Children In Resource-poor Settings Research Articles

Resilience through participation and coping-enabling social environments: the case of HIV-affected children in sub-Saharan Africa

Many children and youths living in low-resource and high-HIV-prevalence communities in sub-Saharan Africa are presented with daily hardships that few of us can even imagine. It is therefore no surprise that most research reporting on the experiences of HIV-affected children in resource-poor settings focuses on their poor health and development outcomes, casting them as victims. However, there is a growing trend to draw on more strengths-based conceptualisations in the study and support of HIV-affected children and youths. In this introduction to a special issue of The African Journal of AIDS Research, we cement this trend by providing a theoretical exposition and critique of the ‘coping’ and ‘resilience’ concepts and draw on the 11 empirical studies that make up this special issue to develop a framework that appropriates the concepts for a particular context and area of study: HIV-affected children in sub-Saharan Africa. The articles included here show, albeit in different ways and to different degrees, that the resilience of HIV-affected children in the region is an outcome of their agency and interactions with their social environment. Policy actors and practitioners working to support HIV-affected children in Africa should take heed of the proposed framework and draw on the research presented here to build coping-enabling social environments — presenting children and youths in Africa with greater opportunity to actively deal with hardship and work towards a more promising future.

Utility of rapid antibody tests to exclude HIV-1 infection among infants and children aged

BackgroundExcluding HIV infection among infants and young children in resource-poor settings where nucleic acid amplification tests (NAAT) are not routinely available remains a considerable challenge. ObjectivesTo assess the performance of two rapid HIV antibody tests (RT) used alone and in parallel for excluding HIV infection among acutely ill infants and children <18 months in comparison to NAAT in a region where maternal HIV prevalence was approximately 7%. Study DesignInfants and children ≥2<18 months admitted to hospital with an acute febrile illness had two rapid antibody tests in parallel, with single and parallel results subsequently compared against NAAT. ResultsHIV prevalence among 1602 enrolled infants was 3.4%. All 1526 infants with 2 negative RT were HIV negative by NAAT. All 46 infants with 2 positive RT were HIV positive by NAAT. The overall specificity of two rapid tests for excluding HIV infection was 99.5%. Sensitivity and specificity were ≥99% and >98%, respectively, across all age brackets ≥2<18 months. Overall sensitivity and specificity for a single RT was 98.2% and 99%, respectively, for Determine, and 85.5% and 99.6%, respectively, for Capillus. ConclusionsIn a setting with a maternal HIV prevalence rate of <10%, a single negative RT had excellent specificity and two negative RT performed in parallel had a perfect negative predictive value for HIV infection among acutely ill patients <18 months of age. In this and similar settings, RT could assist with excluding HIV infection with much lower complexity and cost than NAAT.

Partners In Health Generalist/Specialist Twinning: A Health Delivery Model Used in Treating Childhood Lymphoma in Rural Rwanda,

