Keeping children alive and healthy in South Africa - how do we reach this goal? Perspectives from a paediatrician in a District Clinical Specialist Team

District Clinical Specialist Teams (DCSTs) are part of the primary healthcare re-engineering process in South Africa. These multi-disciplinary clinical teams were established throughout the country in 2012, and their main role is reduction of maternal and childhood mortality and morbidity through improvement of service delivery at primary care level in their health districts. The Tshwane DCST is used as a case study to describe the challenges encountered in establishing the team within the complex district health system. On the other hand, the cross-disciplinary approach has proved itself a winning combination if the team shares a common vision and has a work plan to guide the priorities and facility support visits. Through their clinical expertise, and using extensive networking, DCSTs are well positioned in the health system to have a strong positive effect on child healthhttp://www.sajch.org.za/index.php/SAJCHhb201

Challenges in the provision of tuberculosis preventive therapy to children in Gauteng Province, South Africa

BACKGROUND : Tuberculosis preventive therapy (TPT) offered to children who come into contact with infectious adult pulmonary tuberculosis (TB) cases is an important childhood TB prevention strategy OBJECTIVES : To document paediatric TPT coverage as per South African national TB guidelines, to measure basic knowledge of TPT in adult TB patients and healthcare workers (HCWs), and to determine challenges in TPT delivery in eligible children METHODS : We conducted a descriptive, cross-sectional study at primary healthcare clinics in South-West Tshwane, Gauteng Province, South Africa (SA). Structured interviews were conducted with adult TB patients to obtain socio-demographic data, TB and HIV history, data on child contacts and TPT knowledge. A separate questionnaire probed HCWs' knowledge of TPT. Patient folders and the clinical process flow of adult TB cases and children on TPT were also assessed RESULTS : We interviewed 100 adult TB patients and identified 28 child contacts who were eligible for TPT, including six children (21%, n=6/28) on TPT, all HIV-uninfected and <5 years of age. Instability in household configuration was the most common reason for eligible children not having been brought to health facilities for assessment (57%; n=4/7). Almost all adult TB patients were aware of their TB diagnosis (98%; n=98/100), but only half (48%; n=48/100) had knowledge of their TB type, and 55% (n=6/11) of the adult TB patients with drug-resistant TB were aware of the drug resistance. In addition, we interviewed 71 HCWs, and more than one-third of HCWs (37%; n=26/71) were fully knowledgeable about paediatric TPT eligibility criteria, with 63% (n=45/71) unaware that HIV-infected children of all ages qualified for TPT after exposure CONCLUSIONS : TPT provision in eligible child TB contacts in an urban district in SA was found to be suboptimal, especially for HIV-infected children. Instability in household configuration was an important reason for suboptimal TPT provision. Training of HCWs on paediatric TPT guidelines is required, together with knowledge sharing on TPT with the TB patientshttp://www.sajch.org.za/index.php/SAJCHam2023Paediatrics and Child Healt

