AIDS 2014: Pediatric treatment lag demands planning, action, final plenary speaker says

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AIDS2014postScience Speaks is live-blogging from AIDS 2014 in Melbourne, Australia this week, with updates on research, policy and insights from the 20th International AIDS Conference.

MELBOURNE, AUSTRALIA –   Shaffiq Essajee spoke during today’s plenary session about HIV prevention and treatment for children with a strong focus on the treatment side.

“While we are seeing 60 percent fewer new infections in infants, there has not been a commensurate decline in child deaths,” the physician and New York University pediatric infectious disease professor said. In fact, the treatment coverage gap between children and adults has actually widened over recent years.

He began by dismissing a litany of excuses that have been used to rationalize the differential access for children, including the right doses or formulations — they are not perfect, he acknowledged, but that is not a good reason for not trying to reach more children, he said. Treating children is too complicated, is another excuse, he said.

“No, it is not,” he added, referencing a World Health Organization chart that offers simplified weight doses for all ages and formulations.

We don’t have the tools to diagnose infants, is another, he said. “Yes we do,” he added.

The problem, Essajee said, is a failure to look in the right places to find children. He noted HIV prevalence in children is changing, with more older children with HIV who have “fallen through the cracks.”

To illustrate this point, he looked at a study from Malawi that showed relatively low HIV incidence in infants with PCR testing but very high prevalence of HIV among children in nutrition programs. Testing in inpatient and outpatient settings can find these children, if the children are tested, and not neglected under the illusion that “they are too old to have HIV.”

Many infants who are identified are lost before enrollment into care, which not only risks their lives, but squanders the cost — $240-to- $400 — that was expended to diagnose them. He pointed to strategies like SMS printers that return test results to clinics faster and point-of-care testing “’while you wait’’ that can improve clinical outcomes and preserve resources.

Essajee called for scaled up of task-sharing and task-shifting to improve services for children.

Well-established for adults with HIV, national programs have been slow to do this for children, even though studies show that nurse management delivers comparable quality outcome results when compared with physician management, he said. Some programs in Uganda have improved care through program integration and task-sharing. Ugandan maternal child health nurse midwives are trained in maternal and pediatric HIV care while also maintaining strong linkages with the adult HIV treatment program to better accommodate mothers.

“We have failed to harness to community to support pediatric care and treatment,” said Essajee, highlighting work in Malawi to utilize community health workers to conduct community-based HIV counselling and testing, active case identification, prevention of mother to child transmission services, linkage to care and general support.  The program showed mark improvement in pediatric case finding and was especially effective in identifying older children.

Dr. Essajee concluded his talk by calling for “an end to the false dichotomy between prevention and treatment.”

He added, “Our approach needs to go beyond PMTCT and reinvigorate provider-initiated testing and counselling for children.  As we push for the elimination of new infections, we must also push to treat all children in need.”

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