Abstract 4222In the developed world approximately 80% of children with lymphoma can be cured. As global health initiatives have broadened to address noncommunicable diseases the approach to cancer care for children in resource poor settings becomes of increasing concern. Traditional models of tertiary care provision will not be applicable as there is not an adequate number of existing pediatricians subspecializing in oncology to provide for the world’s children. At Rwinkwavu, a Partners In Health (PIH) supported government district hospital in rural Rwanda, a small cohort of children with lymphoma have received therapy over the past 4 years using a unique approach to care delivery. Each case is managed by a team consisting of a Rwandan physician with no specialty training, a Rwandan nurse coordinator focused on oncology patients, a Rwanda-based US trained pediatrician and a US- based pediatric oncologist. Biopsies and radiologic staging studies were obtained in Rwanda but all pathologic diagnoses were made at Brigham and Women’s Hospital, a Harvard teaching hospital, through a formal arrangement. A treatment plan for each patient was formulated with the consulting pediatric oncologist and a road map was generated. Chemotherapy was administered by nurses in the Rwinkwavu pediatric ward under the daily supervision of the local generalist and with the support of the pediatrician. Blood counts and broad spectrum antibiotics were available but blood cultures could not be performed. If radiation therapy was required patients were transported to Uganda for the treatments. Ten patients aged 3–15 (median age 9.5 years) have been treated using this approach. 5 (50%) have completed therapy - Hodgkin’s Disease (HD) n =2, HIV-associated large cell lymphoma (HIV LCL) n =2, Burkitt’s Lymphoma (BL) n=1. They received either CHOP (cyclophosphamide, adriamycin, vincristine, prednisone), n=3 or ABVD (adriamycin, bleomycin, vincristine, dacarbazine), n=1; 1 patient with Stage 1 Lymphocyte Predominant HD is being observed without adjuvant therapy after complete surgical excision. All 5 have no evidence of disease recurrence 4 months - 4 years following completion of therapy (median = 14 months). 2 patients are currently on therapy (recurrent HD, HIV LCL) and are in remission. 2 patients succumbed to treatment complications (HD- died from cardiomyopathy, BL- died from transverse myelopathy) and 1 patient (BL) died of progressive disease while receiving chemotherapy. We can not determine the number of pediatric patients with lymphoma who died before a diagnosis was made or before receiving appropriate therapy. In the developing world lymphoma is one of the most common oncologic diseases in children. These data suggest that chemotherapy can be administered with curative intent to a subset of these patients in the setting of a confirmed pathological diagnosis. This approach provides a platform for models of care that rely on local physicians acting in concert with trained consultants from the developed countries to deliver subspeciality care in resource poor settings. Disclosures:No relevant conflicts of interest to declare.

Unintentional injuries among children in resource poor settings: where do the fingers point?

Every year, over 875 000 children between 0 and 18 years of age die as a result of unintentional injuries (UIs), with a higher proportion occurring in low- and middle-income...

Supporting collaborations to prevent blindness in children in resource-poor settings

In 2010 there were estimated to be 1.26 million blind children in the world, 10% fewer than the 1999 estimate. The prevalence and major causes reflect socioeconomic development and both can change rapidly over time. For example, corneal scarring from vitamin A deficiency and measles infection has declined in the poorest countries but retinopathy of prematurity is now a major cause in middle-income countries and cities in Asia. In low-income countries, cataract is becoming relatively more important. Although public health interventions play a critical role, eye care services for children are also essential. This meeting was convened to discuss what is currently being done and how clinicians in industrialized countries could contribute. Six priorities were identified from the meeting.

Weight and height z-scores improve after initiating ART among HIV-infected children in rural Zambia: a cohort study

BackgroundDeficits in growth observed in HIV-infected children in resource-poor settings can be reversed with antiretroviral treatment (ART). However, many of the studies have been conducted in urban areas with older pediatric populations. This study was undertaken to evaluate growth patterns after ART initiation in a young pediatric population in rural Zambia with a high prevalence of undernutrition.MethodsBetween 2007 and 2009, 193 HIV-infected children were enrolled in a cohort study in Macha, Zambia. Children were evaluated every 3 months, at which time a questionnaire was administered, height and weight were measured, and blood specimens were collected. Weight- and height-for-age z-scores were constructed from WHO growth standards. All children receiving ART at enrollment or initiating ART during the study were included in this analysis. Linear mixed effects models were used to model trajectories of weight and height-for-age z-scores.ResultsA high proportion of study children were underweight (59%) and stunted (72%) at treatment initiation. Improvements in both weight- and height-for-age z-scores were observed, with weight-for-age z-scores increasing during the first 6 months of treatment and then stabilizing, and height-for-age z-scores increasing consistently over time. Trajectories of weight-for-age z-scores differed by underweight status at treatment initiation, with children who were underweight experiencing greater increases in z-scores in the first 6 months of treatment. Trajectories of height-for-age z-scores differed by age, with children older than 5 years of age experiencing smaller increases over time.ConclusionsSome of the effects of HIV on growth were reversed with ART initiation, although a high proportion of children remained underweight and stunted after two years of treatment. Partnerships between treatment and nutrition programs should be explored so that HIV-infected children can receive optimal nutritional support.

