Keywords
HIV - children - care - Togo
Introduction
According to The Joint United Nations Programme on HIV/AIDS (UNAIDS), the HIV pandemic
has been stabilized in recent years around the world through combined efforts, raising
hopes for its total elimination. Africa is one of the regions that has made the most
progress in this response. The estimated HIV prevalence in sub-Saharan Africa was
4.7% (ranging from 0.2% in Cape Verde to 26.5 in Swaziland).[1] In Togo, one West African country with a population of 6,600,000, HIV prevalence
was estimated at 2.5% in 2013; children under 15 years constituted 7% of people living
with HIV (PLHIV).[1]
[2] Of the 3,275 children living with HIV (CLHIV) registered in healthcare centers,
2,377 (72.6%) were on antiretroviral therapy (ART), or 11.3% of all the 21,000 estimated
HIV-positive children under 15 years of age in Togo.[1]
[3]
HIV Prevention Mother-To-Child Transmission (PMTCT) services in 2013 in Togo covered
87.7% of all health facilities (of which 554/596 were public) while the early infant
diagnosis (EID) covered 27.7% of them.[2]
[4] From global recommendations, Togo retained a first ribonucleic acid (RNA) polymerase
chain reaction (PCR) for HIV EID at the 6th week's visit and a second for the breastfed
child, at 6 weeks after discontinuing any exposure to breast milk. The main EID circuit
in Togo is provided by the National AIDS/STI Program, which has contracted with the
National Post service to forward dried blood samples (DBS) to the two national reference
laboratories (Lomé and Kara). HIV serology (quick tests such as Determine/First Response)
was performed in 12-month-old children with confirmation at 18 months when the 12-month
test was positive.[4]
[5]
[6]
[7]
[8] When CLHIV are put on ART, the first regimen consists of two nucleotide inhibitors
and one non-nucleotide inhibitor. The CLHIV are monitored each month for their clinical
assessment and for the supply in ART. The LFU is defined as a child who has missed
three successive monthly visits. Biological monitoring, consisting at least of a CD4
balance, a hemoglobin level, and an alanine transferase assay, is performed every
6 months.[3]
[5]
[7] Despite progress in HIV care, especially in PMTCT, pediatric coverage for ART was
low.[1]
[6] Pediatric HIV services are limited, particularly, by the number of insufficient
qualified health professionals.[2]
[3] This study is aimed to assess the availability of HIV pediatric care in health facilities
in Togo.
Methodology
This study was a descriptive retrospective of HIV-infected children under 15 years
in Togo, selected from July 22 to September 06, 2014 in 26 out of 140 sites where
PLHIV received medical care. Patients were randomly selected from the ESOPE pediatric
monitoring database (Évaluation et Suivi Opérationnel des Programmes ESTHER [Ensemble
pour une Solidarité Thérapeutique Hospitalière en Réseau], a French public interest
group); their number was retained per site according to the number of patients followed.
On the other hand, the choice of the selected health centers took into account the
level of healthcare delivery, the type of institution (public, non-governmental organization
[NGO], confessional, or private), the rural or urban character, and the PLHIV number
followed, according to the geographical locations. In Togo, the healthcare delivery
system is organized into a pyramid at three levels: primary, secondary, and tertiary.[2]
[9] The primary level, with 1,019 health units, is made up of primary healthcare structures
around the health district and comprises two levels: basic health care facilities
type I (peripherals units care, medico-social centers, and private care practices)
and type II primary care referral facilities (public district hospitals or private
health center). The secondary (intermediate) level is represented by the six regional
hospitals (RH) and specialized referral hospitals. The tertiary level is constituted
by the three teaching hospitals and the specialized health institutions of national
scope. The number of health professionals in those health facilities, as of 2013,
was 11,140, comprising 459 physicians, 706 senior health technicians (physician assistants)
of all categories, 1,374 nurses, 807 midwives, 457 laboratory staff, and 19 clinical
psychologists.[9] The locations of the selected health facilities for this study are provided in [Fig. 1]. The institutions selected at the central level for analysis include two of the
three reference hospitals in Togo: Sylvanus Olympio teaching hospital at Lomé and
Kara teaching hospital. At the intermediate level, a careful choice based on more
than 1-year experience in the field of pediatric HIV management and the occurrence
of CLHIV accounting for more than 5% of national CLHIV has led us to retain the RH
of Tsévié. At the peripheral level, six districts were selected with CLHIV and without
a RH. In the selected districts, in addition to the district hospital, two peripheral
care units (Type I or Type II) providing PMTCT services were selected, including a
PMTCT site collecting DBS for EID and another PMTCT site not doing so. One of the
selected facilities was in a rural area. Each site must have delivered at least one
HIV-exposed infant during the year 2013. The confessional health units (covering 11%
of national CLHIV) were included at the rate of one facility in each region: southern
Togo and northern Togo. As for the NGO facilities involved in the management of HIV
(with ∼40% of CLHIV), two were selected at Lomé and one in northern Togo, as well
as a private health facility.
