Bottlenecks still hindering children's treatment and prevention

Hard work and creative solutions, not magic bullets, are needed if South Africa is to achieve its targets to treat children infected by the virus, delegates heard ahead of the third national AIDS conference, which kicked off on Tuesday in the port city of Durban.

While paediatric AIDS has been virtually eliminated in developed countries, HIV-related illnesses accounted for about one third of the country's under-five deaths in 2000, according to Dr Debbie Bradshaw of South Africa's Medical Research Council.

Determining how many children die as an indirect result of HIV is more difficult, but Prof. Nigel Rollins of the University of KwaZulu Natal said when a mother dies because she failed to access life-prolonging antiretroviral treatment (ART), all of her children were at an increased risk of death.

South Africa is one of only nine countries in the world where child mortality is increasing, he added.

Rollins warned that to achieve the ambitious prevention and treatment goals contained in the recently launched National Strategic Plan for HIV and AIDS, South Africa's ailing prevention of mother-to-child transmission (MTCT) programme would have to be improved.

Some of the weaknesses of the programme include its lack of integration into regular antenatal and postnatal services; lack of monitoring and evaluation; uneven uptake and delivery across the country; and the failure to identify HIV-positive pregnant women and to put them on treatment to improve their CD4 cell counts and reduce their chances of passing the virus to their babies.

The National Strategic Plan's target of reducing MTCT to less than 5 percent also required a switch from the current single dose of the nevirapine regimen for HIV-positive pregnant women, to a six week course of two ARV drugs, Rollins said.

When prevention efforts fail, the next task is to identify HIV-infected children and ensure their survival. No easy task, when basic health care for children in South Africa was failing so many, according to Dr Harry Moultrie, a paediatric ART specialist. He blamed inadequacies in the health care system largely on the country's severe health care worker shortage which has left 36 percent of primary health care posts vacant.

About 25,000 children are currently accessing ART in South Africa, only about a third of those who need it, UNICEF has found.

Huge inequities between different provinces in terms of paediatric ART, remain a major challenge. A child living in the Western Cape had a 14 fold better chance of accessing ART than a child living in Mpumalanga, Moultrie told conference delegates.

"The National Strategic Plan targets are great," he said, "but we need to translate them into district and facility level targets."

Moultrie recommended waiving confidentiality considerations and recording a mother's HIV status on her antenatal records. He also urged health facilities to test children at every opportunity and to screen all children for HIV during their 6-week immunisation visit.

For the growing number of HIV-infected children who, through ART, are now entering adolescence and becoming sexually active, Moultrie
identified the need to start targeting them with "positive prevention" programmes.

In both of their presentations, Rollins and Moultrie emphasised the need to shift from focusing exclusively on HIV to focusing on child survival and well-being more generally.

For more on the South African AIDS Conference: www.sa-aidsconference.com

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