Home-based rehabilitation of severely malnourished children in resource poor setting

To evaluate the feasibility and outcome of home-based rehabilitation of severely malnourished children. Prospective and observational. Rehabilitation at home (16 weeks) following initial assessment or/and stabilization at hospital. Thirty-four severely malnourished (weight for length < 70% of WHO reference) children between the ages of 6 months to 5 years. Initial assessment of the patient was done in hospital. Those with complications or loss of appetite were admitted in hospital and managed as per WHO guidelines. After discharge, they were managed at home using home based diets. Those without complications and with preserved appetite were directly eligible for home-based rehabilitation. Follow up was done in hospital up to 16 weeks. Dietary intake, anthropometry and morbidities were recorded during follow-up. Of the enrolled 34 children, 19 children were admitted in hospital and 15 children were sent home after initial assessment in hospital. Five did not clear the initial stabilization phase (2 died, 3 left hospital). Finally 29 children qualified for home based rehabilitation out of which 26 completed 16 week follow-up. During the home based management phase, the reported mean (±SD) calorie intake increased from 100 (± 5) kcal/kg/d at entry point to 243 (± 13) kcal/kg/d at 16 weeks (P=0.000). Similarly, reported protein intake increased from 1.1 (± 0.3) g/kg/d to 4.8 (± 0.3) g/kg/d (P=0.000). During hospital stay (n=19), children had weight gain of 9.0 (±5.3) g/kg/d, while during home based follow up (n=29), weight gain was 3.2 (± 1.5) g/kg/d only. During home based rehabilitation, only 3 (11.5%) children had weight gain of more than 5 g/kg/d by the end of 16 weeks. Weight for height percent increased from an average (± SD) of 62.9% (± 6.0%) to 80.3% (± 5.7%) after the completion of 16 weeks (P=0.000). Thirteen (45%) children recovered completely from malnutrition achieving a weight for length of >80; % whereas 15 (51.7%) recovered partly achieving weight for length >70;%. There was no death during the home stabilization. Home based management using home prepared food and hospital based follow up is associated with sub-optimal and slower recovery.

Why lipid-based ready to use foods (RUF) must be key components of strategies to manage acute malnutrition in resource poor settings

Malnutrition, common in the developing world, is associated with disease and mortality. Malnutrition frequently occurs among children in the community as well as those with acute illness. Despite global improvements, malnutrition still underlies half of the inpatient morbidity and mortality rates among children in resource poor settings. Malnutrition limits development and the capacity to learn and grossly undermines future economic progress of both individuals and states. Food-based approaches have been an integral part in efforts to alleviate the impact of malnutrition.

Sensitivity of the Autism Behavior Checklist in Indian Autistic Children

The autism behavior checklist (ABC) has potential utility for evaluation of autistic children in resource-poor settings. Although the original total cutoff score has been described as 67, lower cutoffs have been suggested. We evaluated the sensitivity of ABC in the diagnosis of autism in Indian children. This study was conducted over 2 years in the Child Development Clinic of a tertiary care hospital. Children diagnosed with autistic disorder as per the DSM-IV criteria were included. Children with comorbid motor, visual, and hearing deficits were excluded. Each child was evaluated using the Childhood Autism Rating Scale and ABC. Fifty-one children were enrolled in the study. The mean age was 3.28 +/- 1.89 years. The ratio of boys to girls was 2.2:1. The mean Childhood Autism Rating Scale score was 44.7 +/- 6.22, with all children having scores in the autistic range. The mean ABC score was 72.4, with a standard deviation of 14.2. By using the originally suggested cutoff score of 67, only 40 children in this study were diagnosed with autism. When lower cutoffs were used, the sensitivity increased, with a sensitivity of 98% and a cutoff of 45. The ABC cutoff needs to be lowered to increase its sensitivity for diagnosis of autistic disorder.

