Session 2 - ICAP Pediatric Care and Treatment Package
Overview and ICAP Approach: Helena Rabie, MD, Technical Director of South to South, presented overviews of the ICAP and Tygerberg Children’s Hospital approaches to Pediatric HIV Care and Treatment, which include PMTCT and maternal health; general care of exposed and infected infants; HAART preparation, initiation and follow-up of children; and support for psychosocial issues, adherence and disclosure. Helena highlighted the need for implementation to be family-focused, multi-disciplinary, and integrated with and supportive of current services provided by health departments. She then outlined implementation challenges such as identification of at-risk infants and children in all health care settings, work with orphans, and training health care teams.
ICAP Pediatric Standards of Care (SOCs): Ruby Fayorsey, MD, MPH, Pediatric
Clinical Advisor for ICAP, presented ICAP Pediatric SOCs, defining SOC, explaining SOC rationale, describing how to measure and utilize SOCs, and describing how to integrate SOCs into routine practice. Ruby emphasized that the goal of these SOCs is to improve quality of care; they are not intended to test site performance but rather to help identify problem areas so that teams can focus on these areas, problem solve together and implement interventions for improvement.
Country Experience and Challenges: South Africa: Cato Manor: Growth Monitoring to Assess ART Eligibility: Marie Donahue, MPH, MS, CPNP, Pediatric HIV Specialist for ICAP Tanzania, presented the case for the routine use of growth charts for HIV-exposed and HIV-infected children, noting that abnormalities in growth are common in HIV-infected children, can occur throughout the disease course, and may help 1) identify the infected infant; 2) identify the need to initiate ART in infected children; and 3) identify ART failure for the child on therapy. Marie noted that it is not enough to simply be gaining weight or height; the child should be growing at appropriate rates, which can only be recognized with growth charts. The presentation included a case study on growth monitoring.
Country Experience and Challenges: Mozambique: Integrating Pediatric Services within ART Clinics: Maria Grazia Lain, MD, Pediatric Technical Advisor for ICAP Mozambique, and Beatriz Thome, MD, Pediatric Clinical Advisor for ICAP Mozambique, presented issues encountered when initiating pediatric HIV services at adult ART clinics. Issues included: how to create a child-friendly environment; how to get “adult” medical staff to care for pediatric patients; how to “fit” children into an adult-oriented system; readying the lab and pharmacy for pediatric HIV care; and linking with other pediatric services.
Issues raised during Question & Answer session:
- ICAP approach and Tygerberg experience
- Participants noted that there are many very symptomatic children who are not getting on HAART. So we are quite anxious to use tools like CD4 count and other hard data, especially when practitioners are less experienced. Physical exams may not be sufficient, and may not be happening at busy clinics.
- At TCH, qualification for ARV therapy is usually based on CD4 count, but they have found that very small children and infants are often so sick , you can simply tell that they need HAART, and there is no need to wait for the CD4.
- Participant discussed the limited ability of clinicians to recognize severity of disease in children so that children requiring ART often are not treated. Therefore, it is essential to have CD4 available.
- Pediatric SOCs
- Many participants felt that additional areas of focus could be added to the basic SOC presented for pediatric care.
- There are no standard minimum requirements set by SOCs. For each country it depends on the national guidelines, the site’s resources, the local situation, etc. ICAP can help to develop appropriate minimum requirements for each context.
- Quality goes beyond SOCs. We don’t want to get too stuck on monitoring, but it can be a helpful tool. Implementing the PMTCT indicators in Rwanda worked well: the sites said they were helpful, and that it was the first time they really understood some of the processes that ICAP was trying to implement.
- ICAP is working to develop an editable SOC tool to facilitate collecting data. This may be in Excel or Access, but recognizing that some sites may not have access to computers or the database, paper worksheets with instructions on how to calculate may also be distributed. Ideally, clinical staff will own this process, conduct the analysis, create their own charts and report findings.