Fig. 1 Togo's maps with the 26 selected health facilities locations.
At the time of the survey, the criteria for putting children on ART in Togo, based
on revised WHO Pediatric Classification 2006, were[5]
[7]: (1) HIV-positive child under 12 months of age with a virological test (positive
PCR) regardless of the clinical stage or the percentage of CD4 lymphocytes (confirmed
HIV infection), (2) HIV-positive symptomatic child under 18 months of age without
a virological test (presumptive diagnosis of severe HIV infection) but with a serological
confirmation test at 18 months of age to continue ART, and (3) Child over 18 months
of age with confirmed HIV infection, including clinical stage III or IV regardless
of the percentage of CD4 lymphocytes, or clinical stage I or II with CD4 lymphocytes < 25%
(<1,500 cells/mm) in children under 12 months, CD4 lymphocytes < 20% (<750 cells/mm)
in children aged 12 to 35 months, CD4 lymphocytes < 20% (<350 cells/mm) in children
over 36 months.
CLHIV who have fulfilled the conditions to be put on ART should receive antiretroviral
(ARVs) as soon as possible. Any CLHIV under 5 years and at clinical stage III–IV regardless
of age needed a cotrimoxazole chemoprophylaxis. A tuberculosis screening was performed
in those children according to a syndromic approach taking into account the presence
of TB symptoms (cough and chest pain). This is supported by the acid-fast bacilli
(AFB) search in the sputum or in the gastric fluid and a chest X-ray test.
This study was conducted as part of a general retrospective analysis of pediatric
care management in CLHIV that was approved by the national bioethics committee. Under
this ethics clearance, the consent of guardians was not required for retrospective
analysis of routine clinical care data. The data collection was provided by a team
of 12 trained health professionals (four pediatricians, two general practitioners,
five senior health technicians, and one statistician) after training. The administrated
questionnaires were designed to assess the clinical (age, sex, anthropometry, WHO
clinical stage, and diagnosis), biological (serology, PCR, and CD4 percentage), and
therapeutic (ART initiation and follow-up) parameters of the CLHIV as well as to identify
the resources and activities of the care centers. Quantitative analysis, performed
with Stata, was focused on key indicators such as anthropometric, diagnostic, therapeutic,
and evolutionary parameters. The Tanahashi method was also used to determine the level
of the various services offered to children.
Results
Outside of the unavailable data from Sylvanus Olympio Teaching Hospital, the biggest
center of PLHIV care management, CLHIV on ART in selected sites represented 9.4% of
on ART PLHIV or 814 CLHIV. A sample of 244 children was selected.
HIV Diagnosis and Antiretroviral Therapy in Surveyed Children
The average age at diagnosis for CLHIV was 5 years. The most represented age groups
were those of 5 to 9 years (40%) and those of 2 to 4 years (25%). Infants under 2
years accounted for 21% of the total children while adolescents aged 10 to 15 years
accounted for 14%. Male children made up 53.3% (130/244) of the sample.
