs to prevent transmission of the virus to newborns.

“But in resource-limited settings, HIV is an ongoing epidemic, affecting hundreds of thousands of children,” said Dr. Abrams. In 2008, about 230,000 children died of AIDS-related causes, and an estimated 430,000 babies and children were newly infected with HIV, accounting for about 16 percent of all new infections. The vast majority of those occurred through preventable mother-to-child transmission. At the end of 2008, only about 275,700 children were receiving lifesaving antiretroviral therapy (ART), less than 40 percent of those in need.

The consequences of inadequate or inaccessible pediatric HIV treatment are dire, particularly in young children. Worldwide, an estimated 2.1 million children were living with HIV/AIDS in 2008. Without treatment, half of all HIV-infected children will die before they reach their second birthday, and nearly three quarters of these children will die before they turn five.

S2S has helped make significant inroads in building the capacity to respond to this urgent need. In the program’s first four years, more than 400 healthcare workers—from, Nigeria, Ethiopia, Zambia, Rwanda, and South Africa—have come to Stellenbosch. “S2S has helped to put pediatric HIV care and treatment on the map in Africa,” said Dr. Smit. “In part because of S2S, pediatric programs now exist in some countries that previously lacked them.”

One of the fruits of S2S is a recently established Pediatric Center of Excellence in Rwanda. A collaboration with Kigali Central University Hospital, the center is modeled after the comprehensive HIV program at Stellenbosch and provides high-quality HIV care to about 250 children, as well as training and site support to increase the number of infants and children receiving comprehensive HIV/AIDS care and treatment across Rwanda. “The S2S program helped to constitute a pool of trainers who have been, in turn, training other care providers on pediatric HIV care and treatment in Rwanda,” said Dr. Tene. Building on this framework, a pediatric practical training program has been established in Rwanda to enhance implementation of high-quality care for children across the entire country.

Although his treatment was rough going and included some setbacks, Joseph is now doing well on ART after two years on treatment, along with nutrition counseling and psychosocial support for his family. Dr. Tene reports that he weighs 30 pounds and is an active little boy.

This article was adapted from a piece by IDSA’s Center for Global Health Policy. Visit www.idsaglobalhealth.org.

Photo caption: In a hands-on practical experience, Dr. Helena Rabie (left) of Stellenbosch University and a S2S program participant examine an infant infected with HIV.

ICAP Country Program: Tanzania

Tanzania, the largest country in East Africa, has a population of more than 43 million people and an HIV prevalence of 5.7 percent. Since 2004, ICAP has been working with the Ministry of Health to scale up HIV programs and strengthen health systems in Kigoma, Pwani, Kagera, Lindi Regions, as well as in Zanzibar. As of December 2009, ICAP supported 110 healthcare facilities providing HIV prevention and care to more than 53,000 individuals, including antiretroviral therapy to more than 23,000 people.

ICAP works directly with district health systems to provide material, technical, and financial support for programs. In addition, ICAP partners with a variety of nongovernmental and faith-based organizations. Looking ahead, a network of Tanzanian clinical mentors is being developed to improve the quality of HIV services. Over the next year, more than 100 mentors are expected to be in place in the four regions where ICAP works.

“ICAP’s vision is for indigenous organizations—public sector and civil society—to play the major role in scaling up, managing, and monitoring services,” said Amy Cunningham, ICAP-Tanzania Country Director.

Prevention activities are an increasing focus of ICAP’s work in Tanzania. In Kagera Region, where only one quarter of men are circumcised, ICAP is supporting efforts to encourage male circumcision to reduce HIV infections. In Zanzibar, HIV prevention programs target most-at-risk populations, including injecting drug users, men who have sex with men, and sex workers. Finally, an innovative study on “Prevention with Positives” is examining the impact of integrating family planning, sexually transmitted infection screening and treatment, and other HIV prevention services.

A map of ICAP-supported sites in Tanzania.
The colors represent different HIV prevalence rates.