Incidence and Severity of Respiratory Syncytial Virus Pneumonia in Rural Kenyan Children Identified through Hospital Surveillance

Although necessary for developing a rationale for vaccination, the burden of severe respiratory syncytial virus (RSV) disease in children in resource-poor settings remains poorly defined. We conducted prospective surveillance of severe and very severe pneumonia in children aged <5 years admitted from 2002 through 2007 to Kilifi district hospital in coastal Kenya. Nasal specimens were screened for RSV antigen by immunofluorescence. Incidence rates were estimated for the well-defined population. Of 25,149 hospital admissions, 7359 patients (29%) had severe or very severe pneumonia, of whom 6026 (82%) were enrolled. RSV prevalence was 15% (20% among infants) and 27% during epidemics (32% among infants). The proportion of case patients aged 3 months was 65%, and the proportion aged 6 months was 43%. Average annual hospitalization rates were 293 hospitalizations per 100,000 children aged <5 years (95% confidence interval, 271-371 hospitalizations per 100,000 children aged <5 years) and 1107 hospitalizations per 100,000 infants (95% confidence interval, 1012-1211 hospitalizations per 100,000 infants). Hospital admission rates were double in the region close to the hospital. Few patients with RSV infection had life-threatening clinical features or concurrent serious illnesses, and the associated mortality was 2.2%. In this low-income setting, rates of hospital admission with RSV-associated pneumonia are substantial; they are comparable to estimates from the United States but considerably underestimate the burden in the full community. An effective vaccine for children aged >2 months (outside the age group of poor responders) could prevent a large portion of RSV disease. Severity data suggest that the justification for RSV vaccination will be based on the prevention of morbidity, not mortality.

Pediatric Adherence to Antiretroviral Therapy in Resource-Poor Settings: Challenges and Future Perspectives

The HIV pediatric epidemic in low-income countries is still growing with an increasing impact on children. By the end of 2007, more than 2 million children under 15 years of age worldwide were living with HIV, 90% in subSaharan Africa. In that year alone, 370,000 children were newly infected and 270,000 died. AIDS has become one of the leading causes of mortality among children under the age of 5 years in developing countries [101]. In the absence of combination antiretroviral therapy (cART), 52% of children infected with perinatally acquired HIV infection will die by the age of 2 years [1]. Numerous studies have confirmed the clinical efficacy and feasibility of cART in HIVinfected adults in Africa [2,3] but, to date, resources and programs targeting HIV-infected children in resource-poor settings remain limited. Even though the use of cART to treat children has increased in recent years in subSaharan Africa, less than 15% of children needing cART in Africa currently receive it [102]. It is estimated that more than 780,000 children are in need of cART in lowand middle-income countries [103]. When made accessible, treatment for children in this context has proved highly effective [4]. Studies have found the survival probability at 12 months for children on cART to be more than 95% in settings in sub-Saharan Africa [5] and Asia [6]. Education and adherence counseling are therefore essential components of cART and adherence in HIV-infected children is critical to the success of cART.

Intake of Lipid-based Nutrient Supplements during Illness and Convalescence among Moderately-underweight Malawian Childrenhomes

Intake of Lipid-based Nutrient Supplements during Illness and Convalescence among Moderately-underweight Malawian Childrenhomes

Impact of the HIV/AIDS Epidemic on the Neurodevelopment of Preschool-Aged Children in Kinshasa, Democratic Republic of the Congo

