HEALTH-SOUTHERN AFRICA: HIV Treatment Just Beginning for Children

By IPS Correspondents Reprint | | Print |

Tafi Murinzi

BULAWAYO, May 26 2005 (IPS) - Age offers little protection against AIDS; children are often the disease’s unwitting victims. Yet for the young ones in Southern Africa, treatment is only just beginning.

But the long-term health implications are still largely unknown while lack of child-specific dosages presents another major challenge.

‘’There are very few paediatric formulas internationally; the amount of research is minimal,” says Lynde Francis who runs a centre in Zimbabwe with 200 HIV-positive children.

‘’I think it’s partly because it was acceptable that a kid with HIV would die,” she adds.

Around three million children in Sub-Saharan Africa, the world’s worst-affected region, were living with HIV in 2003, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organisation (WHO). In the same year, 700,000 children under the age of 15 were newly infected with HIV/AIDS, 88.6 percent of whom live in sub-Saharan Africa.

In neighbouring South Africa, which has the highest HIV burden in the world with five million people infected, including over 250,000 children below the age of 14, the treatment of children appears to be gathering steam since the launch of the government roll-out programme in 2003. But paediatrician Tammy Meyers, who works at the country’s largest referral hospital as well as at the University of the Witwatersrand, says children are still having problems accessing treatment. ‘’I think paediatric roll-out requires a champion at almost every facility, where this does not exist the care is slow or not happening,” she adds.

The children’s clinic at Chris Hani Baragwanath Hospital has more than 500 children on treatment, through the government plan. Meyers is part of a team that conducted a study on 262 of the children. Results show that while 18 of them died while on treatment, none of the deaths was due to the life-prolonging anti-retroviral drugs (ARVs) they were taking.

The release of the study findings comes after the country’s health minister, Manto Tshabalala-Msimang, voiced suspicion over ARVs. Attacking the WHO for pressing South Africa into accelerating its ARV roll-out, the minister maintains the drugs have negative side effects. Instead, she advocates the use of garlic, lemon, beetroot and olive oil to slow the progression to AIDS. This has enraged activists presently engaged in legal battle with a champion of multivitamins. The latter’s efficacy against AIDS has not been conclusively proven.

In Zimbabwe, the government says it only has resources to provide ARVs to 10,000 people. But there has been no explicit mention of children in a country where 300,000 people need treatment.

Officials in the Ministry of Health’s AIDS and Tuberculosis unit are loath to shed much light on the government’s plans for infected children. According to the United Nations Children’s Fund (UNICEF), HIV-related illnesses claim a child every 15 minutes in Zimbabwe.

‘’There just are no drugs,” Francis says. Part of the reason, she explains, is that Zimbabwe’s ARV roll-out programme – launched early last year – was based on an unsuccessful application for 218 million dollars to Global Fund to Fight HIV/AIDS, Tuberculosis (TB) and Malaria.

But other activists still question the government’s commitment to fight the disease, citing the recent purchase of Chinese-made military hardware including four fighter jets that cost an estimated 120 million dollars when the country is hardly facing an external threat.

However, treating children goes beyond financial commitments. According to Ruedi Luthy, who runs a Swiss-funded clinic that has 50 adolescents and children who receive ARVs, prolonging the lives of infected children – especially the very young ones – presents several challenges.

‘’Their clinical presentation is different, the diagnostic work-up is different and often more difficult and medications are often only available for adults,” he says. Since children are not merely ‘’small adults” with regard to their illnesses and treatment, additional expertise to increase the number on ARV programmes is required, but hardly available.

Located in the capital Harare, Connaught clinic provides ‘’comprehensive care” for HIV-AIDS patients, including drugs, for those who cannot afford medical care. The youngest patients are three months old. ‘’It is absolutely magnificent to see how well most of the children do – even after a period of only four weeks,” Luthy says.

He adds: ‘’experience from the First World tells us that children respond to treatment just as well as adults do, but parents need to be committed and well instructed to achieve this success.”

