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Rapid appraisal of primary level health care services for HIV-positive children at public sector clinics in South Africa For more information on the research, contact either of the principal researchers: ACKNOWLEDGEMENTS
The assistance of the following persons and Institutions is acknowledged: § Health Systems Trust for funding and input on the research methodology and § Angela Rate & Erica Hawkridge for conducting the interviews § Maylene Shungking, Andy Dawes and Marian Jacobs for editing § District Health Information Systems for information on the clinics Special thanks to the participants of the study who took time out of CONTENTS
Administration of cotrimoxazole as a prophylaxis Nutritional supplementation through the PEM Scheme Accessing social assistance grants Knowledge and use of the DOH Guidelines Administration of cotrimoxazole as a prophylaxis Nutritional supplementation through the PEM Scheme Accessing social assistance grants Availability, knowledge and use of DOH guidelines LIST OF TABLES
Table 1: HIV/AIDS and health indicators in South Africa .9 Table 2: Vitamin A deficiency in pre-school children. 11 Table 3: Estimated TB and HIV co-infection (2000) . 12 Table 4: Stunting in children (1998). 12 Table 6: Breakdown of the sample by province . 15 Table 7: Information used to treat HIV+ children at clinics . 17 Table 8: Assistance offered by clinic staff to caregivers in need of social security grants arranged by rural / urban client base . 26 LIST OF FIGURES
Figure 1: Breakdown of sample by client base . 16 Figure 2 Rural / urban nature of SA population17. 16 Figure 3 Proportion of clinics per province with knowledge of the DOH guidelines and that have a copy of the guidelines. . 16 Figure 4: Information used to treat HIV+ children by rural / urban client base. 18 Figure 5: Administration of cotrimoxazole nationally . 18 Figure 6: proportion of clinics within each province administering cotrimoxazole as Figure 7: Administration of cotrimoxazole by rural / urban client base . 19 Figure 8: Administration of cotrimoxazole in clinics which use the DOH guidelines Figure 9: Proportion of clinics per province that administer vitamin A to HIV+ children.
Figure 10: Proportion of clinics that administer Vitamin A to HIV+ children, by rural / Figure 11: Clinic follow up offered to TB contacts. . 22 Figure 12: Proportion of clinics in each province that administered TB prophylaxis to Figure 13: Criteria for inclusion of HIV+ children on the PEM scheme . 23 Figure 14: Proportion of clinics by province that include HIV+ children on the PEM Figure 15: Proportion of clinics that offer a PEM scheme to HIV+ children by rural / Figure 16: Assistance offered with accessing social security grants . 25 ACRONYMS AND ABBREVIATIONS
Integrated Management of Childhood Illnesses South African Vitamin A Consultative group 1. EXECUTIVE SUMMARY

South Africa has a large and growing number of HIV-infected children. While no
policy exists to provide anti retroviral therapy to these children, several other effective
health and social interventions are available which have been shown to improve life
expectancy and quality of life in HIV-infected children. This study was undertaken to
ascertain the extent to which some of these interventions are currently available to
children attending public sector clinics in all 9 provinces of South Africa. The
research was conducted as a rapid appraisal of services and information was
collected through brief telephonic interviews with clinic managers at 11% of the public
sector clinics in South Africa.
The study looked at whether the following five interventions were available:
1. Cotrimoxazole as a prophylaxis to prevent pneumocystis carinii pneumonia (PCP)
2. Vitamin A supplementation 3. Tuberculosis (TB) contact tracing for children 4. Nutritional supplementation through the Protein Energy Malnutrition (PEM) 5. Social assistance grants Several policies and guidelines exist which provide health staff with information on the administration of one or more of these interventions. A set of comprehensive guidelines entitled “Managing HIV in Children” was released by the National Department of Health in March 2000. This booklet was intended as a guide for primary health care staff. This study also looked at the extent to which these guidelines were available to clinics and used by health care staff. The results indicate that the guidelines are not widely accessible but that they are urgently required. Only 20% of the clinics had knowledge of the guidelines. Over 30% of the clinics reported that HIV-positive children are referred elsewhere for treatment. It was not clear from the study whether this included long-term management. Only one third of the clinics had a policy in place for the administration of prophylactic cotrimoxazole to HIV-infected children and most of these clinics were prescribing the drug incorrectly. Clinics were also found to be administering cotrimoxazole inappropriately as a treatment. Nationally, 35% of the clinics reported administering vitamin A to HIV-positive children. The administration of both vitamin A and cotrimoxazole was impeded by their availability at clinics. Most of the clinics reported some system for following up on child contacts of adult cases of TB. 57% of the clinics reported administering prophylatic TB treatment for child contacts as part of their contact tracing. Of the clinics that provided details on the specific prophylatic agent used, only 19% were providing the correct regimen according to the National TB Control Programme recommendations. The majority of the clinics (75%) reported that HIV-positive children were included on the clinic’s PEM scheme. 53% of these clinics reported however that the child had to be underweight or malnourished in order to qualify. Irregular supplies of milk formula and PVM porridge were cited as the major problems with the implementation of the scheme. The vast majority of the clinics (73%) reported that they refer clients elsewhere for advice and assistance with accessing a social security grant. The study highlights the need for monitoring and evaluation of the implementation of existing policies/guidelines and for training of primary health care staff on the appropriate management of HIV in children. The results also indicate the need for greater inter-sectoral collaboration and for clear directives on certain interventions for HIV-infected children, such as the inclusion of all HIV-infected children on the PEM scheme. Finally, the regular supply of necessary drugs and supplements are essential for the successful implementation of existing policy and guidelines. 2. INTRODUCTION AND BACKGROUND