Pediatric HIV infection is a growing problem in most regions of the world. Data on the effects of HIV on the neurodevelopment of children in resource-poor settings are scarce but necessary to guide interventions. The purpose of this study was to compare the neurodevelopment of preschool-aged HIV-infected, HIV-affected (HIV-uninfected AIDS orphans and HIV-uninfected children whose mother had symptomatic AIDS), and healthy control children in Kinshasa, Democratic Republic of Congo. Thirty-five HIV-infected, 35 HIV-affected, and 90 control children aged 18 to 72 months were assessed by using the Bayley Scales of Infant Development II, Peabody Developmental Motor Scales, Snijders-Oomen Nonverbal Intelligence Test, and Rossetti Infant-Toddler Language Scale, as appropriate for age. Overall, 60% of HIV-infected children had severe delay in cognitive function, 29% had severe delay in motor skills, 85% had delays in language expression, and 77% had delays in language comprehension, all significantly higher rates as compared with control children. Young HIV-infected children (aged 18-29 months) performed worse, with 91% and 82% demonstrating severe mental and motor delay, respectively, compared with 46% and 4% in older HIV-infected children (aged 30-72 months). HIV-affected children had significantly more motor and language expression delay than control children. The impact of the HIV pandemic on children's neurodevelopment extends beyond the direct effect of the HIV virus on the central nervous system. AIDS orphans and HIV-negative children whose mothers had AIDS demonstrated significant delays in their neurodevelopment, although to a lesser degree and in fewer developmental domains than HIV-infected children. Young HIV-infected children were the most severely afflicted group, indicating the need for early interventions. Older children performed better as a result of a "survival effect," with only those children with less aggressive disease surviving.

Performance of oscillometric blood pressure devices in children in resource-poor settings

To compare oscillometric blood pressure devices with mercury sphygmomanometry in children. Blood pressure measurements were obtained with a mercury sphygmomanometer and one of two oscillometric devices. Correlations within each device and agreement between the two devices were evaluated. In children, blood pressure measured by the oscillometric device was poorly correlated and had wide limits of agreements with the sphygmomanometer. Furthermore, the oscillometric devices overestimated systolic blood pressure in children with higher readings. The applicability of automated blood pressure measuring devices in children has limitations and cannot be recommended.

Efficacy of Highly Active Antiretroviral Therapy in HIV-1–Infected Children in Kenya

Few studies have investigated the efficacy of antiretroviral therapy among HIV-infected children in resource-poor settings. This observational, retrospective analysis describes the clinical, immunologic, and virologic effects of highly active antiretroviral therapy in treatment-naive, HIV-infected children in Mombasa, Kenya. In keeping with a public health approach, all children were treated by using a simplified, nationally approved, triple-drug regimen. Clinical data and stored plasma samples from 29 children who were followed prospectively between April 2003 and October 2004 were analyzed. All children received generic formulations of nevirapine, zidovudine, and lamivudine and were evaluated at baseline and at 3, 6, 9, 12, and 15 months. At each visit, weight and CD4 lymphocyte counts were measured and plasma samples were stored for analysis. HIV RNA load was determined retrospectively at baseline and 9 months after initiation of therapy. The mean age of the children was 8.5 years (range: 2-16 years). At baseline, the mean CD4 count (+/-SD) was 182.3 x 10(6) cells per microL (+/-145.6). On treatment, CD4 counts increased step-wise by a mean of 187 x 10(6) cells per microL at 3 months, 293 cells per microL at 6 months, 308 cells per microL at 9 months, 334 cells per microL at 12 months, and 363 cells per microL at 15 months. The mean plasma viral load decreased from a baseline level of 622,712 to 35,369 copies per mL, and at 9 months was undetectable in 55% of the patients. Mean z scores for weight for age increased from a baseline of -1.61 to -1.12 at 12 months into therapy. A public health approach using 1 treatment regimen in generic form showed excellent efficacy among treatment-naive, HIV-infected children in a resource-limited country. Clinical and immunologic improvement occurred in all patients, but 9 months after the start of therapy, only 55% of the children had an undetectable viral load.

Gender and race do not alter early-life determinants of clinical disease progression in HIV-1 vertically infected children.

