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Missing Children In HIV Surveillance HIV Surveillance Meeting Bangkok 2-5 March 2009

Missing Children In HIV Surveillance HIV Surveillance Meeting Bangkok 2-5 March 2009. Olive Shisana, Sc.D Chief Executive Officer Human Science Research Council. Outline. Children are missing in HIV programs

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Missing Children In HIV Surveillance HIV Surveillance Meeting Bangkok 2-5 March 2009

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  1. Missing Children In HIV Surveillance HIV Surveillance Meeting Bangkok2-5 March 2009 Olive Shisana, Sc.D Chief Executive Officer Human Science Research Council

  2. Outline • Children are missing in HIV programs • The magnitude and distribution of the HIV/AIDS problem in children and inadequacy of pediatric data • HIV risk factors in children • Proposed approaches to surveillance

  3. 1. Children Are Often Missing In: • Population surveys of HIV • HIV prevention programs • Voluntary counseling and testing campaigns • AIDS care programs

  4. Missing Children In Surveillance • Population-based surveys include people aged 15-49 years, excludes children • Health facility surveys seldom include children aged 5 years and older • Mortality data are limited to infant mortality, neonatal mortality and peri-natal mortality and seldom is AIDS reported

  5. Children Are Often Missing In Prevention Programs • Children are seldom the focus of prevention, treatment and care programs if they are not part of PMTCT services • Even with PMTCT, the focus often ends once the mother is discharged from hospital • No prevention programs for HIV negative mothers who may acquire HIV after birth, but continue to breastfeed well beyond 6 months, increasing the child’s risk of HIV infection.

  6. Children Are Missing In VCT Services • VCT is often reserved for men, women and young people, but seldom for children aged under 10 years (except at birth as part of PMTCT). • WHO indicates that providing VCT for children presents a problem for policy makers, program managers and health care providers. • Consequently, children miss out on this intervention and on surveillance.

  7. Children Often Are Missing In Care And Treatment Programs • Most of the treatment programs focus on those children who are acutely ill with AIDS; few seek out children needing ARV treatment • Even for children in PMTCT, in SA it took very long to provide PMTCT services and even longer to provide guidelines for dual therapy • Care for children often focuses on OVCs and seldom on children who are not infants or OVCs

  8. 2. The Problem: Magnitude • Globally 2.5 million children were living with HIV in 2007, 90% were in SSA • 420 000 were newly infected the same year • 330 000 died of AIDS-related complications --UNAIDS (2008)

  9. Inadequate HIV Epidemiological Data On Children • Child survival data are available for those who acquired HIV through PMTCT (see Newell, et al., 2004) • Population-based surveys seldom include children. • Only Botswana, South Africa and Swaziland included children in the national population-based surveys. • Failure to include children means that targeted HIV prevention, care and treatment programs are unlikely to be prioritized for this population.

  10. Results Of Population-based Surveys In Three Southern African Countries • The studies conducted in Botswana, South Africa and Swaziland show that: • A large proportion of children are living with HIV • This large proportion is not limited to children aged 0-4 years but also to children 5-9 years • Children aged 10-14 are also infected, even if the rates are lower than those under 10 years

  11. HIV Prevalence By Age-group Of Children, Botswana 2004 Botswana population-based survey (BAIS II, 2004)

  12. HIV Prevalence Among SA Children, 2002

  13. Gender Differences In HIV Prevalence Among Children, Botswana 2004 Botswana population-based survey (BAIS II, 2004)

  14. Gender Differences In HIV Prevalence Among South African Children 2-14 Years, 2005

  15. HIV Prevalence Among Children Age 5 To 14 Years, Swaziland 2007 Swaziland population based survey, 2007

  16. 2. HIV Incidence % And Number Of New Infections By Age Group, South Africa 2005 Rehle, Shisana, Pillay, et al, 2007

  17. HIV Risk Factors In Children • HIV positive mother (and father) • Breast-feeding by biological mother and non-biological mother • Sexual abuse • Nosocomial infection

  18. Breastfeeding Risk • The overwhelming majority of HIV positive women sampled in 25 hospitals, 56 primary health care centers in one South African province in 2004 breastfeed their children… • 92.3% breastfed their children, • 86.4% beyond six months, and • 60% longer than one year • Breastfeeding by a non-biological mother (OR:16.9) • This puts children at risk of being infected with HIV

  19. Sexual Abuse In Children • Sexual abuse of children is very common globally; in the areas with high HIV prevalence, the risk for these children contracting HIV increases dramatically • It is estimated that 6-8% of children living in HIV hyper-endemic countries will experience penetrative sex with HIV positive person before reaching 18 years of age • Lalor, K: Child sexual abuse in sub-Saharan Africa: a literature review. Child Abuse Negl. 2004 Apr;28(4):439-60

