A Center of Excellence for Biomedical Research and Training in Africa
  
  

Principal
Investigator
: Dr
Rashida Ferrand

Project
Coordinator
:
Tsitsi Bandason

BACKGROUND

Southern
Africa retains the highest burden of HIV in the world. Zimbabwe in
particular, has had a severe HIV epidemic of very early onset with HIV
prevalence among adults peaking at 29% in 1997 with rates declining
thereafter. In the absence of any interventions, mother-to-child HIV
transmission (MTCT) rates are approximately 35% and a regional epidemic of
vertically-acquired HIV has thus followed in the wake of the adult epidemic.

Contrary
to previous understanding that few HIV-infected infants would survive beyond
5 years without treatment, it is now being appreciated that a significant
proportion of these infants have a longer survival than previously
recognized, with many living to adolescence. Recent National HIV prevalence
surveys in some of the worst-affected countries in the region, such as
Botswana, Zimbabwe, South Africa and Swaziland, report a substantial burden
of HIV in older children.

It is
anticipated that that between 1-3% of older children will be living with HIV
acquired through MTCT in Zimbabwe by 2010 and this is likely to have a
significant impact on adolescent health. An HIV epidemic among older children
is already very prominent in Zimbabwe: our recent study shows that almost 50%
of children aged between 10 to 18 years presenting to the two central
hospitals in Harare are HIV-infected, the majority of whom present with
advanced HIV disease, and have a case-fatality rate of up to 20%. There are
however, very few empiric data on burden of HIV among older children and
these are urgently required to guide policy and service provision.

Late
diagnosis is a prominent feature of HIV in older children leading to a high
burden of irreversible chronic consequences of HIV. Diagnosis is often
delayed until life-threatening opportunistic infections occur. Prominent
features common to these HIV-infected children include: high prevalence of
orphanhood, history of sick/dead siblings, short stature, skin disease, long
history of minor illnesses and frequent absenteeism from school as a result
of ill-health with consequent failure to attain fundamental educational
skills.

Older
children may be unable to access HIV testing services because of their poor
social circumstances, limited personal resources, their inexperience and
legal restrictions. Current antiretroviral therapy (ART) access initiatives
also tend to exclude older children from priority groups for ART. Many of
these vertically-infected older children will be orphaned and therefore even
less likely to be successful in accessing health services, as illustrated by
the 2004/5 UNICEF survey on orphans and other vulnerable children (OVC).

 Thus
without specific targeting, they are unlikely to succeed in accessing HIV
diagnosis and care services. There are few existing empirical data on the
burden of HIV among older children. Quantification of the HIV burden in
primary schools will help understanding of magnitude of the emerging HIV
epidemic among older children. Such data are critical to inform planning of
appropriate HIV diagnostic and care services for this age-group.

OBJECTIVE
The objectives are: 

  • To quantify HIV prevalence
    in primary schools with age-group trends
  • To develop a
    case-definition of an HIV suspect based on simple indicators (e.g.
    height, frequent absenteeism, orphanhood status, skin problems), with
    indications of sensitivity and specificity
  • To determine the number of
    HIV diagnoses made through the PSI CT service

METHODS

Prevalence
Survey

Six
primary schools in the South Western high-density suburbs of Harare and the
communities in which the schools are nested will be sensitised to the planned
prevalence survey. This will take the form of presentations in selected
schools for teachers and children at morning/afternoon assembly times. Parent
meetings will be arranged at the school with presentations, when the school
conducts their parent teacher meetings or school development association
meetings, and written information will be provided to inform
parents/guardians of the planned project. Once sensitisation has been
completed and ethical approval from relevant Institutional Review Boards
obtained, parents/guardians will be asked to give written consent for their
child to participate in the survey and to provide information on the vital
status of biological parents. The school focus person in liaison with the
school head will give a date when it is convenient to conduct the survey at
the school. Two teams each consisting of a research assistant and a
nurse-counsellor will conduct the survey in the 6 designated schools. The
research assistant will give each child a consent form, information sheet and
flier and asked to give to their parents and asked to return with it on the
day the study team will be at the school. On the designated day, the research
assistant will collect forms from those with written consent, administer the
baseline questionnaire, measure the height and weight of the student, then
refer the child for collection of HIV specimen. Blood will be taken for
anonymised HIV testing (Abbott DetermineTM). Participants who assent to
inclusion but decline venepuncture will be tested using oral mucosal
transudate (OMT). Teachers will be asked to identify pupils who are
frequently absent and any pupil who may be absent on the days of the survey.
Children who are absent on the day of the survey will be followed up in the
community by the survey team after completion of the main survey using an
address list given by the school focal person. Information from the survey
will be used to develop and validate a case definition, to identify children
who may potentially be HIV positive. A train-test approach,will be used to
create and validate the algorithm and this is described in more detail below.
Data on clinical and social variables: orphanhood status, previous illness,
stunting and self-rated health will be used to develop an algorithm to
identify those who are at risk of being HIV-infected in this age-group. These
variables have been selected because of their strong association with HIV
infection, observed in the Adolescent Morbidity study. A train-test approach,
will be used to create and validate the algorithm.

Feasibility
of School-linked HIV Counselling and Testing: A Demonstration Project

Population
Services International (PSI) will set up testing sites in the vicinity of the
six primary schools in the South Western high-density suburbs of Harare and
will offer counselling and testing (CT) to any pupil and/or family member who
requests it. Testing of pupils will be carried out only with the consent of
the parent/guardian. The student will be given a study card. An evaluation of
the acceptability and uptake of HIV CT among school pupils and their families
will be carried out by determining how many school children went to the PSI
Testing Site using the referral card given by study team. Individuals testing
HIV-positive through the PSI HIV CT service will be given tests required for
initial assessment of HIV, (CD4 count and full blood count). All patients
will be started on cotrimoxazole prophylaxis. The study will provide
cotrimoxazole for one month and refer for follow-up HIV Care Services
Centres.

INSTITUTIONAL
PARTNERS

The
project is supported by:

  • Ministry of Health and
    Child Welfare (MOHCW)
  • Ministry of Education
    (MOE)
  • University of Zimbabwe
  • City Health, Harare
  • Ministry of Labour, Public
    Service and Social Welfare Population Services International
  • Funded by UNICEF

We have
a long history of successful collaboration with MOHCW and City Health who
have actively supported our work in hospitals and in primary care clinics in
Harare and in schools. Since the formation of the Government of National
Unity, we have also had the support and approval of the MOE and we anticipate
continued support for work in schools as well as support for integration of
proposed interventions into existing School Health Program

POTENTIAL
IMPACT OF THE PROJECT

Accessible
HIV Diagnostic Services:

Development
of a unique model of accessible HIV diagnostic services for children and
teachers in a non-clinical setting. Strengthening HIV Prevention: HIV testing
is an integral part of HIV prevention. CT will aid improve HIV knowledge
among children, parents/guardians and school teachers and availability of HIV
testing in schools may contribute to destigmatising HIV, which in turn
consolidates prevention programs already operating outside schools.

 

Clinical Trials


Our Future

With the contributions from a dedicated and professional staff complement, BRTI has achieved  20 years of continuing growth. From its inception in 1995, the BRTI has strived to become a a centre for excellence in health research and training in Africa. We are confident that the philosophy behind the formation of BRTI, that African scientists must take responsibility for improving their own working environment, was correct. We predict that, in spite of a degree of economic uncertainty in Zimbabwe, the gains that have been made during these years can be consolidated and expanded. We look forward to the future with confidence.

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