The diagnosis of HIV infection was done mainly by serological testing after 18 months
(90.5%), or to a lesser extent by presumptive diagnosis before 18 months (5.4%) or
PCR (4.1%). The initial clinical evaluation (n = 213) revealed that most children were in stage III (35%) or IV (14%) according
to the WHO classification. Twenty-six percent of them were in stage II, and 25% were
asymptomatic. Seventy-one percent of children were underweight (weight-for-age < − 2
Z scores), of which 41% were severely underweight. The patient height was not recorded
in 82% of the cases, and this was not enough to appreciate nutritional and growth
status disorders. Biological evaluation (in 198 children) revealed a mean rate of
CD4 at 607. The interpretation of this CD4 level by age (reference to the WHO standard)
showed 77.3% of patients with immunosuppression, of which 35% were severe (70 cases)
and 42% were moderate (82 cases), correlating with advanced clinical stages. In 22.8%
of the cases CD4 was normal.
ART initiation occurred at a mean age of 5.4 years. In 90% of the cases (220 children),
guidelines were compliant with ART criteria as defined by the WHO in 2010 and the
national protocol: CD4 inferior to 25% and WHO stages III–IV made up the most common
criteria used to initiate ART ([Table 1]). The average delay (from diagnosis) to start an ART was 216 days. [Table 2] summarizes the different ART received by children. The first-line regimen was correct
in 96% (208/217) of patients older than 3 years, mainly constituted by zidovudine/lamivudine/nevirapine
(AZT/3TC/NVP) (47.0%) and stavudine/lamivudine/nevirapine (d4T/3TC/NVP) (38.7%) in
accordance with national guidelines in progress. Under the age of 2 years, 6/14 children
were on the protease inhibitor-based regimen, and 7/14 were NVP based.
Table 1
Distribution of children according to ART criteria
|
ART criteria
|
Number (n = 220)
|
Percentage (%)
|
|
CD4 counts < 25%
|
123
|
55.9
|
|
WHO Stages III and IV
|
106
|
48.2
|
|
Positive PCR
|
08
|
03.6
|
|
Children living with HIV < 18 mo old
|
03
|
01.4
|
Abbreviations: ART, antiretroviral therapy; HIV, human immunodeficiency virus; PCR,
polymerase chain reaction; WHO, World Health Organization.
Note: Certain criteria can be combined in children to start an ART.
Table 2
Distribution of children by primary ART regimen received
|
First-line regimen
|
Number (n = 217)
|
Percentage (%)
|
|
3TC/AZT/NVP
|
102
|
47.0
|
|
d4T/3TC/NVP (before 2012)
|
84
|
38.7
|
|
ABC/3TC/LOP/R
|
7
|
3.2
|
|
AZT/3TC/LOP/R
|
6
|
2.8
|
|
ABC/3TC/NVP
|
4
|
1.8
|
|
AZT/3TC/EFV
|
3
|
1.4
|
|
TDF/3TC/EFV
|
3
|
1.4
|
|
ABC/3TC/EFV
|
2
|
0.9
|
|
Other combinations
|
6
|
2.8
|
Abbreviations: ABC, abacavir; ART, antiretroviral therapy; AZT, zidovudine; d4T, stavudine;
EFV, efavirenz; LOP/R, lopinavir/ritonavir; NVP, nevirapine; 3TC, lamivudine; TDF,
tenofovir.
More than half of the HIV-infected children were followed up in public health facilities
(55.5%), one third in NGO (30.6%), and 13.6% in confessional facilities. Children
in the private sector accounted for 0.3% of infected children. In CLHIV follow-up,
the absence of the height measurement (85.2% or 208 cases), that of the weight (20.8%
or 51 cases) and a low rate of biannual biological follow-up (19.8% or 45 cases) were
recorded in the files. Two-thirds of the children (62.7% or 146 cases) were ARV compliant.
The prevention of opportunistic infections was done using cotrimoxazole in 70.2% (170
cases) and tuberculosis (TB) screening in 64.8% (153 cases). The LFU (out of sight
for3 months) proportion was 8.9% (19 cases). Survival at 12 months on ART of children
surveyed was 83.2%, and that of those at 24 months was 61%.
