Doctoral Degrees (Paediatrics and Child Health)

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Browsing Doctoral Degrees (Paediatrics and Child Health) by Subject "Antenatal care -- South Africa"

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    Improving the care of HIV-infected and -affected children during the implementation phase of the large-scale antiretroviral therapy programme in South Africa
    (Stellenbosch : Stellenbosch University, 2015-12) Feucht, Ute Dagmar; Kruger, Mariana; Forsyth, Brian; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Human immunodeficiency virus (HIV)-infection poses a major threat to childhood health and survival. The aim of this research was to evaluate the Prevention of Mother-to-Child Transmission (PMTCT) and paediatric HIV programmes as new child health interventions with the long term goal of improvement if necessary. The research was conducted at Kalafong Hospital, Gauteng Province in South Africa. PMTCT has become a successful childhood HIV prevention strategy in South Africa. We conducted a mixed-methods study using clinical data review and structured caregiver interviews to determine the missed implementation opportunities. PMTCT cascade analysis of 201 children demonstrated improvements in known maternal HIV-diagnosis, mother-infant antiretroviral interventions and infant HIV diagnosis. Gaps identified included a lack of preconception HIV-services, tuberculosis screening and psychosocial support, while infant feeding messaging worsened over time. The need to optimise the implementation of the entire PMTCT cascade is highlighted in order to reach paediatric HIV elimination. Accurate HIV diagnosis is the next crucial step in the children’s care pathway. We reviewed diagnostic tests in children referred for antiretroviral therapy (ART) and assessed predictive values of HIV virological tests. Analysis of 1,526 records revealed 51 HIV-uninfected children (3.3%) referred for ART, with 6.3% false-positive HIV virological tests in children below 18 months. We calculated positive predictive values of HIV virological tests and demonstrated the exponential increase in false-positive test results with declining HIV transmission rates. The need for robust diagnostic algorithms and meticulous confirmation of HIV status before ART initiation was proven. Barriers to HIV-care were subsequently studied. In 250 children, presenting for care five years after establishment of the ART-services, advanced/severe disease was common (82%), with referrals mostly from hospital inpatient services (61%). Caregiver interviews revealed good access to routine healthcare, but gaps included maternal psychosocial support, early infant diagnosis and testing at primary healthcare. One-third of children had prior HIV-diagnoses, with caregivers failing to attend ART-services, which requires further investigation. Additionally a pro-active strategy on paediatric HIV case finding at primary healthcare is required. Emerging HIV drug resistance threatens continued ART programme efficacy. We analysed clinical and drug resistance data of children failing protease inhibitor(PI)-based ART. Of children on PI-based ART-regimens, 43% received ritonavir as single-PI (RTV-sPI), mainly due to concomitant tuberculosis treatment. One-third had virological failure (RTV-sPI group), with a high prevalence of major PI- and multiclass mutations on genotyping. In children failing any PI-regimen, PI mutations were associated with timing of tuberculosis treatment and resultant ART-regimen choice. We assessed growth in children on ART due to the increasing importance of long-term health outcomes in HIV-children. The 159 children demonstrated rapid initial weight gain within the first year of ART initiation, with older age, tuberculosis and lack of electricity negatively affecting weight gain, while height improvement was delayed and negatively affected by tuberculosis co-infection. The importance of monitoring growth outcomes is discussed, as well as the need to determine the best nutritional interventions when poor growth is detected. Long-term outcomes in HIV-exposed-but-uninfected (HEU) children are equally important, since so many infants are born to HIV-infected mothers in South Africa. We studied growth in a prospective, longitudinal cohort showing consistently worse growth outcomes in HEU-children compared to HIV-unexposed children. Exposure to tenofovir-containing combination ART was particularly associated with lower weight and length gain over time for the HEU children. Maternal ART-duration significantly affected length, especially with first trimester-exposure versus later in pregnancy. This important finding highlights the need to carefully assess the outcomes of children born to mothers who are on ART during conception and pregnancy in order to balance the risks and benefits of these interventions in preventing paediatric HIV infection, but ensuring optimal child health. The PMTCT and paediatric HIV programmes have been successful in improving outcomes for HIV-infected and HIV-affected children. However, continued clinical governance is critical to ensure access to care and excellence in service provision within the clinical practice setting. Operational research is crucial to determine which aspects of the HIV care pathway need improvements or interventions.