The Need for Pediatric Formulations to Treat Children with HIV

Over 3.2 million children worldwide are infected with HIV, but only 24% of these children receive antiretroviral therapy (ART). ART adherence among children is a crucial part of managing human-immunodeficiency virus (HIV) infection and extending the life and health of infected children. Important causes of poor adherence are formulation- and regimen-specific properties, including poor palatability, large pill burden, short dosing intervals, and the complex storage and transportation of drugs. This review aims to summarize the various regimen- and formulation-based barriers to ART adherence among children to support the need for new and innovative pediatric formulations for antiretroviral therapy (ART). Detailing the arguments both for and against investing in the development of pediatric HIV medications, as well as highlighting recent advances in pediatric ART formulation research, provides a synopsis of the current data related to pediatric ART formulations and adherence

Qualitative study of healthcare providers’ current practice patterns and barriers to successful rehydration for pediatric diarrheal illnesses in Kenya

Background For children worldwide, diarrhea is the second leading cause of death. These deaths are preventable by fluid resuscitation. Nasogastric tubes (NGs) have been shown to be equivalent to intravenous fluids for rehydration and recommended by the World Health Organization (WHO) for use in severe dehydration. Despite this, NGs are rarely used for rehydration in Kenya. Our objective was to evaluate clinicians’ adherence to rehydration guidelines and to identify barriers to the use of NGs for resuscitating dehydrated children. Methods A case-based structured survey was administered to pediatric care providers in western Kenya to determine their choices for alternative rehydration therapies when oral rehydration and intravenous fluids fail. Providers then participated in a qualitative, semi-structured interview to identify barriers to using nasogastric tubes for rehydration. Analysis included manual, progressive coding of interview transcripts to identify emerging central themes. Results Of 44 participants, only four (9%) followed WHO guidelines that recommend quickly switching to NG for rehydration in their case responses. Participants identified that placing intravenous lines in dehydrated children is a challenge. However, when discussing NG use, many believed NGs are not effective for rehydration. Other participants’ concerns surrounded knowledge and training regarding guidelines as well as not having NGs available. Discussion Healthcare providers in western Kenya do not report using NGs for rehydration in accordance with WHO guidelines for diarrheal illness with severe dehydration. Barriers to the use of NG tubes were lack of knowledge and availability. Education and implementation of guidelines using NG tubes for rehydration may improve outcomes of children suffering from diarrheal illness with severe dehydration

Physical and sexual abuse in orphaned compared to non-orphaned children in sub-Saharan Africa: A systematic review and meta-analysis

This systematic review assessed the quantitative literature to determine whether orphans are more likely to experience physical and/or sexual abuse compared to non-orphans in sub-Saharan Africa (SSA). It also evaluated the quality of evidence and identified research gaps. Our search identified 10 studies, all published after 2005, from Zimbabwe, South Africa, Kenya and Uganda. The studies consisted of a total 17,336 participants (51% female and 58% non-orphans). Of those classified as orphans (n = 7,315), 73% were single orphans, and 27% were double orphans. The majority of single orphans were paternal orphans (74%). Quality assessment revealed significant variability in the quality of the studies, although most scored higher for general design than dimensions specific to the domain of orphans and abuse. Combined estimates of data suggested that, compared to non-orphans, orphans are not more likely to experience physical abuse (combined OR = 0.96, 95% CI [0.79, 1.16]) or sexual abuse (combined OR = 1.25, 95% CI [0.88, 1.78]). These data suggest that orphans are not systematically at higher risk of experiencing physical or sexual abuse compared to non-orphans in sub-Saharan Africa. However, because of inconsistent quality of data and reporting, these findings should be interpreted with caution. Several recommendations are made for improving data quality and reporting consistency on this important issue

Early Childhood Development in Children Born to HIV-Infected Mothers: Perspectives From Kenyan Clinical Providers and Caregivers

Objective. To understand the perspectives of clinical providers and caregivers regarding early childhood development (ECD) in children born to HIV-infected mothers in Kenya. Methods. This was a qualitative study of provider and caregiver perspectives on ECD at 5 Kenyan HIV clinics, using semistructured interviews and focus group discussions. Constant comparison and triangulation methods were employed to elucidate the concepts of ECD. Results. Twenty-five providers and 67 caregivers participated. While providers understood ECD in terms of milestones, caregivers strongly equated ECD with physical growth. Factors affecting ECD, such as nutrition, perinatal effects, and illness, were perceived differently by providers and caregivers. Both groups generally believed that HIV-infected children would have typical ECD if adherent to their HIV treatment. Conclusions. Important considerations regarding ECD in this population were uncovered. Understanding provider and caregiver perspectives’ on ECD in HIV-exposed children is critical for promoting ECD in this community

