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Challenges in providing HIV care to paediatric age group in India.

Over 90 per cent of the 2 million HIV infected children worldwide, live in developing countries (1). In India, 3.8 per cent (2) (approximately 100,000 (3)) of an estimated 2.5 million persons living with HIV/AIDS (PLHA) are children. As of September 2008, of about 1,77,808 individuals started on antiretroviral therapy (ART) since its launch in April 2004, about 12,116 are children and, over 42,000 are registered in pre-ART programme (personal communication, Rewari BB). Since median duration of progression from HIV to AIDS in children is two years (4), many infected children, particularly infants may not be able to access ART.

Paediatric HIV/AIDS Initiative of Government of India comprises Prevention of Parent to Child Transmission (PPTCT) on one hand and co-trimoxazole (CTX) prophylaxis to avert opportunistic infections (OI) and ART, on the other. However, endeavours at scaling up comprehensive care for children living with HIV/AIDS (CLHA) are met with many barriers, such as low access to treatment, difficulty in early diagnosis, diagnosis and management of OI, implementing CTX prophylaxis, need of specific as well as frequently changing drug dosages, trained human resource, etc. One of the greatest challenges to paediatric HIV care and treatment in India is the low coverage of ANC and PPTCT services. Less than 20 per cent of pregnant women (5) in India access public health facilities for delivery, resulting in low utilization rate of PPTCT services. In fact, the reported percentage of estimated HIV-infected pregnant women in India who received anti-retrovirals for PPTCT was only 10 per cent (6).

As highlighted by Rajasekaran et al (7) in the current issue, low access to treatment is a culmination of multiple factors. People have to travel long distances to reach the nearest designate ART centre for availing care and treatment. Over 60 per cent of children in this study had to travel more than 200 km to avail ART. Absence of facilities to care and treat HIV near home, non availability of resources at local health centres to treat HIV, inability to pay for services in private facilities and fear of stigma and discrimination if identified in local community, were cited as reasons for travelling such large distances. Since the time of data collection for this study, the ART programme in India has expanded considerably. Although the number of ART centres in India has been substantially scaled up from 10 in December 2004 to more than 170 as of October 2008, access to treatment still remains a challenge as ART centres are not present in each district, especially in low prevalence States. Moreover, many of the HIV infected children are either orphans or have parents affected by illness due to HIV who are unable to accompany them. These difficulties eventually reflect not only on access but also on subsequent follow up. Moreover, as reported by another study (8), ART adherence is significantly related with developmental needs of child and psychosocial issues related to caregiver. However, evidence about correlates of adherence to ART in paediatric age group is required from India.

Early diagnosis is important for timely initiation of ART because it is desirable to start treatment before severe immune deficiency sets in (9). Infants, if severely immuno-compromised at start of therapy, experience higher mortality (10), one of the reasons being development of immune reconstitution inflammatory syndrome (IRIS) (11). A study from Thailand documented that children with CD4 less than 5 per cent at start of treatment were least likely to reach target outcome of CD4 more than 25 per cent (12). On the other hand, children put early on ART while CD4 was more than 25 per cent experienced 75 per cent reduction in mortality compared with those who received it after CD4 had fallen below 20 per cent (13).

However, HIV diagnosis in infants is complex and is a hindrance in scaling up paediatric HIV programme in India. The low cost antibody tests furnish false positive results for up to 18 months of age because of the presence of maternal antibodies. Antibody testing may be probable at 9-12 months in non breast fed infants but in a developing country like India breastfeeding is the rule rather than exception. The available options for early diagnosis (six weeks onwards) are either real time PCR assays to detect HIV DNA or HIV RNA (14) or assays to detect p24 antigen. However, as these are resource intensive and prohibitively costly, implementing this technology across India is a challenge. PCR testing can be done with either whole venous blood or dried blood spots (DBS). While paediatric venepuncture is a demanding skill to come across at peripheries, for DBS, a small stick is made on child's foot and blood is dripped onto a special filter paper. As storage and transportation of DBS do not require stringent cold chain requirement, it might be an appropriate solution to transfer specimens from periphery to centrally situated laboratories. However, arduous manpower training is a prerequisite for use of DBS. As experience of implementation of DBS for HIV diagnosis is limited, several operational issues need to be considered for scale up. In addition, availability of PCR in select centrally located laboratories leads to delay in getting results and consequently initiation of treatment. Clinical case definitions can be useful to suspect children infected with HIV. Intricacies in diagnosis are complicated by hurdles in identifying some clinical manifestations that can be non specific in these children. These will help in identification and referral of infected child to avail necessary diagnostic services treatment, but are not an alternative to laboratory testing (15) for young infants.