Missing HIV prevention opportunities in South African children – A 7-year review

CITATION: Feucht, U. D., Meyer, A., & Kruger, M. 2014. Missing HIV prevention opportunities in South African children – A 7-year review. BMC Public Health, 14:1265, doi:10.1186/1471-2458-14-1265.The original publication is available at http://bmcpublichealth.biomedcentral.comBackground: The prevention of mother-to-child transmission (PMTCT) program in South Africa is now successful in ensuring HIV-free survival for most HIV-exposed children, but gaps in PMTCT coverage remain. The study objective was to identify missed opportunities for prevention of mother-to-child transmission of HIV using the four PMTCT stages outlined in National Guidelines. Methods: This descriptive study enrolled HIV-exposed children who were below the age of 7 years and therefore born during the South African PMTCT era. The study site was in Gauteng, South Africa and enrolment was from June 2009 to May 2010. The clinical history was obtained through a structured caregiver interview and review of medical records and included socio-demographic data, medical history, HIV interventions, infant feeding information and HIV results. The study group was divided into the “single dose nevirapine” (“sdNVP”) and “dual-therapy” (nevirapine & zidovudine) groups due to PMTCT program change in February 2008, with subsequent comparison between the groups regarding PMTCT steps during the preconception stage, antenatal care, labor and delivery and postpartum care. Results: Two-hundred-and-one HIV-exposed children were enrolled: 137 (68%) children were HIV infected and 64 (32%) were HIV uninfected. All children were born between 2002 and 2009, with 78 (39%) in the “sdNVP” and 123 (61%) in the “dual-therapy” groups. The results demonstrate significant improvements in antenatal HIV testing and PMTCT enrolment, known maternal HIV diagnosis at delivery, mother-infant antiretroviral interventions, infant HIV-diagnosis and cotrimoxazole prophylaxis. Missed opportunities without improvement include pre-conceptual HIV-services and family planning, tuberculosis screening, HIV disclosure, psychosocial support and postnatal care. Not receiving consistent infant feeding messaging was the only PMTCT component that worsened over time. Conclusions: Multiple missed opportunities for optimal PMTCT were identified, which collectively increase children’s risk of HIV acquisition. Although HIV-testing and antiretroviral interventions improved, all PMTCT components need to be optimized to reach the goal of total pediatric HIV elimination.http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1265Publisher's versio

Missing HIV prevention opportunities in South African children - a 7-year review

BACKGROUND : The prevention of mother-to-child transmission (PMTCT) program in South Africa is now successful in ensuring HIV-free survival for most HIV-exposed children, but gaps in PMTCT coverage remain. The study objective was to identify missed opportunities for prevention of mother-to-child transmission of HIV using the four PMTCT stages outlined in National Guidelines. METHODS : This descriptive study enrolled HIV-exposed children who were below the age of 7 years and therefore born during the South African PMTCT era. The study site was in Gauteng, South Africa and enrolment was from June 2009 to May 2010. The clinical history was obtained through a structured caregiver interview and review of medical records and included socio-demographic data, medical history, HIV interventions, infant feeding information and HIV results. The study group was divided into the “single dose nevirapine” (“sdNVP”) and “dual-therapy” (nevirapine & zidovudine) groups due to PMTCT program change in February 2008, with subsequent comparison between the groups regarding PMTCT steps during the preconception stage, antenatal care, labor and delivery and postpartum care. RESULTS :: Two-hundred-and-one HIV-exposed children were enrolled: 137 (68%) children were HIV infected and 64 (32%) were HIV uninfected. All children were born between 2002 and 2009, with 78 (39%) in the “sdNVP” and 123 (61%) in the “dual-therapy” groups. The results demonstrate significant improvements in antenatal HIV testing and PMTCT enrolment, known maternal HIV diagnosis at delivery, mother-infant antiretroviral interventions, infant HIV-diagnosis and cotrimoxazole prophylaxis. Missed opportunities without improvement include pre-conceptual HIV-services and family planning, tuberculosis screening, HIV disclosure, psychosocial support and postnatal care. Not receiving consistent infant feeding messaging was the only PMTCT component that worsened over time. CONCLUSIONS : Multiple missed opportunities for optimal PMTCT were identified, which collectively increase children’s risk of HIV acquisition. Although HIV-testing and antiretroviral interventions improved, all PMTCT components need to be optimized to reach the goal of total pediatric HIV elimination.http://www.biomedcentral.com/bmcpublichealthhb201

The ability of continuous-wave Doppler ultrasound to detect fetal growth restriction