Impact of the Kenya post-election crisis on clinic attendance and medication adherence for HIV-infected children in western Kenya

<p>Abstract</p> <p>Background</p> <p>Kenya experienced a political and humanitarian crisis following presidential elections on 27 December 2007. Over 1,200 people were killed and 300,000 displaced, with disproportionate violence in western Kenya. We sought to describe the immediate impact of this conflict on return to clinic and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya.</p> <p>Methods</p> <p>We conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. Eligible patients were HIV-infected children, less than 14 years of age, seen in the AMPATH HIV clinic system between 26 October 2007 and 25 December 2007. We extracted demographic and clinical data, generating descriptive statistics for pre- and post-conflict antiretroviral therapy (ART) adherence and post-election return to clinic for this cohort. ART adherence was derived from caregiver-report of taking all ART doses in past 7 days. We used multivariable logistic regression to assess factors associated with not returning to clinic. Interview dialogue from was analyzed using constant comparison, progressive coding and triangulation.</p> <p>Results</p> <p>Between 26 October 2007 and 25 December 2007, 2,585 HIV-infected children (including 1,642 on ART) were seen. During 26 December 2007 to 15 April 2008, 93% (N = 2,398) returned to care. At their first visit after the election, 95% of children on ART (N = 1,408) reported perfect ART adherence, a significant drop from 98% pre-election (p < 0.001). Children on ART were significantly more likely to return to clinic than those not on ART. Members of tribes targeted by violence and members of minority tribes were less likely to return. In qualitative analysis of 9 key informant interviews, prominent barriers to return to clinic and adherence included concerns for personal safety, shortages of resources, hanging priorities, and hopelessness.</p> <p>Conclusion</p> <p>During a period of humanitarian crisis, the vulnerable, HIV-infected pediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique program strengths may have minimized these disruptions.</p

Assessment of the face validity of two pain scales in Kenya: a validation study using cognitive interviewing

Background: Patients in sub-Saharan Africa commonly experience pain, which often is un-assessed and undertreated. One hindrance to routine pain assessment in these settings is the lack of a single-item pain rating scale validated for the particular context. The goal of this study was to examine the face validity and cultural acceptability of two single-item pain scales, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), in a population of patients on the medical, surgical, and pediatric wards of Moi Teaching and Referral Hospital in Kenya. Methods: Swahili versions of the NRS and FPS-R were developed by standard translation and back-translation. Cognitive interviews were performed with 15 patients at Moi Teaching and Referral Hospital in Eldoret, Kenya. Interview transcripts were analyzed on a question-by-question basis to identify major themes revealed through the cognitive interviewing process and to uncover any significant problems participants encountered with understanding and using the pain scales. Results: Cognitive interview analysis demonstrated that participants had good comprehension of both the NRS and the FPS-R and showed rational decision-making processes in choosing their responses. Participants felt that both scales were easy to use. The FPS-R was preferred almost unanimously to the NRS. Conclusions: The face validity and acceptability of the Swahili versions of the NRS and FPS-R has been demonstrated for use in Kenyan patients. The broader application of these scales should be evaluated and may benefit patients who currently suffer from pain

Specific Image Characteristics Influence Attitudes about Chimpanzee Conservation and Use as Pets

Chimpanzees are endangered in their native Africa but in the United States, they are housed not only in zoos and research centers but owned privately as pets and performers. In 2008, survey data revealed that the public is less likely to think that chimpanzees are endangered compared to other great apes, and that this is likely the result of media misportrayals in movies, television and advertisements. Here, we use an experimental survey paradigm with composite images of chimpanzees to determine the effects of specific image characteristics. We found that those viewing a photograph of a chimpanzee with a human standing nearby were 35.5% more likely to consider wild populations to be stable/healthy compared to those seeing the exact same picture without a human. Likewise, the presence of a human in the photograph increases the likelihood that they consider chimpanzees as appealing as a pet. We also found that respondents seeing images in which chimpanzees are shown in typically human settings (such as an office space) were more likely to perceive wild populations as being stable and healthy compared to those seeing chimpanzees in other contexts. These findings shed light on the way that media portrayals of chimpanzees influence public attitudes about this important and endangered species