South Africa is experiencing one of the fastest growing paediatric HIV/AIDS
epidemics in the world. The latest national HIV and syphilis sero-prevalence survey
of women attending public antenatal clinics found 25% of these women to be HIV+1.
With no comprehensive programme in place to prevent the transmission of HIV from
mother to child, over 100 000 infants are estimated to have been born HIV+ during
the year 20001.
With large numbers of HIV+ children and HIV-infected caregivers, experts predict a
close to doubling of child and infant mortality rates by 2010.2 Table 1 below presents
recent child health indicators and HIV sero prevalence data in pregnant women.
Table 1: HIV/AIDS and health indicators in South Africa indicators
1 National Department of Health, 2000 3 South African Health Review, 2000.
The impact of HIV on health and social services is already being felt with an
increased demand for services, coupled with reduced capacity to provide services as
a result of HIV infection and related stresses among service providers4.
In order to facilitate the improvement of primary level health care services for HIV-
infected children, information is needed on what services are currently available and
what the barriers are, if any, to service delivery. Given the urgency of the situation
and the daily cost to life of failure to provide adequate care, the decision was taken to
collect this information through a rapid appraisal of HIV paediatric services.
3. FOCUS OF THE STUDY

While life-saving anti retroviral therapy remains inaccessible to the majority of South
African’s, several other interventions exist to increase life expectancy and improve
the quality of life of HIV+ children.
A number of policy documents and management guidelines have been drafted which
provide primary level health care workers with guidelines for implementation of the
interventions available to HIV+ children. The most relevant of these is the
Department of Health’s HIV/AIDS policy guidelines entitled “Managing HIV in
children” (hereafter referred to as the “DOH guidelines”). The guidelines were
released in March 2000 and outline the primary interventions currently recommended
for the prevention of opportunistic infections and the management of common clinical
problems in HIV-infected children as well as recommendations for the overall care of
an HIV+ child.
In addition to the DOH guidelines, several other existing national policies / guidelines
are relevant to the issues addressed in this research. These include; the guidelines
for the Integrated Management of Childhood Illnesses, the Integrated Nutrition
Programme (INP) guidelines, the Vitamin A policy guidelines, the National TB Control
Programme Guidelines and Social Assistance legislation. Provincial and local
guidelines and hospital circulars have also been developed in some areas, that
provide health care staff with information on the management of HIV and related
conditions in children.
With the Department of Health’s decision to shift resources towards primary level
facilities5, the bulk of public health care services is delivered through clinics,
community health centres and district hospitals, with preventative, promotive and
curative care for children provided predominantly at the level of the clinic. The rapid
appraisal therefore focuses on the interventions available to HIV+ children at public
sector clinics.
The research focuses on clinical, nutritional and social security interventions for
which various policy guidelines exist and the necessary medication/supplements are
widely available. The results will therefore reflect the extent to which existing policies
are implemented. The research also looks at the extent to which clinics use the DOH
guidelines for managing HIV in children.

The research focuses on 5 interventions, namely:
1. Administration of cotrimoxazole as a prophylaxis to prevent PCP in children
2. Vitamin A supplementation
3. TB contact tracing
4. Nutritional supplementation through the Protein Energy Malnutrition Scheme
5. Social assistance grants
The National HIV/AIDS Directorate has indicated that the results of the rapid
appraisal will be used to inform the Department on priority areas around services for
HIV+ children which need to be addressed as a matter of urgency. It is hoped that
the study will provide a baseline against which further improvements to services can
be measured and the implementation of policy monitored.
3.1 Administration of cotrimoxazole as a prophylaxis

Pneumocystis carinii pneumonia (PCP) is a major cause of morbidity and mortality in
young infants who are HIV positive6. Trimethoprim-sulphamethoxazole
(Cotrimoxazole) prophylaxis prevents PCP as well as other bacterial infections7.
International policy recommends that all HIV- exposed infants be given prophylaxis
from 6 weeks to 4 months of age. If at this stage a Polymerase Chain Reaction
(PCR) test indicates the infant is HIV negative then prophylaxis is stopped. If the
infant is truly infected then prophylaxis is continued until 1 year. Older children should
be given prophylaxis only if their CD4 count falls below 15% or after an episode of
PCP. If CD4 counts are not available (as is the case in most parts of South Africa)
then all symptomatic children over the age of 12 months should be given prophylaxis
for life. Cotrimoxazole can be given daily or 3 times a week on consecutive days
according to weight.

Since PCR tests for HIV are not available in South Africa, the DOH guidelines specify
that all ELISA positive children should be given cotrimoxazole from 4-6 weeks of age
up to 15 months of age (unless it can be proven before this time that the child is not
HIV-infected).
3.2 Vitamin A supplementation