In Zimbabwe’s second city, Bulawayo, the Spanish chapter of Medicins San Frontieres (MSF), is the main provider of ARVs. Since last year, when the government launched its national programme, MSF has pledged to supply ARVs, in the initial phase of its programme, to 1,500 infected people. At least a tenth of the beneficiaries will be children. Currently some 250 children are on ARV drugs, according to co-coordinator Alexandre Boon.

‘’We don’t have in Africa children who’ve been put on treatment for more than three, four or five years because the drugs were unavailable before, though perhaps some private patients, but then you are looking at a very small number,” he adds.

One mother whose child is on the programme is 50-year-old Angeline Dube. Her 11-year-old daughter, Patience, was put on ARVs in February. ‘’We didn’t know what was wrong with her; she had pneumonia, her father died in 2003. I was also ill and she had the same symptoms as me.”

Almost three months into the programme, Patience’s health has improved and she is now regularly attending school. ‘’She sometimes reminds me to take my own drugs,” says Dube who is also on ARVs.

However, the absence of medication meant specifically for very young children presents peculiar problems. According to critics, drug companies have little interest in developing or marketing paediatric formulations adapted to poor countries.

Generic ARVs usually come in fixed dose combinations (FDC) of two or three medicines per tablet. Thus, says Luthy, since ARVs must be dosed according to a child’s body weight, often FDC cannot be used because one or more of the drugs may not be dosed appropriately.

‘’Therefore we often have to resort to the brand mono-compounds,” he says. ‘’As a first line we give Stavudine, Lamivudine and Nevirapine while some small children receive Nelfinavir and Zidovudine and Lamivudine.”

For the very small children, mothers are instructed on how to crush the tablets as well as how to dissolve them in breast milk or other liquids. Sometimes the clinic crushes the tablets and fills the correct dose into capsules.

MSF also faces similar challenges. ‘’What we do,” says Boon, ‘’is that we split those tablets in half and we add up some Nelfinavir for some children who need it and we add some Nevirapine for others to be sure that they respect the optimal dosage of drugs.” According to Boon, ‘’very standardised” tables allow this to be done with relative accuracy.

However, problems arise when the babies are small, weighing below eight kilogrammes. ‘’The drug that we have now doesn’t allow us to treat those children because then you’d have to split the tablets in four or something, which perhaps makes the dosages too inaccurate,” Boon says.

But the dosage problem could soon be a thing of the past as a local company, known as Varichem, is working on producing children’s ARVs, possibly in syrup-form. The company already produces initial first line drugs used for the initial treatment of AIDS.

Even then, the most nagging question is how long children on ARVs are expected to live as well as what quality of life they are expected to have.

Boon says due to the rapid advances in medicine, where many drugs have been developed in the last 20 years, there is room for optimism. Researchers are already talking of ‘fusion inhibitors’ – new drugs which prevent the virus from infecting new cells, as well as ‘integrate inhibitors’ which stop the virus from getting into the nucleus of the host CD4 cell.

‘’The future is hopefully one day we’ll be able to tackle the disease on time and to prevent that too many CD4s are invaded which would be the purpose of the fusion inhibitors,” he says.

According to Luthy a child on ARVs can be expected to have a life span that is not much different from non-infected children provided he is responding well to treatment and not missing any doses.

However, he adds poverty, malnutrition and other serious illnesses will probably have a more serious impact on their life expectancy than HIV – even where ARV programmes are continued.

A recent survey in 10 districts across Zimbabwe has recorded alarmingly high levels of malnutrition among children. It showed stunting or chronic malnutrition levels as high as 47 percent among children aged six months to 59 months on commercial farms.

Malnutrition is the result of a political and economic crisis that has led to the collapse of Zimbabwe’s health delivery system, rampant food shortages as well as escalating poverty levels. These have exacerbated the impact of the AIDS pandemic in the country, according to analysts.

A World Bank analysis last year found that Zimbabwe received four dollars in donor support for each person infected with HIV, compared to 187 dollars per infected person in neighbouring Zambia.

But even in the less financially hamstrung countries of Southern Africa, it will be some time before ARVs are easily accessible to the children who need them.