In India, tuberculosis (TB) is reported as the most common OI (7,16). Respiratory infections including Peumocystis carinii pneumonia (PCP), recurrent diarrhoea and oral candidiasis have been reported as other important OIs. It is difficult to identify tuberculosis in the presence of HIV infection as tuberculin skin test has poor sensitivity when used in HIV infected children. However, clinical suspicion can give a lead to suspect a case of TB.

Malnutrition is a common problem in CLHA with Indian studies reporting 6 per cent (7) to 56.7 per cent (16,17) HIV infected children suffer from protein energy malnutrition. The co-morbidity with malnutrition substantially influences morbidity and mortality in these children (18). Further, the dilemma in management of CLHA with severe malnutrition is whether to start ART before or after nutritional rehabilitation (19). While improvement in nutritional status unearths appearance of IRIS with potential fatal prognosis, the potential adverse effects of ARV drugs or OIs may themselves affect food intake, resulting limited improvements in growth and consequently decreased adherence to therapy. These underscore the importance of regular follow up for care including nutritional care.

It is thus evident that public health approach is required for improved coverage. Basic elements of this approach are availability of standard diagnostic procedures, simplified ARV regimens; suitability of drug formulations for paediatric dosages; capacity to manage co-existing conditions such as TB, malnutrition, etc; and robust drug procurement and supply systems.

Access to treatment in India, however, is still a challenge. To increase access of CLHA to ART centres it would be important to establish and strengthen a system of linkages and two way referrals between peripheral and specialist centres. The primary and secondary level health care providers are proximal to the beneficiary. Skill building of health care workers at primary and secondary levels is required whereby; they are able to identify suspect cases and refer them for further investigation and care at early stages. They should be able to manage the complaints of patients such as management of TB, respiratory and gastrointestinal infections. They should encourage and utilize the follow up visits to impart information to the mother or care giver on common HIV related features, address psychosocial concerns, provide counselling on available options of infant feeding, nutritional care to manage malnutrition and importance of adherence to ART. As CTX prophylaxis protects the infant from PCP, toxoplasmosis and other bacterial diseases, its availability at primary and secondary care levels and, capability of health care personnel at that level to take decision to provide CTX as per indication, would further help in reducing the morbidity and mortality of children. This would also take the burden off from higher centres who can concentrate on serious patients. These co-morbidities can be handled efficiently at primary and secondary levels, even during pre-ART period if there is a strong two way referral system.

The WHO- initiated Integrated Management of Adolescent and Adult Illness (IMAI), Integrated Management of Childhood Illness (IMCI), Integrated Management of Pregnancy and Childbirth (IMPAC) (20) are such an integrated primary care approach that emphasises building clinical teams that are able to deliver HIV prevention, care and treatment, along with basic primary care. IMPAC also emphasises that Prevention of Mother to Child Transmission (PMTCT) interventions be integrated with antenatal, delivery, post-partum, newborn and infant care. This would ensure support for healthy pregnancy, childbirth, infant and child nutrition and development.