In 1994 the South African Vitamin A Consultative group (SAVACG) conducted a
national survey which highlighted the fact that a third of all children in SA under the
age of 6 years were vitamin A deficient8. The findings of this study are shown in
Table 2.
Table 2: Vitamin A deficiency in pre-school children GAU KZN MPU NP
pre-school
children8
Source: South African Vitamin A Consultative Group, 1994
Vitamin A deficiency is common in HIV infected children. Vitamin A supplementation
in HIV infected children has been associated with reduced morbidity, particularly in
relation to diarrhoeal disease, reduced mortality and improved immune function9 10.
The Nutrition Directorate has approved the Vitamin A Supplementation Policy,
intended to provide Vitamin A capsules to children through the immunisation
schedule. The use of high dose Vitamin A supplementation is seen as a short term
strategy for improving the Vitamin A status of infants and children11.
The DOH Guidelines state that all HIV-infected children should be given Vitamin A
supplements in accordance with the following schedule:
§ < 6 months – 50 000 i.u § 6 to 12 months – 100 000 i.u § > 12 months – 200 000 i.u While the DOH Guidelines provide instructions on dosage and administration of Vitamin A, a number of other guidelines exist which provide the same type of information with varying degrees of similarity. These include the guidelines for the Integrated Management of Childhood Illnesses (IMCI), the Vitamin A deficiency booklet and the Integrated Nutrition Programme (INP).
3.3 TB contact tracing

Tuberculosis is the most common opportunistic infection in HIV infected persons. The
risk of tuberculosis developing in a HIV infected person who has been infected with
Microbacterium Tuberculosis is 10% per year compared to a lifetime risk of 10% in
HIV-negative persons. Chemoprophylaxis of HIV infected persons with a positive skin
test has been shown to be effective in preventing TB.
Table 3: Estimated TB and HIV co-infection (2000) Proportion of EC
GAU KZN MPU NP
expected to
be HIV co-
infected12
Source: Medical Research Council, 2000
HIV infected children who have had household contact with sputum-positive patients
or who are positive tuberculin reactors (mantoux reactions of 4mm or greater) should
be given supervised prophylaxis to prevent them from developing tuberculosis. The
National TB Control Programme recommends that children under the age of 5 years
who are household contacts should receive INH prophylaxis for 6 months.
3.4 Nutritional supplementation through the Protein Energy Malnutrition
The 1998 South African Demographic and Health Survey found that 23% of children (1 to 6 years of age) in South Africa are stunted i.e have evidence of chronic malnutrition. Table 4 shows the breakdown per province. % Stunting in EC
GAU KZN MPU NP
6 years)4
Source: South African Demographic and Health Survey, 1998
Children admitted to hospitals with HIV related illnesses commonly present with
severe malnutrition13 14. Changes in the immune system functioning due to HIV is
very similar to changes in the immune system as a result of malnutrition. Poor
nutritional status in turn hastens disease progression15: In addition to this, HIV/AIDS
compromises the capacity of caregivers and breadwinners to provide the resources
necessary to purchase food and to provide the child with a nutritionally balanced diet.
Both children from HIV affected households and HIV-positive children are therefore
at risk for malnutrition.
The Draft Policy Guidelines for Health Facility Based Nutrition Interventions (2001)
states that all children who fail to grow adequately, especially those below the age of
two years, should be included on the food supplementation programme (the Protein
Energy Malnutrition Scheme - PEM). The scheme targets various vulnerable groups,
including pre-school children, pregnant and lactating women, the chronically ill and
the aged. The scheme distributes food supplements through primary level clinics and
has been in operation since the early 1960’s16.
The DOH Guidelines state that where nutritional supplements are available and
affordable, they should be given to all HIV+ children.
3.5 Accessing social assistance grants

Approximately 60% of children in South Africa live in poverty17 and research
suggests that this number is increasing, at least partly as a result of the HIV/AIDS
pandemic17. Table 5 shows the proportion of children (aged 0 to 5 years) in each province and nationally who live in conditions of poverty. GAU KZN MPU NP
rates (age 0-
5 years)18
Source: IDASA, 2000
In many households, the diagnosis of HIV in a family member has an immediate
socio-economic impact, with a reduction in household income and an increase in
health-related expenditure3. Children who are HIV+ and living in conditions of poverty
are at greater risk of contracting and dying from opportunistic infections and
malnutrition. Poverty alleviation measures are therefore an important component of
the broader strategy to address the impact of HIV/AIDS on children.
The government’s poverty alleviation measures include the allocation of social
assistance in the form of cash grants, to the caregivers of children who qualify. While
there are no special provisions for children infected / affected by HIV/AIDS,
caregivers of these children can access some financial support in the form of the
child support grant, care dependency grant or foster grant. For children younger than
7 years, the most widely accessible of these grants is the child support grant (CSG).
However, lack of knowledge of available grants and numerous administrative
hurdles, make accessing the grants difficult for many caregivers.
Caregivers attending public health sector clinics with their children provide a window
of opportunity for service providers to provide information on the existence of relevant
grants and to advise them on how best to access these grants. The DOH Guidelines
highlight social support as an appropriate intervention, including referrals where
appropriate and assistance with grant applications.
4. AIMS AND OBJECTIVES

The aim of the rapid appraisal is to determine whether recommended interventions
that are known to improve life expectancy and quality of life in HIV-infected children,
are being implemented at public sector clinics around South Africa.
The objectives are:
4.1. To determine whether clinic managers are aware of the DOH Guidelines on
4.2. To determine whether clinics are administering prophylactic cotrimoxazole to HIV+ children according to accepted regimens. 4.3. To determine whether clinics offer Vitamin A supplementation to HIV+ children. 4.4. To determine whether clinics follow up on children living in homes where an 4.5. To determine whether clinics offer nutritional supplements to HIV+ children through the Protein Energy Malnutrition scheme. 4.6. To determine whether clinic staff advise the caregivers of HIV+ children on how to access financial support in the form of social assistance eg. Child Support Grant. 4.7. To determine what, if any, the barriers are to providing the services mentioned 4.8. To make recommendations for improvements to primary level health care services offered to HIV+ children at public sector clinics.
5. METHODOLOGY