BACKGROUND: Fetal growth restriction (FGR), defined as a fetus failing to reach its genetic growth potential, remains poorly diagnosed antenatally. This study aimed to assess the ability of continuouswave Doppler ultrasound of the umbilical artery (CWD-UmA) to detect FGR in healthy women with low-risk pregnancies. METHODS AND FINDINGS: This prospective longitudinal descriptive cohort study enrolled infants born to low-risk mothers who were screened with CWD-UmA between 28–34 weeks’ gestation; the resistance index (RI) was classified as normal or abnormal. Infants were assessed at 6, 10, 14 weeks, and 6 months postnatally for anthropometric indicators and body composition using the deuterium dilution method to assess fat-free mass (FFM). Neonates in the abnormal RI group were compared with those in the normal RI group, and neonates classified as small-for-gestational age (SGA) were compared with appropriate-for-gestational age (AGA) neonates. Eighty-one term infants were included. Only 6 of 26 infants (23.1%) with an abnormal RI value would have been classified as SGA. The abnormal RI group had significantly reduced mean FFM and FFM-for-age Z-scores at 6, 10, 14 weeks, and 6 months compared with the normal RI group (P<0.015). The SGA group’s FFM did not show this consistent trend when compared to AGA FFM, being significantly different only at 6 months (P = 0.039). The main limitation of the study was the small sample size of the infant follow-up. CONCLUSIONS: Abnormal RI obtained from CWD-UmA is able to detect FGR and is considered a useful addition to classifying the neonate only by SGA or AGA at birth.UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored program executed by the World Health Organizationhttp://www.plosone.orgpm2022Obstetrics and GynaecologyPaediatrics and Child Healt

Growth and the pubertal growth spurt in South African adolescents living with perinatally-acquired HIV infection

BACKGROUND : The majority children living with HIV infection now survive into adulthood because of effective antiretroviral therapy (ART), but few data exist on their growth during adolescent years. This study investigated growth patterns and evaluated factors associated with suboptimal growth in adolescents with perinatally-acquired HIV infection. METHODS : This retrospective cohort study included HIV-infected adolescents, aged 13 to 18 years, with at least 5 years of ART follow-up at a large HIV clinic in the Gauteng Province, South Africa. Weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and body mass index (BMI)-for-age Z-scores were calculated using World Health Organization (WHO) growth standards. Growth velocity graphs were generated utilising the mean height change calculated at 6-monthly intervals, using all available data after ART initiation, to calculate the annual change. Other collected data included WHO HIV disease staging, CD4%, HIV viral loads (VLs), ART regimens and tuberculosis co-infection. RESULTS : Included were 288 children with a median age of 6.5 years (IQR 4.2;8.6 years) at ART initiation, and 51.7% were male. At baseline the majority of children had severe disease (92% WHO stages 3&4) and were started on non-nucleoside reverse transcriptase inhibitorbased regimens (79.2%). The median CD4% was 13.5% (IQR 7.9;18.9) and median HIV viral load log 5.0 (IQR 4.4;5.5). Baseline stunting (HAZ <-2) was prevalent (55.9%), with a median HAZ of -2.2 (IQR -3.1;-1.3). The median WAZ was -1.5 (IQR -2.5;-0.8), with 29.2% being underweight-for-age (WAZ <-2). The peak height velocity (PHV) in adolescents with baseline stage 3 disease was higher than for those with stage 4 disease. Being older at ART start (p<0.001) and baseline stunting (p<0.001) were associated with poorer growth, resulting in a lower HAZ at study exit, with boys more significantly affected than girls (p<0.001). CONCLUSIONS : Suboptimal growth in adolescents with perinatally-acquired HIV infection is a significant health concern, especially in children who started ART later in terms of age and who had baseline stunting and is more pronounced in boys than in girls.http://www.plosone.orgdm2022Paediatrics and Child Healt

False-positive HIV DNA PCR testing of infants : implications in a changing epidemic