Providing of Pediatric Care at the Sites
Concerning the level of availability of maternal, newborn, and child health (MNCH),
PMTCT and pediatric ART services in the different sites surveyed ([Table 3]), provider-initiated HIV testing and counseling (PITC) (27%), psychosocial monitoring
(42%), and antiretroviral drugs dispensing (50%) were the least available pediatric
care management. Infants' consultation (100%), follow-up of HIV-infected mothers and
their children (88%), vaccination (88%), and nutritional management (73%) were the
most commonly available services across all sites. MNCH and pediatric HIV services
were complete at the central and intermediate level facilities (100% for each of the
services), lower and incomplete at the peripheral level and in the private health
facilities. At the peripheral level 1, PITC and psychosocial care only existed in
50% of the cases. Also, only one of the six district hospitals had a psychologist,
and two of them had neither a psychologist nor a counselor. At the peripheral level
2, the most available services were infants' consultation (100%), immunization (100%),
and PMTCT (83%). In half of the cases, EID and nutrition were not available. There
was little ART (25%), and PITC was almost absent (8%). According to the private sector,
MNCH was poorly developed: PMTCT at 60%, vaccination at 40%, management of malnutrition
at 60%, and EID by DBS at 40%. Confessional health facilities in this sector had a
comprehensive package of services (100%), which was better than that at NGO and private
centers.
Table 3
Level of availability of MNCH services and pediatric HIV care by level of healthcare
delivery
|
Level of health care delivery
|
Central and intermediate level (n = 3)
|
Primary level (n = 23)
|
Total of facilities (n = 26)
|
|
Confessional and NGO institutions
(n = 5)
|
Peripheral level 1
(n = 12)
|
Peripheral level 2
(n = 6)
|
|
MNCH services and pediatric HIV care
|
|
Mother–baby follow-up in PMTCT
|
3 (100%)
|
3 (60%)
|
12 (100%)
|
5 (83%)
|
23 (88%)
|
|
EID
|
3 (100%)
|
2 (40%)
|
12 (100%)
|
3 (50%)
|
17 (65%)
|
|
PITC
|
3 (100%)
|
3 (60%)
|
6 (50%)
|
1 (17%)
|
7 (27%)
|
|
ART
|
3 (100%)
|
5 (100%)
|
12 (100%)
|
2 (33%)
|
17 (65%)
|
|
Antiretroviral drugs dispensing
|
3 (100%)
|
4 (80%)
|
12 (100%)
|
0 (0%)
|
13 (50%)
|
|
Infants' consultation
|
3 (100%)
|
5 (100%)
|
12 (100%)
|
6 (100%)
|
26 (100%)
|
|
Vaccination
|
3 (100%)
|
2 (40%)
|
12 (100%)
|
6 (100%)
|
23 (88%)
|
|
Nutrition
|
3 (100%)
|
3 (60%)
|
12 (100%)
|
4 (67%)
|
19 (73%)
|
|
Psychosocial monitoring
|
3 (100%)
|
4 (80%)
|
6 (50%)
|
1 (17%)
|
11 (42%)
|
Abbreviations: ART, antiretroviral therapy; EID, early infant diagnosis; HIV, human
immunodeficiency virus; MNCH, maternal, newborn and child health; NGO, non-government
organization; PITC, provider-initiated HIV testing and counseling; PMTCT, prevention
mother-to-child transmission.
The HIV-infected children were monitored at the main hospitals by a pediatrician,
a general practitioner, or a senior health technician (physician assistant). At the
peripheral care unit, this monitoring did not exist or was limited at a control and
promotion of the growth and immunization visits. With NGO, the follow-up with the
infected child was performed concomitantly with the hospital follow-up because there
is neither a vaccination unit nor an early diagnosis.