5.1 Consent

The researchers obtained the support and consent of the National HIV/AIDS
Directorate within the National Department of Health. Letters were then sent to the
Head of Health in each province, informing them of the research and inviting their
comments. Two of the nine provinces requested further information before granting
permission for the research to be undertaken. Where necessary, permission was
also obtained telephonically or in writing from the relevant District Health Managers.
The research was approved by the Health Sciences Faculty Research and Ethics
Committee of the University of Cape Town.
5.2 Sampling

The study focused on fixed clinics and did not include mobile, satellite or specialized
clinics. A fixed clinic is a facility with its own building / structure, permanent staff and
equipment, and where services are provided on site on most work days19.
Information on clinics was obtained from the District Health Information Systems
software. The list of 3238 clinics that fit the criteria for the study was stratified by
province and then randomly sampled within each province.
The research originally intended to stratify the sample by whether the clinics served
rural or urban populations. It was however not possible to obtain accurate information
for all of the clinics prior to sampling. Clinic managers were therefore asked whether
the majority of the clients that they served lived in rural or urban areas. On the basis
of their responses, the data could be analysed by rural/urban client base.
The final sample of 383 clinics represents each provinces’ proportional share of
clinics and amounts to 11% of clinics nationally (95% confidence level).
Obtaining telephone numbers for clinics was extremely difficult. Less than half the
numbers were available through Telkom and those numbers supplied by Telkom
services were often incorrect. In many instances, the researchers had to make
several calls in order to obtain the correct telephone number for each clinic. Useful
sources of telephone numbers included District Hospitals (which provided telephone
numbers of clinics in their area), Municipalities and other clinics.
In the event of the researchers being unable to contact a clinic in the original sample,
a substitution strategy was developed. The preferred option was to select a clinic
within the same district as the clinic being removed from the sampling frame. If this
was not possible, another clinic within the same province was randomly selected to
replace the clinic that was removed.
The interview schedule was telephonically piloted in 10 clinics in 4 provinces prior to
data collection and the final interview schedule was modified based on feedback from
interviewees and interviewers.
5.3 Data collection

Information was collected through telephonic interviews with clinic managers. Where
clinic managers were unsure of answers to the questions, they consulted with other
staff members in the clinic. On a few occasions, the researcher was referred to
someone other than the clinic manager. After the first 44 interviews, the interview
schedule was pre-coded with the most common responses from interviewees. The
schedule took between 5 and 15 minutes to administer. The interviews were
conducted over a period of 4 months by two researchers.
6. RESULTS

6.1 Sample

Of the original 383 clinics sampled, 105 clinics were replaced using the substitution
strategy. These clinics were replaced for the following reasons:
• The telephone was out of order or the clinic did not have a telephone (101 clinics)
• The clinic no longer existed (3 clinics)
• The clinic provided only specialized services (1 clinic)
11 of the clinics that were interviewed were removed from the sample prior to data
analysis because they:
• Did not serve paediatric patients eg. mine workers clinic (5 clinics)
• Provided only specialized services eg. oncology clinic (5 clinics)
• Refused to answer any questions out of fear of repercussions (1 clinic)
Data analysis was therefore conducted on 372 clinics.
The table below shows the breakdown of the sample by province. The difference
between the number of clinics sampled in each province and the number of clinics
included in data analysis is also shown.
Table 6: Breakdown of the sample by province of clinics included in data analysis Proportion 11.7 12.4 11.5 11.3 (%) of provincial clinics included in data analysis Clinic managers were asked whether the majority of the clients using the clinics’ services lived in rural or urban settings or both (i.e. clients evenly distributed). The figure below shows the breakdown of clinics in the sample. By way of comparison, Figure 4 shows the percentage of the population of South Africa living in urban and rural areas. Figure 1: Breakdown of sample by client base
The clinic sample shows a similar pattern of distribution to the national estimates.
55% of the clinics in the sample served clients living in rural areas, while in South
Africa as a whole, 46% of the population live in rural areas.
6.2 Knowledge and use of the DOH Guidelines

Eighty percent of the clinic managers who were interviewed had no knowledge of the
DOH Guidelines. Of the 20% that had heard of the guidelines, 50% had a copy and
almost all those who had a copy reported using it. In summary therefore, about 10%
of clinics sampled reported using the DOH guidelines. The figure below shows the
proportion of clinics with knowledge of the DOH guidelines that had a copy of the
guidelines in their clinics.
Figure 3 Proportion of clinics per province with knowledge of the DOH guidelines and that have a copy of the guidelines. While the Western Cape had the greatest percentage of clinics with knowledge of the guidelines (39%), the same province had one of the lowest percentages of clinics with copies of the guidelines (6%). The research found very little difference in knowledge of the guidelines between rural and urban clinics. In the absence of guidelines for managing HIV in children, the researchers were interested to know what information was used to inform the treatment of HIV-infected children. Over 30% of clinics reported that HIV+ children were referred to a doctor or hospital as the first line of treatment. Some of these children would then be referred back to the clinic with guidelines for treatment provided by the doctor/hospital. The research did not however determine the proportion of these children who were referred back to the clinics. Fifty percent of the clinics reported that they use other guidelines. These guidelines included guidelines for the management of signs and symptoms, IMCI guidelines, prevention of mother to child transmission (PMTCT) guidelines, the essential drug list protocol, TB guidelines, nutrition guidelines, basic primary health care guidelines, guidelines issued by hospitals eg. Edendale circular and guidelines produced and distributed by district or provincial departments of health. Five percent of the clinics reported that they used the information that they had learnt at workshops to assist them in managing HIV in children. These workshops included in-service training, workshops run by a hospital, departmental workshops and workshops run in association with the PMTCT programmes. Table 7 summarises responses by province and nationally. Table 7: Information used to treat HIV+ children at clinics Figure 4 presents the data from Table 7 divided by rural/urban client base. The pattern of information available is very similar for urban and rural areas, with the most common response in all three categories being that clinic staff make use of other guidelines when treating HIV+ children. Figure 4: Information used to treat HIV+ children by rural / urban client base Use other guidelines including guidelines
6.3 Administration of cotrimoxazole as a prophylaxis

