Principal Investigator: Dr Rashida Ferrand
Project Coordinator: Tsitsi Bandason
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.
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.
The project is supported by:
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.