Caregiver's HIV disclosure to children 12 years and under: a review and analysis of the evidence.

A systematic review and analysis of the empirical evidence through June 2010 on HIV disclosure to children 12 and under was conducted using methods validated by the Cochrane group. Fifteen articles focusing on caregiver disclosure (255 total) were analyzed using GradePro 3 software. Results suggest that there is evidence of health and future care planning benefit for HIV+ and healthy children (12 and under) of HIV+ caregivers if the caregiver discloses his/her HIV status to them. Children of the maturity of school age youth (e.g., beginning at 6 years and continuing through 12) can be told of their caregivers' HIV status, while younger children may be informed partially in an age-appropriate manner.

Using a sociological model to analyze access to pediatric HIV/AIDS care in rural sub-Saharan Africa.

The decentralization of pediatric HIV/AIDS-treatment programs to primary health care centers in rural Africa has lagged behind. In order to guide an analysis of current access to care, a sociological conceptual framework was developed. This framework focused on conditions of seeking pediatric HIV care among community members and initiating pediatric HIV care by primary health care workers (PHCWs). The use of the sociological conceptual framework helped in determining basic research questions and current gaps in knowledge (e.g. the effectiveness and long-term impact of Western counseling models in rural African settings), exploring the need for healthcare level specific research and policy (e.g. in infant HIV-testing), identifying potential pitfalls in decentralizing pediatric HIV treatment programs to rural African communities (e.g. lack of self-confidence in HIV counseling among PHCWs). Consequently, the use of the sociological model is helpful in maximizing efforts and resources allocated to such roll-out. A renewed appreciation for primary health care in general, however, remains crucial for a successful decentralization of pediatric HIV/AIDS-treatment programs to rural Africa.

The unique features of pediatric HIV-1 in sub-Saharan Africa.

In order to adapt African programs for antiretroviral treatment (ART) to children's needs, a good understanding of the unique features of pediatric HIV in Africa and realistic expectations of the results of such programs are crucial. We compared pediatric HIV in African settings to pediatric HIV in Western settings and to adult HIV in African settings. As an illustration, we also compared baseline characteristics and ART-outcomes from 15 African pediatric studies, 11 Western pediatric studies and 15 studies of African adults. Several differences in diagnostic, clinical, immunological and virological characteristics were identified, as well as variations in the most influential factors for disease progression and response to ART. Environmental factors may influence disease progression, mortality, loss to follow-up, adherence and the need to adapt the regimen. Many of the responses to ART are two-phased, the first phase taking longer in children than in adults. The selected African pediatric programs recorded a higher increase in median CD4-percent than the selected Western pediatric programs and a higher increase in CD4-count than the selected African adult programs. Compared to the adult programs, the African pediatric programs had lower drop-out rates, higher reported adherence levels and comparable mortality rates. The Western pediatric programs, however, had the lowest mortality rates. While several challenges complicate comparisons between ART-programs, increased knowledge of the unique features of pediatric HIV in Africa may greatly assist in improving pediatric HIV care on a global level.

HIV disclosure and discussions about grief with Shona children: a comparison between health care workers and community members in Eastern Zimbabwe.

Research in HIV-related counseling for African children has concentrated on urban tertiary hospitals, but most children have their first health care encounter at a rural primary health care center. This study investigated perceptions about the acceptability of disclosing the parents' or child's HIV status to a child and talking about grief with children, as well as the preferred time, type and setting for HIV disclosure. An anonymous survey was taken from 64 primary health care workers and 131 community members from rural Eastern Zimbabwe. The results expressed a high need and desire for such communications and should be interpreted against a background of high perceived confidence to talk about grief with adults and a high degree of familiarity with child bereavement and foster care. The participants preferred that partial disclosure occurs from the age of 10.8 (+/-4.2) years and full disclosure from the age of 14.4 (+/-4.5) years. Compared to community members, health care workers were significantly more open to full disclosure and disclosure at a younger age but were slightly less open to discussing grief. The different preferred combinations of persons to initiate such communications included a health care worker in up to 56% of the responses and a family member in up to 52%. The most commonly preferred family members were father's sister (up to 37%) and grandmother (up to 40%) rather than the partner (up to 15%). Southern African family dynamics may hinder a mother initiating HIV disclosure and discussions about grief, even though she is traditionally present during HIV diagnosis, counseling and health education. A more culturally adapted approach than the standard Western 'couple approach' may thus be required. Consequently, counseling training models may need to be adapted. Further research into empowering mothers to involve significant members from the extended family may be highly beneficial.

Access to occupational postexposure prophylaxis for primary health care workers in rural Africa: a cross-sectional study.

BACKGROUND: For many primary health care workers in developing countries, the limited availability and cost of public transport hinders timely access to occupational postexposure prophylaxis (PEP) at referral hospitals. Adapted PEP training and a starter's kit (for human immunodeficiency virus, hepatitis B virus, and syphilis prophylaxis) could improve access. METHODS: The evaluation method, based on the 12 steps of the decentralized phase of PEP management, calculated different scores from the responses for 51 anonymous surveys and allowed comparison among different groups. Listed obstacles and clinic visits provided further information. RESULTS: Respondents who received in-service PEP training had significantly higher mean knowledge and confidence scores but no different mean attitude scores than those who did not. The mean total score for those who received the adapted PEP training (10.7 of 12) was significantly higher (P = .008) than for those who did not (8.8 of 12). CONCLUSION: Decentralizing the first phase of PEP management for primary health care workers in rural Zimbabwe attends to an unmet need. The evaluation facilitates checking completeness of course contents, stresses the need to pay equal attention to attitudes toward the referral and reporting system, and identifies specific challenges for delivering PEP in rural settings. The finding may inspire to improve access to PEP for other health care workers and phlebotomists employed in remote areas.

Care and treatment of HIV-infected children in Africa: issues and challenges at the district hospital level.

More than 90% of pediatric HIV infection occurs in sub-Saharan Africa and 75% of these children currently die before their fifth birthday. Most HIV-infected children in Africa rely on district hospitals for HIV treatment, but insufficient attention has been paid to improving HIV/AIDS care at this level. Considerable confusion exists about optimal use of combination antiretroviral treatment, prophylaxis for opportunistic infections and other rational healthcare interventions that can greatly improve the quality of life for these children. A simple and inexpensive infant HIV diagnostic assay and alternative laboratory markers of pediatric HIV disease progression would be highly beneficial. Routine anthropometric and neurodevelopmental assessments could help guide initiation and monitoring of antiretroviral therapy. Even in the absence of antiretroviral therapy, interventions such as immunizations, provision of micronutrients and nutrition counseling, prevention and treatment of opportunistic as well as endemic infections (such as helminths and malaria) can substantially reduce pediatric HIV-related morbidity and mortality. The need for pain relief, palliative care, counseling and emotional support is often underestimated. Surmounting the sense of hopelessness by providing district healthcare workers with training in basic pediatric HIV/AIDS care is an urgent priority.