One third (33%) of the clinics reported that they administer cotrimoxazole as a
prophylaxis to HIV+ children. 40% reported not administering cotrimoxazole to HIV+
children at all. 27% of the clinics reported administering cotrimoxazole as a treatment
(see Figure 5).
Figure 5: Administration of cotrimoxazole nationally Figure 6 below breaks these results down by province. Figure 6: proportion of clinics within each province administering cotrimoxazole as prophylaxis, treatment or neither. Data analysis showed that 41% of clinics in urban areas were administering cotrimoxazole as prophylaxis, compared to 29% in rural areas. The figure below shows a breakdown of the results. Figure 7: Administration of cotrimoxazole by rural / urban client base Of the 124 clinics that reported routine use of cotrimoxazole prophylaxis only 5 (4%) specified that the dose was weight related (this is the correct way of administering cotrimoxazole prophylaxis). Most respondents specified a 5ml twice a day dosage (treatment dose), whilst a few indicated that the dose varied according to age. 100 clinics (27%) specified that cotrimoxazole was used as a therapeutic option for children who were ill. The drug was prescribed in 37% of clinics for upper and lower respiratory tract infections, in 30% of clinics for diarrhoea, and occasionally for other conditions such as urinary tract infections. 40% of clinics (149 clinics) reported not giving cotrimoxazole as either a treatment or prophylaxis. The 3 main reasons given by respondents for why cotrimoxazole was not administered are: 1. No guidelines for administering the drug (15%) 2. Don’t have cotrimoxazole (9%) 3. HIV+ children are referred to doctor or hospital (76%) A comparison was done between the administration of cotrimoxazole (as treatment or prophylaxis) in those clinics that use the DOH guidelines and those that do not. Figure 8 shows the findings. Figure 8: Administration of cotrimoxazole in clinics which use the DOH guidelines compared to those which do not. 43% of clinics that use the guidelines administer cotrimoxazole as prophylaxis,
compared with 32% of clinics that do not use the guidelines.
6.4 Vitamin A supplementation

Nationally, 35% of the clinics reported that they routinely administer Vitamin A to
HIV+ children (i.e. according to an age based regimen). The figure below shows the
breakdown by province.
Figure 9: Proportion of clinics per province that administer vitamin A to HIV+ children. 65% of the clinics reported that they did not administer vitamin A to HIV-positive children. From the responses it was clear that the majority of these clinics were not discriminating against HIV-positive children, but were not administering vitamin A to any of the children using their services. Vast differences can be seen between provinces in the proportion of clinics that reported that they administer vitamin A to HIV-positive children. Figure 10: Proportion of clinics that administer Vitamin A to HIV+ children, by rural / urban client base
Of the 130 clinics where vitamin A was dispensed, only 20 (15,4%) clinics prescribed
the appropriate and correct regimen for HIV infected children. In a few cases where
vitamin A was not given to HIV+ children (16 clinics), vitamin A was given to women
in the immediate post-partum period.
6.5 TB contact tracing

