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

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

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

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

Incorrectly diagnosing children as HIV-infected : experiences from a large paediatric antiretroviral therapy site in South Africa

OBJECTIVE: To assess the extent to which children may be falsely diagnosed as HIV-infected, using data from an antiretroviral therapy (ART) site in Pretoria, South Africa. METHODS: This was a retrospective patient record review of all ART-naïve children referred to Kalafong hospital’s paediatric HIV clinic between April 2004 and March 2010, with detailed review of those found to be HIV-uninfected. RESULTS: There were 1 526 patient files analysed, with a male-to-female ratio of 1.01:1 and median age at first visit of 20 months (range 26 days - 17.5 years). Nearly half (n=715; 47%) of the children were aged <18 months. Fifty-one children were found to be HIV-uninfected after repeated diagnostic tests. Incorrect laboratory results for children aged <18 months included false-positive HIV DNA PCR tests (40), detectable HIV viral loads (4) and a false-positive HIV p24Ag test (1). One child above 18 months had false-positive HIV ELISA results. An additional 4 children were inappropriately referred after being incorrectly labelled as HIV-infected and 1 child aged <18 months was referred after an inappropriate diagnostic test for age was used. In summary, 1 in every 30 (3.3%) children was discharged HIV-uninfected, and below age 18 months, 1 in 16 children (6.3%) had false-positive HIV virological tests. CONCLUSIOS: Urgency in ART initiation in HIV-infected children is life-saving, especially in infants. However, HIV tests may produce false-positive results leading to misdiagnosis of children as HIV-infected, which has serious consequences. Meticulous checking of HIVpositive status is of utmost importance before committing any child to lifelong ART.Data presented as a poster at the 5th South African AIDS Conference 7 - 10 June 2011, Durban, South Africa.http://www.sajch.org.za/index.php/SAJC

Leveraging the Road to Health booklet as a unique patient identifier to monitor the prevention of mother-to-child transmission programme

BACKGROUND. Currently there is no unique patient identification system in the South African public health sector. Therefore, routine laboratory data cannot effectively be de-duplicated, thereby hampering surveillance of laboratory-diagnosed diseases such as mother-tochild transmission of HIV. OBJECTIVES. To determine the uptake of Road to Health booklet (RTHB) identifiers at HIV polymerase chain reaction (PCR) birth test and describe their performance in linking follow-up test results in the early infant diagnosis programme. METHODS. Between May 2016 and May 2017, Tshwane District Clinical Services implemented a unique patient identifier pilot project in which a sticker-page of unique, readable, barcoded patient identifiers was incorporated in the patient-retained immunisation record (the RTHB) before distribution. Uptake of RTHB identifiers at birth was calculated as the proportion of HIV PCR tests in infants aged <6 days registered with an RTHB identifier over the total number of registered HIV PCR tests. Descriptive analysis of demographic details was performed among infants with two registered HIV PCR tests linked by the RTHB identifier, and performance of the National Health Laboratory Service Corporate Data Warehouse (NHLS CDW)-linking algorithm in matching RTHB-linked results was calculated using a 2 × 2 table. RESULTS. A total of 5 309 HIV PCR birth tests registered with an RTHB identifier were extracted from the NHLS CDW over the 13-month period of the pilot project. The number of registered RTHB identifiers increased from 24 (2% of birth PCR tests) in May 2016, peaking at 728 (56% of birth PCR tests) in May 2017. Among infants with a registered RTHB identifier at birth, 635 (12%) had a subsequent linked HIV PCR test, as indicated by the same RTHB number registered for a later specimen. Demographic details at the time of birth and subsequent PCR test were compared, demonstrating that <4% of infants had exact matches for name, surname, date of birth and sex; 74% of birth tests had variations such as ‘born to’ or ‘baby of ’ in place of a first name; surnames matched exactly in 61% of cases; 18% (n=116) of infants had both tests performed at the same facility, of which only 27% (n=31) had the same patient folder number on both test results. CONCLUSIONS. Leveraging RTHBs as unique patient identifiers, even if used temporarily until linkage to other future national unique identifiers, promises to be an effective scalable approach to laboratory-based surveillance, facilitating healthcare provider access to all test results from birth.AHM acknowledges support from the Discovery Foundation (ref. no. 034203).http://www.samj.org.zaam2018Medical VirologyPaediatrics and Child Healt

Monitoring diagnosis, retention in care and viral load suppression in children testing HIV polymerase chain reaction-positive in two districts in South Africa

BACKGROUND: Retention in care is associated with improved virological control and survival among HIV-infected children. However, retention of children in HIV care remains a challenge. OBJECTIVES: To describe, using routine laboratory HIV test data, the retention-in-care and virological outcomes of HIV-infected children aged <18 months in two districts in South Africa. METHODS: HIV polymerase chain reaction (PCR)-positive results of children from uMkhanyakude and Tshwane districts in KwaZulu- Natal and Gauteng provinces, respectively, tested between April 2015 and May 2016, were extracted from the National Health Laboratory Service’s Corporate Data Warehouse (CDW). HIV-related tests (PCR, viral load (VL), CD4+) were documented longitudinally for each child for ≥13 months after the first positive PCR result by manually searching demographics within the CDW, supplemented by an automated patient-linking algorithm. Test sets were linked if two or more demographics (surname, name, date of birth, folder number) matched exactly. Programmatic indicators assessed included age at first positive PCR test, presumed confirmatory test rates, retention in care, and VL suppression at 6 and 12 months. RESULTS: Ninety-four and 304 children tested HIV PCR-positive in uMkhanyakude and Tshwane, respectively. The median age at diagnosis was 3.6 months (interquartile range (IQR) 1.4 - 7.1) for uMkhanyakude and 2.3 months (IQR 0.1 - 6.7) for Tshwane. In uMkhanyakude, confirmed in utero infections accounted for 18.1% of transmissions (n=17), compared with 29.6% (n=90) in Tshwane. Presumed confirmatory test rates following an initial positive PCR result were 77.7% and 71.7% for uMkhanyakude and Tshwane, respectively. Within 6 months of starting antiretroviral therapy, 43 children (58.9%) were lost to follow-up in uMkhanyakude compared with 160 (73.4%) in Tshwane. Of those retained in care at 6 months with a VL measurement, 15 (60.0%) from uMkhanyakude had a VL <1 000 copies/mL, compared with 24 (48.0%) in Tshwane. For both districts, a third of all HIV PCR-positive children were retained in care at the end of followup, with 29 (30.9%) in uMkhanyakude and 99 (32.5%) in Tshwane. Of these, 12 (41.4%) had a VL <1 000 copies/mL in uMkhanyakude compared with 28 (28.3%) in Tshwane. CONCLUSIONS: We demonstrate the value of routine laboratory data in monitoring diagnosis, retention and VL suppression in HIV-infected children. This approach is scalable, can be reported near real-time, is relatively inexpensive to implement, and provides a tool for improving paediatric HIV services until clinical databases can assume this role.UNICEF and ELMA Foundation.http://www.samj.org.zapm2020Medical Virolog