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Treating children living with HIV – a doctor’s perspective

As any parent knows, it can be difficult to give medicine to infants and young children. Even for the most mundane illnesses, parents worry about having the most easy-to-take meds for their kids. But for HIV-positive children and their caretakers in Zambia, it wasn’t just difficult to dose – until recently it often meant the difference between life and death.

"There were few options for HIV-positive children before 2006," says Dr. Mutinta Nalubamba, a paediatric specialist who worked at the Zambian Ministry of Health. "It wasn’t a pretty picture – we were cutting adult pills in half. It was quite distressing for us clinicians."

Only a few years ago, it was costly and complicated to treat HIV-positive children in Zambia. The few paediatric formulations available were expensive and foul-tasting syrups that required refrigeration – in a country where many homes still lack a refrigerator.

Dr. Mwiya Mwiya, today the Clinical Director at the University Teaching Hospital Paediatric Centre of Excellence in Lusaka, remembers that his staff would use clay pots or sand pits so patients could store the drugs at home. "We felt hopeless as physicians because there was nothing one could do at the time," he says. "We saw a lot of children dying when they shouldn’t have been dying."

"In 2005 we felt hopeless as physicians because kids were left behind. By 2007 we saw a drastic reduction of children admitted with HIV-related illnesses. In 2011, it was clear how far we advanced, with proper formulations and tests for children. Now we know we can make a difference."

In 2006, UNITAID and CHAI began operations in Zambia to create a market for paediatric HIV care. By working with the Ministry of Health, CHAI’s in-country team helped to train paediatricians, health workers and clinicians throughout the country on the special care needed to treat HIV-positive children. National guidelines on treatment were drawn up with CHAI’s assistance.

Crispin Moyo is the National Coordinator for antiretroviral treatment at the Ministry of Health. "When UNITAID and CHAI came on board, we managed to expand our formulas to include paediatric formulations, basically similar to what adults had," he says. "We didn’t know what the demand was for these products in Zambia. With the help of these partners we were able to bring in a lot of stock to deal with any eventuality."Dr Mwiya Mwiya

Child-friendly fixed-dose combinations (FDCs) were introduced in the country in 2008, replacing burdensome syrups. But uptake was slow and the market remained fragmented with 20 different paediatric drugs available. Only two of these were fixed-dose combinations. In 2010, CHAI worked with the Ministry of Health to gain buy-in for these formulations, advocating for new guidelines and developing training materials.

One innovation used by CHAI was the 'dosing wheel' (see photo of Dr. Mwiya Mwiya). This easy-to-use devise helped clinicians figure out how much medicine to give based on a child’s weight.

"For paediatric care we needed to make the parents comfortable and create interest for fixed-dose combinations," says Dr. Moyo. "Many people in HIV clinics had no experience with children so we had to sensitize clinicians. It was thought that HIV medication had horrible toxic side effects for children – working with a few children we were able to demonstrate that this wasn’t the case."

 

By 2011, eight drugs were used in Zambia and five were fixed-dose combinations. Uptake has been exceptional. At the end of 2006, only 7000 kids in Zambia were on treatment. Today, over 27 000 are on treatment thanks to UNITAID funding.Paediatric patients receiving FDCs in Zambia Source: CHAI 2011

Dr. Mwiya Mwiya told the story of one of these children:

"I had one child born with HIV. She was about five and she almost died. We started treatment, but around 2007 it was clear that her family couldn’t store the drugs. We put her on fixed-dose combinations when they were made available - we soon saw the opportunistic infections she was suffering from disappear.

Today she is healthy. Initially the parents were so discouraged that they didn’t want another child. After their child was saved, they came to me and said they wanted another baby. We discussed prevention of mother to child transmission, they followed my advice and fortunately the mother delivered an HIV-negative baby boy."

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