Only 11 (3%) clinics reported that they do not do any contact tracing. The most
common reasons for not doing contact tracing were staff shortages (4) and the fact
that the clinic did not have a vehicle (3).
A mechanism for contact tracing for children who were exposed to a case of TB was
reported in the remaining 358 clinics. Contact tracing mechanisms included referrals
for follow up, home visits (by clinic staff, community health worker, health inspector or
volunteers) or asking the TB patient to bring contacts to the clinic.
The type of follow up offered to children exposed to TB varied and the results are
displayed graphically in the figure below (n=365 because 7 of the clinics did not
specify type of follow up).
Figure 11: Clinic follow up offered to TB contacts. Refer to hospital, doctor or TB clinic for follow up Screen adults & children, no prophylaxis given to children Screen adults & children, prophylaxis given to children A total of 207 clinics (57%) reported administering TB prophylaxis to children exposed to TB. Of the 207 clinics that administered TB prophylaxis to children, 154 clinics (74%) reported that child contacts received specific prophylatic agents and 124 (60%) reported correctly that children under 5 years of age should be given prophylaxis. In 70 clinics INH was the prescribed drug. Of these clinics, 36 clinics prescribed INH for 3 months; 30 for 6 months (the correct regimen) and 4 for 4-6 months. In 84 instances rifampicin on its own or in combination with INH was prescribed. The proportion of clinics per province that administered TB prophylaxis to child contacts varied. As can be seen from the figure below, the proportion of clinics that administered TB prophylaxis to child contacts ranged from 88% in Gauteng (n=27) to 33% in the Northern Province (n=49). Figure 12: Proportion of clinics in each province that administered TB prophylaxis to children A comparison was made between the TB contact tracing provided at rural and urban
clinics. 61 urban clinics (73%) reported providing TB prophylaxis to children
compared with 96 rural clinics (47%). 51 rural clinics (25%) reported that they refer
child contacts to a hospital, doctor or TB clinic for follow up. This compares with 13
urban clinics (16%).
6.6 Nutritional supplementation through the Protein Energy Malnutrition
Only 367 clinics provided a response to questions related to the PEM scheme. 276 of these clinics (75%) reported that they included HIV+ children on the PEM scheme. Figure 13: Criteria for inclusion of HIV+ children on the PEM scheme In 47% of the clinics that included HIV+ children on the PEM scheme, a child (within the correct age range) who was HIV+ automatically qualified for the scheme. In the remaining 53% of cases where PEM schemes were available, the HIV+ child had to be underweight / malnourished to qualify. The percentage of clinics providing the PEM scheme to HIV-positive children varied quite substantially between provinces with 100% of clinics in the Northern Cape reportedly administering the scheme, compared with just over 30% of clinics in the Northern Province and Mpumalanga. Figure 14: Proportion of clinics by province that include HIV+ children on the PEM scheme Data analysis showed slight differences between the availability of PEM schemes in rural and urban clinics. Figure 15: Proportion of clinics that offer a PEM scheme to HIV+ children by rural / urban client base Over 90% of the clinics that did not provide HIV+ children with nutritional supplements cited unavailability of the porridge or formula at the clinic as the main reason for not giving it. It can therefore be assumed that these clinics were not providing any children (HIV-infected or not) with supplements through the PEM scheme. Irregular supplies of porridge and formula was also a problem for those clinics that did administer the PEM scheme. Many clinics reported that they often provided advise to caregivers on the importance
of a nutritionally balanced diet for HIV+ children.
6.7 Accessing social assistance grants

In 79 clinics (21%), clinic staff reported that they assisted clients in accessing a grant.
In these cases, either a clinic-based social worker processed a grant application, or
the nursing staff assisted the client in applying for a grant (types of assistance
included making appointments for clients with a social worker, helping the clients to
complete a grant application form or writing a letter of introduction on behalf of the
client).
Figure 16: Assistance offered with accessing social security grants 253 clinics (68%) reported that they referred clients to social workers for grant applications without providing any form of assistance. When asked to provide the interviewer with details on a grant that could be accessed by a caregiver with an HIV+ child, 61 of the interviewees (16%) could not provide details on any of the grants. Table 8 shows the difference between the assistance provided in rural and urban clinics. Table 8: Assistance offered by clinic staff to caregivers in need of social security grants arranged by rural / urban client base Assistance offered
Social worker comes to the clinic to process 8% Staff refer client to an external social worker 19% and assist client in accessing grant Staff refer client to an external social worker 64% and provide no further assistance Staff refer client to someone other than a 7%
In both urban and rural areas, the majority of clinics referred clients to a social worker
outside of the clinic.
7. DISCUSSION

This study was designed to determine the practical implementation of DOH policy
and guidelines for the care and treatment of HIV-positive children at primary level
health care facilities. Data was collected telephonically, through a rapid appraisal.
The research design was selected in order to quickly identify problem areas where
more in-depth assessment is needed.
In most instances clinic managers were willing to talk with the interviewer and many
were even relieved to be able to speak to someone about the problems and
challenges they face. A few were however very reluctant to speak about services for
HIV+ children and one clinic manager went so far as to say: “I am afraid, I am afraid”
and then put the phone down. Health care workers are at the forefront of the
HIV/AIDS pandemic and clinic managers highlighted the need for staff support.
“People are dying like flies” – a comment by one of the clinic managers that
encapsulates the desperation expressed by many of the research participants.
Human resource constraints, irregular supplies of drugs and poor infrastructure were
repeatedly cited as problems that impact on the clinic’s ability to provide the
recommended interventions.
Stigma surrounding HIV/AIDS was also cited as a barrier to service delivery. Clinic
managers reported that parents are reluctant to have their children tested for HIV and
when they know the child’s HIV+ status, are reluctant to share this information with
clinic staff.
7.1 Availability, knowledge and use of DOH guidelines

Many of the clinic managers who were interviewed requested copies of the DOH
guidelines and indicated that they were urgently needed. The rapid appraisal has
highlighted the fact that these guidelines are not widely available at clinics. Between
65 000 and 70 000 copies of the guidelines were originally printed. The responsibility
for distribution to clinics and other health facilities fell with the provincial HIV/AIDS
directorates. The National Department of Health reportedly distributed copies to the
provinces from where the document should have been distributed to clinics. Copies
were also made available on request from the “Beyond Awareness Campaign”, the
company awarded the government tender to distribute health information and
promotional material.
The National Department of Health have indicated that they will be reprinting and
distributing the guidelines. Effective distribution of the guidelines is obviously
dependent on there being a database of health facilities that is maintained and
regularly updated.
Many of the clinics that did not have the DOH guidelines reported using a range of
other guidelines. These guidelines often provide different information for the
treatment of the same condition eg. the DOH guidelines for the administration of
Vitamin A and cotrimoxazole differs slightly from the IMCI guidelines for the
administration of Vitamin A and cotrimoxazole. Apart from the fact that this leads to
confusion, it could also impact on the quality of the treatment received by the child.
Over 30% of the clinics reported that, in the absence of guidelines for the treatment
of HIV+ children, these children were automatically referred to the nearest hospital or
available doctor for assessment and treatment. The research did not ascertain what
proportion of these children were then referred back to the clinic for ongoing care and
support. The referral of children to secondary level facilities for conditions that could
be handled at primary level facilities has implications for service providers and
clients, particularly in rural areas where this pattern was more common and transport
is problematic. Training and support for primary level facility staff could reduce the
rate of referral by building staff capacity and confidence.
It was not possible to determine the extent to which the guidelines were being
appropriately used because of the very small number of clinics that reported using
the guidelines.
7.2 Cotrimoxazole