  20. Sexual Abuse Of Children • There is evidence that sexual abuse of children is prevalent in South Africa • Of the 52 733 rapes reported in 2003/4 in SA, half were children. • At a children’s hospital age of raped children was between 10 months to 13 years (mean 5.8 years). • 450 - 500 acute and chronic sexually abused children are treated at the South African children’s hospital annually. • S Cox, G Andrade, D Lungelow, W Schloetelburg, H Rode: The child rape epidemic. Assessing the incidence at Red Cross Hospital, Cape Town, and establishing the need for a new national protocol. October 2007, Vol. 97, No. 10 SAMJ

  21. Nosocomial Infections In Children • During the 20 years of the HIV epidemic there have been many reports of HIV transmission through health care. The first such report came from investigations in Russia in 1988-89, where injections and other hospital procedures spread HIV from an index patient to over 250 other children in several hospitals • Less than a year later, doctors in Romania uncovered a much larger outbreak in which medical procedures in orphanages and hospitals had infected over 1,000 Romanian children. • In Libya in 1998, medical procedures at one hospital spread HIV from one child to more than 390 others • Hospitals in Southern Africa are not immune to these kinds of practices

  22. Assessment Of Infection Control In Maternity And Pediatric Units, South African Province 2004 • 101 maternal and child units were visited • Clinical practice: • 60% of health workers used gloves when inserting intravenous device • 56% wore gloves during delivery of babies • 79% used a new needle to draw medication • 86% used a single use syringe to draw medication Expressed Breast Milk management • Nearly 25% of women who expressed milk destined for the milk room were HIV positive; • - Due to mislabelling it is likely that the milk will be served to the wrong child.

  23. Replies To Critical Steps In Milk Preparation To Prevent HIV Transmission In A High-careFacility, South African Province 2004

  24. Assessing The Presence Of Occult And Visible Blood From Maternity And Pediatric Units, South African Province, 2004 • Overall, there were 165 samples taken from the various wards and units, • 74 (44.8%) were positive for occult blood. • 29 (17.5%) had visible blood • All these were ready to be used on another patient

  25. 4. Proposed Approaches To Include Children In HIV Surveillance: Testing • Population-based survey of HIV should include all age groups, starting with infants; • Children under 2 years measure HIV infection using polymerase chain reaction (PCR) to test for the presence of HIV-1 virus infection. • Children older than 2 years use DBS using HIV-1 enzyme-linked immunosorbent (ELISA)

  26. 4. Proposed Approaches To Include Children In HIV Surveillance: Questionnaire • Under 2 (parent/guardian/road to health card) • 2-11 (parent/guardian) • 12-14 (child) • 15-18 (child)

  27. Questionnaires For Parents/Guardians Of Children Under 2 Yrs • Breast feeding • Supplementary feeding • Mother’s ANC • Mother and child tested for HIV • Scarification • PMTCT indicator on road to health card/vaccination • Child getting cotrimoxazol

  28. 4. Questionnaires For Children Aged 2-11 • Care and protection of child • Education of child on life issues • Sex • Knowing signs of sexual abuse and unwanted advances • Health status of child • Names of medicines the child is taking (ARV)

  29. 4. Questionnaire For Children 12-14 • Source of educational information on HIV and AIDS • Care and protection of child • Sexual experience • Sexual behaviour • Health status • Violence at home

  30. 4. Possible Approaches To HIV Surveillance In Children • “Incidence” of HIV among infants attending primary health centers for immunization services (early infant diagnosis)( Rollins CROI) - Clinic-based HIV testing of all infants attending any of the first three immunizations (6, 10, 0r 14 weeks) - HIV antibody testing (infant exposure status) with subsequent PCR testing (early infection rate) -Testing was performed with informed consent, provision of post test counseling and linkage to care and treatment for mother and baby -Acceptable and feasible in three clinics in South Africa

  31. Possible Approaches To HIV Surveillance In Children: Additional Indicators 1. Number of births to HIV-infected women 2. Coverage of key interventions for HIV exposed children (CTX, PCR testing, infant feeding) and HIV-infected children (ART) 3. HIV prevalence among children, by specific age groups (e.g., <2, <5, <15, <18) 4. Incidence of HIV among children born to HIV-infected mothers (early and late) 5. Mortality 6. Additional risk factor data for HIV infections among children that are not MTCT (e.g., sexual, blood-borne, etc)

  32. Conclusions • To get children into surveillance in health facilities we must immediately ensure they have access to existing prevention, care and treatment programs and new ones • Need epidemiological data on children to improve planning • Need for increased pediatric surveillance to evaluate HIV prevention programmes • Impact of PMTCT programs on incidence • Infection control • Sexual abuse • Need data to assess impact of care and treatment programs on mortality • Guide strategic programmatic decision making

  33. Thank you for your attention

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