Characteristics of HIV-infected children seen in Western Kenya

Objectives: To describe the characteristics and outcomes of children registered for care in a large HIV care programme in Western Kenya. Design: A retrospective descriptive study. Setting: USAID-AMPATH HIV clinics in health centres; district and sub-district hospitals; Moi Teaching and Referral Hospital in Western Kenya. Subjects: HIV-infected children below age of 15 years seen in a network of 18 clinics in Western Kenya. Interventions: Paediatric HIV diagnosis and care including treatment and prevention of opportunistic infections and provision of combination antiretroviral therapy (CART). Main outcome measures: Diagnosis, clinical stage and immune status at enrollment and follow-up; hospitalisation and death. Descriptive statistical analyses and chi square tests were performed. Results: Four thousand and seventeen HIV-infected children seen between June 2002 and April 2008. Median age at enrollment was four years (0-14.2 years), 51% girls, 25% paternal orphans, 10% total orphans and 13% maternal orphans. At enrollment, 25% had weight-for-Age Z scores (WAZ)\u3e -1 and 21% had WAZ scores \u3c 3. Orphaned children had worse WAZ scores (p=0.0001). Twenty five per cent of children were classified as WHO clinical stage 3 and 4, 56% were WHO clinical stages 1 and 2 with 19% missing clinical staging at enrollment. Cough (25%), gastroenteritis (21%), fever (15%), pneumonia (10%) were the commonest presenting features. Twenty six per cent had been diagnosed with tuberculosis and only 25% started on cotrimoxazole preventive therapy (CPT). Median CD4% at enrollment was 16% (0-64%); latest recorded values were 22% (0-64). Sixty four per cent were on cART (cART+), median age at start was 5.4 (014.4 years).The median initial CD4% among cART+ was 13 (0-62) compared to 24 (0-64) for those not on ART (cART-). Median CD4% for cART+ improved to 22% (0-59); whereas cART- was 23% (0- 64) at last appointment. During the period of follow-up, one fifth (19%) of children on cART were lost to follow-up compared to slightly over one third (37%) for those not on cART. Thirty four percent were hospitalised; 41% diagnosed with pneumonia. Six per cent of 4017 were confirmed dead. Conclusions: HIV -infected children were enrolled in care early in childhood. Orphanhood was prevalent in these children as were gastroenteritis, fever, pneumonia and advanced immuno-suppression. Orphans were more likely to be severely malnourished. Only a quarter of children were put on cotrimoxazole preventive therapy. Children commenced on cART late but responded well to treatment. Loss to follow-up was less prevalent among those on cART

Morbidity and mortality in HIV - infected children admitted at Moi Teaching and Referral Hospital in Western Kenya

Background: HIV-infected children are at higher risk of opportunistic infections that could result in hospitalisation. The outcomes of hospitalisation are variable and depend on the admission diagnosis, the patients’ immune status and whether or not the patient is on anti-retroviral drugs.Objective: To describe the characteristics and causes of hospitalisation and mortality for HIV infected children admitted to Moi Teaching and Referral hospital in western Kenya.Design: a retrospective study of prospectively collected data.Setting: The paediatric wards of Moi Teaching and Referral Hospital (MTRH). A Kenyan National Referral Hospital.Subjects: HIV-infected children admitted the paediatric wards.Interventions: Treatment with combination anti-retroviral therapy (cART), treatment of common opportunistic infections.Main outcome measures: Demographic and clinical data, including diagnosis, immune status, and treatment with combination anti-retroviral therapy (cART), were extracted from hospital admission records of HIV-infected children registered with the USAIDAcademic Model Providing Access to Healthcare (AMPATH) partnership. We conducted descriptive statistical analyses and used chi-square and fisher’s exact tests to assess for associations between categorical variables and each of the independent variables.Results: Between December 2006 and May 2009, 396 HIV-infected children were admitted to MTRH. Median age at admission was 2.0 years (range 0-15); 236 (59%) were male; 36 (15%) of available 236 orphan status entries were orphaned; 198 (73%) were in CDC categories B and C and 61 (16%) of available 386 had been on ART. Among 108 patients with documented immunologic status, the mean CD4 cell percentage was 16% (SD 10.8). Among the 396 children, 104 (15%) were diagnosed with pneumonia, 92 (14%) with gastroenteritis, 36 (9%) with tuberculosis and 37 (9%) with malaria. Deaths occurred in 28(7%) of the patients. The median duration of hospitalisation was seven days (range 1- 516) for discharged patients and six days (range 0-72) for those who died. A significantly higher percentage of the children who were not previously enrolled in AMPATH died, signifying 14 (15%) mortality among this population of admitted patients, p = 0.0017. Of those who died, (17%) were diagnosed with pneumonia and 22 (79%) of them were not on cART.Conclusion: The common diagnoses at hospitalisation included pneumonia, gastroenteritis, malaria and tuberculosis. Higher mortality occurred among those diagnosed with pneumonia and those not previously enrolled in the HIV care programme. Aggressive treatment and prevention of the most prevalent diseases and early enrollment into HIV care are recommended for HIV-infected children. A follow-up study to investigate the pathological causes of death in this population is recommended