PCP is the most common opportunistic infection in the first year of life and can be
prevented through prophylaxis with cotrimoxazole. However, only a third of the clinics
sampled had such a policy in place. Even at these clinics the prescribed dosage in
most instances was inappropriate. Only 5 clinics indicated the correct manner of
prescription i.e. a weight dependent dose.
The situation will hopefully improve when the prevention of mother to child
transmission intervention rolls out to all the districts in the country. This programme
allows for the early identification and follow-up of the HIV exposed infant, including
cotrimoxazole prophylaxis from 6 weeks of age.
It is also rather disconcerting to note that 26% of the clinics surveyed were using
cotrimoxazole as a therapeutic option for acute respiratory (ARTI) and
gastrointestinal tract infections. Such a policy is incorrect since most of the
pathogens causing ARTI are generally resistant to cotrimoxazole20 and the current
SA national IMCI guidelines for the management of acute respiratory tract infections
recommend amoxycillin as the first line of treatment. In addition cotrimoxazole is not
recommended for the treatment of gastro-intestinal infections21. Training on the
appropriate use of prophylactic cotrimoxazole and the correct use of antibiotics in
general, is therefore essential.
In the vast majority of clinics that did not administer cotrimoxazole, the reason given
was that the clinic referred all HIV+ children to hospitals. This practice was more
common in rural clinics than in urban clinics, which could be a result of the fact that
urban clinics are more likely to be bettered resourced and have access to staff
training and drug supplies.
7.3 Vitamin A

In 1994 the SAVACG highlighted the problem of vitamin A deficiency in preschool
children8. This national survey indicated that a third of all children under the age of 6
years was vitamin A deficient. SAVACG made a number of recommendations
including guidelines for vitamin A supplementation (VAS). The Department of Health
has developed a VAS policy and distributed a handbook to primary care workers
describing the importance of vitamin A deficiency and highlighting interventive
measures. Vitamin A is also recommended for HIV positive children.
It is disturbing to note that only a third of clinics sampled were aware that Vitamin A
should be prescribed for HIV positive children and that only 20 clinics had knowledge
of the appropriate regimen. One of the major stumbling blocks in implementing the
VAS policy has been the availability of vitamin A capsules and this may account for
the extremely low coverage. While it was not specifically asked, it can be assumed
from the responses that most of the clinics that did not administer Vitamin A to HIV+
children, did not administer Vitamin A to children generally.
Interestingly, unlike with the administration of cotrimoxazole, a greater proportion of
rural clinics than urban clinics reported administering Vitamin A to HIV+ children.
7.4 TB contact tracing

Most of the clinics reported that they had a system for following up child contacts of
adult cases of TB. However, it was not clear from the responses how many of the
clinics actually conducted home visits. Many clinics reported that their contact tracing
involved asking the TB patient to bring contacts to the clinic. The reliability of this
mechanism for contact tracing requires further research, particularly in the case of
households with HIV+ children.
While the majority of the clinics reported that they provided prophylaxis for child
contacts under the age of 5 years, only 30 of them provided the appropriate regimen
of treatment. The provision of TB prophylaxis was more common in urban areas
(73% of clinics) than in rural areas (47% of clinics), whereas referral to hospitals for
follow up was more common in rural than in urban areas. This is similar to the pattern
which emerged in the administration of cotrimoxazole.
The research indicates a pattern, particularly in rural clinics, of clinic staff referring
HIV+ children to hospitals or doctors for treatment. In rural areas, where transport is
expensive and unreliable, the chances are good that a child who is referred to a
hospital many kilometers away may not be able to access the necessary treatment.
PEM scheme

The impact of HIV/AIDS on childhood malnutrition can be observed at many levels.
HIV infection in children compromises their nutritional status and with poor nutritional
status, disease progression is hastened. This creates a vicious cycle that undermines
the health of the infected child4.
It is therefore reassuring to note that the vast majority (75%) of clinics reported that
they included HIV+ children on the clinic’s PEM scheme. However, while the intention
was there, in many instances milk formula and PVM porridge were not available and
mealie meel and beans were commonly used alternatives.
Poor health and increased rates of stunting are common among children living in
HIV-infected households22. Acknowledging the increased vulnerability of these
children, a few clinics reported that they include children on the PEM scheme who
are not HIV+ but who are living with an HIV+ caregiver.
The removal of children from the PEM scheme on the basis of weight gain is
problematic. Children are removed from the scheme when they are no longer
considered to be “at risk”. At present, this is based largely on the child’s weight gain,
with little consideration given to the socio-economic circumstances in which the child
lives. In households affected by HIV or where an AIDS related death has occurred,
the child will remain vulnerable to malnutrition until the socio-economic
circumstances in the household improve. The PEM scheme may be the child’s only
regular source of food and once removed from the scheme, the child is once again
made vulnerable to severe malnutrition.