Discussion
The average age at HIV diagnosis in CLHIV was 5 years in the study conducted. The
initiation of ART began in an average delay of 216 days (31 weeks). HIV diagnosis
and ART initiation were delayed in this study. The same findings were made by other
sub-Saharan researchers.[10]
[11]
[12] The diagnosis was often made very late, around 5 years, which explained the advanced
clinical stages (49% in Stages III–IV) as well as moderate or severe immunosuppression
cases (this series:77%, Nigeria:78.4%, and Tanzania:48%).[10]
[12] This situation is somewhat better in Malawi, where from October 2004 to October
2010, the median admission age was 24 months (interquartile range [IQR]: 12–62).[13] If opportunistic affections could not be well reported in this study, malnutrition,
pneumonia, and malaria were the most common primary admission diagnoses.[13] In CLHIV (age 5–14 years) who had not yet started the ART and were enrolled in four
HIV sub-Saharan African programs, advanced HIV disease at presentation (low body mass
index, stage 3 or 4, low CD4 count, or tuberculosis diagnosis) was associated with
increased mortality and LFU.[14] In Nigeria, the average time to initiate ART was 26 weeks (42% of the children had
an initiation delay of 12 weeks), and 81.5% of CLHIV were on AZT/3TC/NVP combination
therapy.[10] In this study, the ART was based on AZT/3TC/NVP (47.0%) and d4T/3TC/NVP (38.7%).
These regimens are administered based on countries' resources.
Early diagnosis of HIV and related diseases and their treatment, in the study area,
face several pitfalls, which need to be improved: disruption of inputs data, geographical
accessibility, managerial and organizational problems, inadequate human resources,
and training problems.[3]
[6]
[10]
[15] To avoid rapid progression in CLHIV and death, this diagnosis and treatment must
be done early, and all HIV-infected children must be initiated on ARVs irrespective
of their clinical or laboratory status. Late presentation and delays in initiating
ART among eligible children were the basis for a large incidence of patient losses
during pre-ART follow-up in sub-Saharan Africa.[14] Strategies must be developed to shorten this delay, such as delegation of tasks
and training of paramedic caregivers to cope with the insufficiency of physicians
in health centers. ARVs dispensation must be introduced on all sites offering care
to the PLHIV; patients sometimes moved to get ARVs in accredited sites. Only 56% of
140 sites where PLHIV receive medical care (70 sites) in Togo dispensed ARVs at the
time of the study. This ART was stabilized and improved by the WHO 2015 recommendations
stipulating ABC/3TC/LOP/R as the first-line regimen.[16]
The results also indicate an insufficient quality of care for followed up ART CLHIV.
There were missing data in clinical monitoring (anthropometric, clinical signs, and
diagnosis) and the biological checking was performed in only 19.8% of cases. Concerning
cotrimoxazole, chemoprophylaxis (performed in 70.2%), stock-outs, non-control, or
omission of indications by prescribers were the main reasons for this non-optimal
prevention. As for TB research, it was performed in two-thirds (64.8%) of cases, while
it was systematically recommended. TB prevalence in Togo was 104 for 1,00,000 inhabitants
in 2012.[17] An emphasis should be placed on training and sensitization of prescribers on TB/HIV
co-infection and other HIV-related opportunistic diseases. Monitoring of the CLHIV
on ART is important to ensure better follow-up and compliance to reduce the occurrence
of infections. In Togo, in 2009, follow-up of CLHIV on ART in rural areas showed a
decrease in severe acute malnutrition (56% after 3 months of follow-up to 25% at 12
months) and an increase in the number of CD4 in 60% of children after 12 months of
treatment.[11]
A similar study to this one in Nigeria (2012) showed a follow-up failure in 35% and
a mean duration of child follow-up of 24.4 months.[10] Children who were lost sight of during follow-up in these series accounted for 8.9%
(over 3 months), a better proportion than reported in Nigeria and Zambia (respectively,
19.1% and 14% over 2 years).[10]
[15] Moderate-to-severe immunosuppression, age less than 2 years, and a delay of ART
initiation greater than 12 weeks were significantly associated with loss to follow-up.[10]
[15] The mortality rate in this study at 12 months ART follow-up was 16.8%. This mortality
rate was 4.2% in Nigeria and 5% in Zambia during follow-ups. Follow-up failure requires
qualitative and quantitative reinforcement of the care staff, a good psychosocial
accompaniment for children, and a minimum standard of equipment and conditions for
care centers to provide a better-quality care.