Thus, to ensure comprehensive paediatric HIV care in India, in addition to expansion of the availability of skilled paediatricians (21) and laboratory infrastructure for diagnosis at specialist centres, the capacity building of health care workers at primary and secondary levels should be a priority. This would immensely improve access to treatment, care and CTX prophylaxis for CLHA in India. Appropriate guidelines for management and referral at different levels need to be developed and distributed. An integrated approach with the ongoing scale up of PPTCT in India would also be important to impart effective primary prevention for children since more than 95 per cent of children acquire HIV infection from mother by perinatal transmission.


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(3.) Jadhav M, Pensi T, Chan P, Purohit V, Paithankar P, Rewari B, et al. Scaling-up access to paediatric antiretroviral treatment: lessons from India; XVII International AIDS Society Conference 2008, Abstract THAB0104. Available at: http: //, accessed on December 14, 2008.

(4.) Spectrum system of policy models: Available at: http: // accessed on October 15, 2008.

(5.) International Institute for Population Sciences (IIPS). National Family Health Survey-III (2005-06), Bombay: IIPS; 2006.

(6.) UNAIDS/WHO/UNICEF (3 April 2008), "Children and AIDS: Second stocktaking report" Available at: http: // Children_and_AIDS_-_Second_Stocktaking_Report.pdf accessed on January 17, 2009.

(7.) Rajasekaran S, Jeyaseelan L, Raja K, Ravichandran N. Demographic and clinical profile of HIV infected children accessing care at Tambaram, Chennai, India. Indian J Med Res 2009; 129: 42-9.

(8.) Mellins CA, Brackis-Cott E, Dolezal C, Abrams EJ. The role of psychosocial and family factors in adherence to antiretroviral treatment in human immunodeficiency virus-infected children. Pediatr Infect Dis J 2004; 23: 1035-41.

(9.) Becquet R, Mofenson LM. Early antiretroviral therapy of HIV infected infants in resource limited countries: possible, feasible, effective and challenging; AIDS 2008; 22: 1365-8.

(10.) Arrive E, Marquis B, Tumwesiye N, Cotton M, Holland M, Renner L, et al. Response to ART in children in Sub-Saharan Africa: A Pooled Analysis of Clinical Databases, the KIDS-ART-LINC Collaboration. Conference Abstract 14th CROI 2007. Abstract 727. Available at: http: // accessed on December 14, 2008.

(11.) Puthanakit T, Aurpibul L, Oberdorfer P, Akarathun N, Kanjanajit S, Walmarit P, et al. Hospitalization and mortality among HIV infected children after receiving highly active antiretroviral therapy. Clin Infect Dis 2007; 44: 599-604.

(12.) Puthanakit T, Kerr S, Ananworanich J, Bunupuradah T, Boonrak P, Butterworth O, et al. Immunological recovery in children starting NNRTI-based HAART in a resource limited setting. Poster exhibition: 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention: Abstract no. TUPEB131. Available at: pageId=11&abstractId=200703476, accessed on December 14, 2008.

(13.) Violari A, Cotton M, Gibb D, Babiker A, Steyn J, Jean-Phillip P, et al. Antiretroviral therapy initiated before 12 weeks of age reduces early mortality in young HIV-infected infants: evidence from the Children with HIV Early Antiretroviral Therapy (CHER) Study. Special session: 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention: Abstract no. WESS103. Available at: ult.aspx?pageId=11&abstractId=200705557, accessed on December 14, 2008.

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(19.) Heikens GT, Bunn J, Amadi B, Manary M, Chhagan M, Berkley JA, et al. Case management of HIV infected severely malnourished children: challenges in the area of highest prevalence. Lancet 2008; 371: 1305-7.

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(21.) Kline MW. Perspectives on the paediatric HIV/AIDS pandemic: catalyzing access of children to care and treatment. Paediatrics 2006; 117: 1388-93.

Partha Haldar & D.C.S. Reddy *

World Health Organization

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Maulana Azad Road

New Delhi 110 011, India

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Title Annotation:Commentary; human immunodeficiency virus
Author:Haldar, Partha; Reddy, D.C.S.
Publication:Indian Journal of Medical Research
Article Type:Report
Geographic Code:9INDI
Date:Jan 1, 2009
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