7.6 Social assistance grants

Almost all of the clinic managers reported that where needed, clinic staff referred
clients to social workers for grant applications. In a few of the clinics, staff also
provided some form of assistance to the client in the application process. However,
1 out of every 6 clinic managers who were interviewed were not able to provide
details on a single grant available to children who were HIV affected.
The clinic environment provides an ideal opportunity for sharing information on social
security and clinic staff should be informed of what is available and kept up to date
on the latest developments with respect to accessing grants. Grant application forms
could be made available at clinics, as well as information on how to apply for a grant
and how to obtain the necessary documents. Collaboration between the Departments
of Health, Social Development and Home Affairs could go a long way towards
improving the take up of the much needed child support grant.
7.7 Recommendations

1. One set of reliable, comprehensive and easy to use guidelines on the
management and treatment of HIV in children needs to be available at primary level health care clinics and should be accompanied by training on the use of the guidelines. 2. Systems need to be in place to monitor, on an ongoing basis, the implementation of interventions such as the Vitamin A supplementation programme and the PEM scheme. 3. Systems for the ordering and management of stocks of pharmaceuticals could be included in the training of clinic managers to reduce the chances of clinics running out of stock of vital medications or supplements. At the same time, district health managers should ensure that basic medications and supplements are available to clinics. 4. Because PCP is preventable, training is needed for health care workers on the appropriate use of prophylactic cotrimoxazole. 5. Management support for health care workers is essential in order to assist them to cope with the additional burdens placed on them as a result of the HIV/AIDS pandemic. 6. The criteria for accessing the PEM scheme need to be reviewed in light of the impact of HIV/AIDS on children. All children at risk, including HIV+ children and children with HIV+ caregivers, should be provided with nutritional supplements through the PEM scheme. The socio-economic conditions in which the child lives should be taken into consideration when considering removing the children from the scheme and the child should not be removed purely on the basis of weight gain. 7. Practical steps could be taken to assist caregivers of HIV+ children to access the financial support that would better enable them to care for their children, such as making grant application forms available at clinics. 8. Infrastructural needs of clinics (including access to telephone and electricity) should be addressed as a matter of priority. 9. An accurate and up to date list of clinic contact details should be available to facilitate research, monitoring and support. 10. There is a need for stigma to be acknowledged as a serious barrier to accessing services and for this issue to be prioritised.
7.8 Further research required

1. Further research is needed to explain the differences in the implementation of
interventions between provinces, between rural and urban areas and even between clinics with similar resources. Such research could draw on the experiences of clinic and district managers where interventions are being successfully implemented. 2. Research is needed to establish the reasons for drug and supplement shortages at clinic level in order for practical steps to be taken to overcome this problem. 3. More research is needed into the reasons why so many clinics reported that they refer HIV+ children to hospital for treatment and on the impact of this practice on the care and treatment of HIV+ children. 4. Research is needed into the reliability of contact TB tracing that relies on the patient bringing household members to the clinic for treatment. This is particularly relevant in households with HIV+ children where stigma and poverty are potential confounding factors. 5. More information is needed on what happens to HIV+ children (or children living with an HIV+ caregiver) when they are removed from the PEM scheme purely on the basis of weight gain. This research could include a comparison between the costs of providing the supplements versus the costs of possible future hospitalisation if the child is removed from the scheme. 6. Research is needed into the health outcomes for children who are able to access the recommended interventions and how their outcomes compare with children who are not able to access the recommended interventions.
8. LIMITATIONS

As indicated earlier, 101 (27%) of the clinics in the original sample were not contactable by telephone. By excluding these clinics from the sample, it is likely that the results that are presented are biased. Clinics without telephones are likely to be less well resourced than clinics with telephones and, had we been able to collect information from these clinics, we expect that the results would have shown a smaller proportion of the clinics were providing the recommended interventions. In many instances, the researcher had to call the same clinic several times in order to make contact with the clinic manager who was not always available. While most of the research participants were happy to be interviewed (some were even grateful to have the opportunity to talk about their problems), many were reluctant and even fearful of answering questions related to HIV. The interviewers reported that many of the participants felt threatened by the questions relating to knowledge of the national guidelines. Once they were assured of the anonymity of the study however, they seemed more relaxed. The interviews were conducted predominantly in English and, while this was not found to be a major problem, the fact that interviews were not conducted in the interviewee’s first language is a limitation of the study. In many instances, the responses given by clinic staff raised issues that required further questioning and clarification. The research was not able to explore each of these issues thoroughly. As a result, the researchers are unable to provide further insight into why certain patterns emerged eg. the referral of HIV+ children to hospital for treatment. The fact that the results were not validated with follow up visits to the clinic is another shortcoming of the study. In a few instances where more than one member of staff from a particular clinic was interviewed, different responses were obtained for the same questions. However, due to the nature of the study (rapid appraisal), the decision was taken that the results would be presented on the basis of the telephonic interviews and that follow up studies could be conducted to look in more detail at each of the issues raised. These studies could include site visits to clinics. 9. CONCLUSION
In summary, the rapid appraisal found that interventions known to improve quality of
life in HIV+ children are not being adequately implemented in clinics around South
Africa. The main reasons for this are lack of training on how to implement
recommendations and sporadic / non-existent supplies of the necessary medication
and supplements.
The Department of Health has made it a priority to support children with HIV infection
and have taken several steps to improve on health sector service delivery in this
regard. It is hoped that this study and its recommendations will assist the Department
in its efforts.


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Source: http://www.ci.org.za/depts/ci/pubs/pdf/health/resrep/rapidapp.pdf