To identify early life predictors of clinical progression before and beyond age 1 year. Prospective follow-up of 161 vertically HIV infected children in the ongoing European Collaborative Study provided data from birth over 16 years. Kaplan-Meier and Cox regression procedures were used to assess the predictive value of first available laboratory and clinical markers for progression defined as serious disease or death. We investigate gender and race effects on associations and the optimal threshold for longitudinal CD4+ percentage measurements after age 6 months for predicting disease progression. Earliest (during the first 6 months) measurements of CD4+ percentage below 20% [three-fold increased risk (P = 0.041)] and absolute lymphocytes (AL) (reduction of risk of three-quarters for a one log increase (P =0.014)) were independently associated with overall and rapid disease progression during the first year. Persistent lymphadenopathy (or hepatomegaly) in early life was also additionally associated with overall disease progression, and after age 1 year [greater than doubling of risk, (P = 0.040)], but not with rapid progression. Associations were not significantly dependent on gender or race. CD4+ percentage of 10% was the best prognostic cut-off. Early clinical markers are strongly predictive of disease progression after 1 year of age into adolescence. However, rapid progression is less straightforward to predict, probably due largely to early progression during the first few months in such individuals. The independently predictive value of AL measurements suggest they could be used alone in the management of children in resource-poor settings.

Alternatives to HIV-1 RNA concentration and CD4 count to predict mortality in HIV-1-infected children in resource-poor settings.

Cheaper, simpler alternatives to CD4 lymphocyte count and HIV-1 RNA detection for assessing the prognosis of HIV-1 infection are needed for resource-poor settings. However, little is known about the predictive value of alternative assays, in particular in children. We assessed the prognostic value of total lymphocyte count, immune complex-dissociated p24 antigen, white blood cell count, packed-cell volume (haematocrit), and serum albumin for mortality in 376 HIV-1-infected, mainly African-American or Hispanic children enrolled during March, 1988 to January, 1991. In a Cox proportional hazards model, including all assay-alternatives to CD4 and RNA, total lymphocyte count (p<0.0001) and serum albumin (p=0.0107) independently predicted mortality. Further assessment of these markers is warranted in resource-poor settings.

Growth, morbidity, and mortality in a cohort of institutionalized HIV-1-infected African children.

As a result of the HIV epidemic in Africa, much debate exists on whether institutionalized compared with community-based care provides optimum management of infected children. Previous reports calculated 89% mortality by age 3 years among outpatients in Malawi. No similar data are available for infected children in institutionalized care. We characterized patterns of morbidity and mortality among HIV-1-infected children residing at an orphanage in Nairobi. Medical records for 174 children followed over 5 years were reviewed. Mortality was analyzed by Kaplan-Meier methods with adjustment to account for survival in the community before admission. Anthropometric indices were calculated to include mean z scores for weight for length and length for age. Low indices reflected wasting and stunting. Opportunistic infections were documented. Of 174 children, 64 had died. Survival was 70% at age 3 years. Morbidity included recurrent respiratory tract infections, gastroenteritis, parotitis, and lymphoid interstitial pneumonitis. No new cases of tuberculosis disease were noted after admission. Mean z scores for length for age suggested overall stunting (z = -1.65). Wasting was not observed (z = -0.39). The optimal form of care for HIV-infected children in resource-poor settings may be the development of similar homes. Absence of tuberculosis disease in long-standing residents may have contributed to improved survival. Stunting in the absence of wasting implied that growth was compromised by opportunistic infections and other cofactors.

Pediatric tuberculosis in rural South Africa--value of directly observed therapy.

Tuberculosis is a major cause of mortality and morbidity among children in resource-poor settings. A strategy of community-based, directly observed therapy employed in a rural health district in South Africa since 1991 is described. Most children (75 per cent) diagnosed with tuberculosis were treated in the community and most of them (85 per cent) completed treatment. Supervision was either by clinic-based health workers (26 per cent), community health workers (20 per cent), or volunteer lay people (46 per cent). Among children diagnosed with tuberculosis who were also HIV infected, the case-fatality rate was higher than among the HIV uninfected, and a larger proportion of the HIV infected failed to complete treatment.