This descriptive and retrospective evaluation was limited by the deficiencies in the
data quality collected due to inadequacies in the patient monitoring system and health
information system. However, it gives us important information about the level of
care and services offered to CLHIV in our facilities to improve the quality of this
care. With regard to the availability of MNCH, provider-initiated HIV testing and
counseling (PITC) (27%), psychosocial monitoring (42%), and antiretroviral drugs dispensing
(50%) were the least available pediatric care management, followed by EID (65%). Apart
from the PITC strategy, providers have not yet integrated the proposal for screening
in childcare, a screening only performed in case of presumption. Furthermore, the
proportion of health institutions practicing PITC in Togo was low (20 pilot centers
in 2013, i.e., 2%). The exercise of this approach stopped at main hospitals where
the complete care package was available. Medical care sites were mainly urban (85%)
consisting of public health institutions (50%), NGO (25%), and confessional institutions
(11%).[17] The proportion of HIV screening tests given in Togo was very low (2.7%) among children
under15 years at voluntary screening centers in 2014 (PITC strategy performed in 5%
of children at pilot centers showed 221 HIV-infected children or a rate of 6%).[17] An obvious gap in missed opportunity for EID of HIV (performed in 13%) was also
observed in comparison with Pentavalent 1 vaccination (performed in 89%)[4]
[17] showing the need to reinforce early diagnosis and PITC to scale up a more rigorous
identification of these children. The Togolese context is marked by an insufficiency
of skilled and trained health professionals: 1 doctor for 16,670 inhabitants and 1
nurse per 5,000 inhabitants.[2] Only doctors and senior health technicians were authorized by the national HIV/AIDS
policy to care for CLHIV on ART. The follow-up of CLHIV was almost non-existent in
peripheral level 1 (peripheral unit care and medico-social centers) where care offers
are limited to vaccination and control of population growth. The insufficiency of
human resources (both in quality and quantity) in health centers are also the basis
of the non-optimal level of psychosocial monitoring and ARVs dispensing. In this study,
psychologists (in 8 sites out of 26) and counselors, key stakeholders who can assist
in therapeutic education and improve the functioning of the circuit, are very insufficient
or non-existent, or recruited temporarily for one-time projects. To reach better integrative
HIV pediatric care in our institutions, the role of care managers must be considered.
In this management in Togo, focal points were selected among care providers in health
districts and hospitals to ensure input management and follow-up. In Zambia, in 2011,
barriers to the provision of quality pediatric HIV treatment included challenges in
diagnosing treatment failure, human resources constraints, lack of caregiver involvement,
lack of disclosure, limited adolescent-specific care, dysfunctional laboratory systems,
and inadequate data management systems.[15] These findings reinforce the need for a comprehensive care package. In 2012, implementation
of a comprehensive package HIV care in rural Tanzanian clinic resulted in an increased
number of mothers and children diagnosed and linked into care, a higher detection
of children with AIDS, universal treatment coverage, lower loss to follow-up, and
an early mother-to-child transmission rate below elimination limit.[12] A successful implementation of a care delivery value chain as a strategy to optimize
care delivery and inform quality improvement efforts was also reported in a NGO in
northern Togo.[18] These experiences must inspire public pediatric HIV/AIDS care management to improve
the quality of pediatric HIV care.
Conclusion
HIV diagnosis and therapy in children are still delayed. Despite significant efforts
noted in Togo, the monitoring of CLHIV needs to be improved. Maternal, neonatal, and
child health care and HIV care are not optimal, partially integrated into main public
health centers and more limited in urban areas. Integrating HIV pediatric care is
a necessity for better survival of CLHIV. This will inevitably require strengthening
the capacity of health professionals, delegating tasks to other health workers, monitoring
the integration of various maternal and child care, and performance-based funding
to improve the comfort and life expectancy of these children in resource-limited settings.