AIM: To examine false-positive HIV DNA polymerase chain reaction (PCR) test results in children, and the potential implications for the paediatric HIV epidemic in sub-Saharan Africa. METHODS: A review was done of records over a 6-year period of children less than 18 months old at an HIV treatment site in South Africa, to evaluate those with an initial ‘false’-positive HIV DNA PCR result, but later proven to be HIV-uninfected with HIV DNA PCR and/or quantitative HIV RNA PCR tests. We calculated the influence of changing HIV transmission rates on predictive values (PV) of HIV DNA PCR tests in a hypothetical population of all HIV-exposed infants over a 1-year period. (Positive PV: proportion of individuals with a positive test with disease; negative PV: proportion of individuals with negative test and no disease). ReSULTS: Of 718 children, 40 with an initial positive HIV DNA PCR test were subsequently proven to be HIV-uninfected, resulting in a positive PV of 94.4%. Most (75%) uninfected children had PMTCT interventions and were asymptomatic or mildly symptomatic (77.5%). Calculations using a test specificity of 99.4%, as reported previously, show a decrease in positive PV using a single-test strategy from 98.6% at 30% HIV transmission rate, to 94.8% at 10% transmission, to 62.5% at 1% transmission. Reduction in test specificity further decreases positive PV at low transmission rates. CONCLUSION: Decreasing mother-to-child HIV transmission rates reduce the positive predictive value of a single HIV DNA PCR test result, necessitating adaptations to diagnostic algorithms to avoid misdiagnosis and inappropriate treatment, especially with early initiation of antiretroviral therapy in asymptomatic infants.http://www.samj.org.z

Taking kangaroo mother care forward in South Africa : the role of district clinical specialist teams

The global agenda for improved neonatal care includes the scale-up of kangaroo mother care (KMC) services. The establishment of district clinical specialist teams (DCSTs) in South Africa (SA) provides an excellent opportunity to enhance neonatal care at district level and ensure translation of policies, including the requirement for KMC implementation, into everyday clinical practice. Tshwane District in Gauteng Province, SA, has been experiencing an increasing strain on obstetric and neonatal services at central, tertiary and regional hospitals in recent years as a result of growing population numbers and rapid up-referral of patients, with limited down-referral of low-risk patients to district-level services. We describe a successful multidisciplinary quality improvement initiative under the leadership of the Tshwane DCST, in conjunction with experienced local KMC implementers, aimed at expanding the district’s KMC services. The project subsequently served as a platform for improvement of other areas of neonatal care by means of a systematic approach.http://www.samj.org.zaam2016Paediatrics and Child Healt

Growth in HIV-infected children on long-term antiretroviral therapy

OBEJECTIVES : To describe growth in HIV‐infected children on long‐term antiretroviral therapy (ART) and to assess social, clinical, immunological and virological factors associated with suboptimal growth. METHODS : This observational cohort study included all HIV‐infected children at an urban ART site in South Africa who were younger than 5 years at ART initiation and with more than 5 years of follow‐up. Growth was assessed using weight‐for‐age Z‐scores (WAZ), height‐for‐age Z‐scores (HAZ) and body mass index (BMI)‐forage Z‐scores (BAZ). Children were stratified according to pre‐treatment anthropometry and age. Univariate and mixed linear analysis was used to determine associations between independent variables and weight and height outcomes. RESULTS : Majority of the 159 children presented with advanced clinical disease (90%) and immunosuppression (89%). Pre‐treatment underweight, stunting and wasting occurred commonly (WAZ<‐2= 50%, HAZ<‐2= 73%, BAZ<‐2= 19%). Weight and BMI improvement occurred during the initial 12 months, while height improved during the entire 5‐year period. Height at study exit was significantly worse for children with growth impairment at ART initiation (p<0.001), whilst infants (<1 year) demonstrated superior improvement in terms of BMI (p=0.04). Tuberculosis was an independent risk factor for suboptimal weight (p=0.01) and height (p=0.02) improvement. Weight gain was additionally hindered by lack of electricity (p=0.04). Immune reconstitution and virological suppression were not associated with being underweight or stunted at study end point. CONCLUSIONS : Malnutrition was a major clinical concern for this cohort of HIV‐infected children. Early ART initiation, tuberculosis co‐infection management and nutritional interventions are crucial to ensure optimal growth in HIV‐infected children.http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-31562017-05-31hb2016Paediatrics and Child Healt