State-of-the-art treatment centre but children still die

Fidgeting in a small, plastic chair outside her grandmother's house in Ha Makhoathi, a village near Maseru capital of Lesotho, Limpho Matthews, 7, looks like an ordinary, healthy child. In fact, the first six years of her life consisted of a miserable series of colds, asthma and other illnesses. By the time her mother died in 2005, she was too weak to walk and had to be carried on her grandmother's back.

"Doctors were saying, 'it's just a common cold'," said her grandmother, Manthabiseng Matthews. "I was running up and down, trying to get help."

Help finally arrived when a Lesotho Red Cross care facilitator gave Matthews transport money to take her granddaughter to the newly opened Baylor Children's Centre of Excellence in Maseru.

The centre, one of seven that the Baylor International Paediatric AIDS Initiative (BIPAI) has established in Africa since 2003, is a gleaming, state-of-the-art facility which shows what can be achieved when foreign expertise and resources combine with government commitment.

Before it opened on World AIDS Day in 2005, there were only two paediatricians practicing in Lesotho and less than 20 children accessing life-prolonging antiretroviral (ARV) treatment. The centre was set up with funding from pharmaceutical company Bristol-Myers Squibb, technical expertise from BIPAI and an annual budget from Lesotho's health and social welfare department.

It provides free HIV treatment to children and testing for both children and adults. Limpho is now one of 344 children receiving ART at the Baylor Centre, a figure that represents 30 percent of the children accessing treatment nationally.

To put this achievement in context, one need only take a tour of the centre's spacious building with its pleasant waiting area and 12 consultation rooms, where 13 doctors, 10 of whom are on loan from the US, a nutritionist, a pharmacist, a team of nurses and four social workers comfortably handle its 90 patients per day.

The contrast between this facility and many of Africa's public health facilities, with run-down buildings, cramped examination rooms, aging equipment and over-worked staff, is overwhelming.

Now her grandmother's main chore is persuading Limpho to break off her after-school games with her friends so she can take her daily medication. "If it weren't for Baylor, she wouldn't be here," said Matthews. "With proper medication, I think she'll survive and grow up."

UNEVEN COVERAGE

Of the 18,000 children UNAIDS estimates are living with HIV in Lesotho, only 6.3 percent are accessing ARV treatment; that Limpho is one of them is largely because she lives close to Maseru. Had she been born in one of Lesotho's many remote, mountain communities, where even basic healthcare is hard to come by, let alone something as complex as paediatric HIV treatment, it is unlikely she would have survived.

Matumelo Rapita, 29, who lives in the mountainous region of Mapholaneng, separated from the nearest major town by 200km of twisting roads, buried her 6-month-old son last week. The nearest hospital is 25km away in Mokhotlong, but it lacks the technology to test children under 18 months for HIV, or even to do a CD4 count test to measure the strength of the immune system.

The wife of a shepherd who works away from home for six months at a time, Rapita had heard of HIV before she tested positive about a month ago, but did not know how it was transmitted, or that it could be treated.

Soon after the baby was born, he developed a rash, as well as a persistent cough and a case of oral thrush so severe he was unable to breastfeed. A private doctor gave her medicine that did not help and by the time she took the child to the Red Cross clinic in Mapholaneng, he weighed just 3.9kg. A counsellor there advised Rapita to test for HIV.

"I only agreed to test because my child was ill, but I accepted it [her HIV-positive status] and I was looking forward to getting help," she told PlusNews, speaking through a translator.

The help Rapita received was too little and too late. A local nongovernmental organisation gave her formula milk, which helped her baby gain a little weight, but he was not tested, nor did he receive treatment. A doctor from Mokhotlong Hospital, who visits the Red Cross clinic every week, examined the baby and promised to consult a colleague before following up, but he never did.

BARRIERS TO ACCESS

Without treatment, most HIV-infected children die before the age of two, making the early diagnosis of potentially positive children critical. The technology to test babies under 18 months, known as PCR testing, is only available at a few pilot sites in Lesotho. Blood samples are sent to South Africa and the results can take up to two months to arrive.

Even where it is available, testing children early is a huge challenge, according to Rachel Cohen of the international humanitarian aid organisation, Medecins Sans Frontieres (MSF). "A lot of awareness building still needs to happen," she said. "Childhood illnesses are very common here, so people don't necessarily think of HIV."

Even those parents who know or suspect they are HIV positive often do not bring their children to be tested because of stigma, denial or lack of information. "Two children died in our wards this week before we had a chance to find out their status," said Cohen.

MSF provides HIV care to nearly 4,000 people and ARV treatment to over 1,000 people, 60 of them children in a mainly rural area about 40km south of Maseru that encompasses 14 clinics and one district hospital. The focus of the programme is to move HIV treatment from hospitals down to local health clinics staffed by nurses. MSF offers training and support, and doctors make weekly visits to the clinics, enabling the nurses to initiate and manage ARV treatment, even for children.

On a recent visit to a Red Cross clinic managed by MSF in the isolated mountain community of Kena, MSF doctor Pheello Lethola examined a baby suffering from a skin infection on her face. According to Lethola, the mother is HIV positive and PCR test results have confirmed that the child is also infected. As soon as blood can be transported to the nearest hospital, in Morija, for CD4 count testing, she will likely become the third child in Kena to begin ARV treatment.

"Baylor is a great thing," said Cohen, head of MSF's Lesotho mission. "But that kind of expertise needs to be spread throughout the country. If I had 13 paediatricians they would be on a rotating schedule, going to all of the clinics to boost and empower the nurses, so they can do the job over the long term."

Dr Edith Mohapi, the Baylor Centre's executive director, said they were helping the government scale up paediatric ARV treatment. The centre's doctors are training staff to treat HIV-infected children at five of Lesotho's district hospitals, including Mokhotlong. But training has not yet extended to the primary healthcare level, which is often the first place parents who cannot afford public transport to the nearest hospital bring their sick children.

The Lesotho government provides free ARV drugs but the Christian Health Association of Lesotho, which manages about 40 percent of hospitals and health centres in the country, charges user fees that are often another barrier to HIV-infected children who need care.

PREVENTION EFFORTS LAG

Meanwhile, lack of awareness and access to prevention of mother-to-child transmission (PMTCT) in Lesotho means more children need treatment every year.

Despite having a skin infection during her pregnancy, a common opportunistic infection in people living with HIV, Rapita was not offered an HIV test by her antenatal clinic. Had her status been known, she could have received treatment that would have significantly reduced the chances of passing the virus to her child.

UNAIDS estimates that only 5.1 percent of pregnant women in Lesotho accessed PMTCT in 2005. Many primary healthcare centres still lack rapid testing kits, and even those that have them often do not have staff trained to administer them.

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