Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV

Abstract

BackgroundIntegrated Management of Childhood Illness (IMCI) is a WHO/UNICEF strategy to improve child survival in resource poor settings. South Africa adopted IMCI in 1997, and IMCI guidelines were adapted to include identification and management of HIV infected and exposed children. This study describes the validity of the IMCI/HIV algorithm when used by IMCI experts, the use of IMCI/HIV guidelines by IMCI trained health workers in routine clinical practice, and the burden of HIV among children under 5 years attending first level health facilities.MethodsSeventy seven randomly selected IMCI trained health workers were observed in 74 health facilities in two provinces of South Africa. Consultations were observed with 1357 sick children; each child was reassessed by an IMCI expert to confirm the correct findings. Consent was requested for HIV testing of all children who attended with a parent or legal guardian. Positive rapid HIV tests were confirmed with HIV PCR in children aged less than 18 months. HIV positive children had a CD4 count and HIV clinical staging done.ResultsOf 1064 children with HIV results available, 76 (7.1% CI: 5.7% - 8.9%) children were confirmed HIV positive. IMCI experts using the HIV algorithm classified 54/76 (71.1% CI: 59.5%-80.9%) HIV positive children as suspected symptomatic HIV, and 15/22 remaining HIV positive children were identified as HIV exposed. Therefore, 69/76 (90.8% CI: 81.9-96.2) HIV infected children were identified by IMCI experts. No classification was made for HIV by observed health workers in 899/1357(66.2%) children.906/1243(72.9%) mothers had been tested previously for HIV, of whom 221(24.4%) reported testing positive. Of 221 children therefore identified as HIV exposed, only 78(35.3%) had been tested for HIV within routine services.ConclusionThe HIV algorithm is a valid tool for identifying HIV infected and exposed children when correctly and comprehensively implemented. However, it is not being used by IMCI trained health workers in routine practise, leading to a failure to implement life saving interventions.

How children access antiretroviral treatment at Kgapane District Hospital, Limpopo, South Africa

“…Some may also feel poorly trained and lack the confidence to handle the epidemic or share in the stigma that surrounds it. 11,21,[23][24][25] Primary care nurses work under extremely difficult conditions, with little support, often without the necessary drugs and equipment, and with a large numbers of ill patients. They may have little influence over their working conditions, which may make them feel disempowered.…”

The effect of an automated integrated management of childhood illness guideline on the training of professional nurses in the Western Cape, South Africa

“…Implementation of the IMCI guideline has been shown to lead to improved quality of care, better case management and improved child health. [8][9][10] In SA, the Department of Health adapted the WHO's generic version of the IMCI guideline to the South African context. 11 The South African version of the IMCI guideline, for children aged one week to five years, includes the management of diarrhoea, acute respiratory infections, asthma, ear infections, malnutrition, tuberculosis, HIV/AIDS, child abuse, meningitis and the critically ill child.…”

“…12 Reasons for the lack of impact of the IMCI programme have been ascribed to insufficient IMCI coverage, in terms of the percentage of primary care staff trained, and by a lack of adherence to the guideline recommendations after training. 10,13 Ineffective implementation of IMCI due to poor adherence to the guideline recommendations, with incorrect or incomplete assessments of the child, has been identified as a critical factor in the poor quality of care for the sick child. 8,10 Previous studies indicate that adherence to the IMCI guidelines decreases over time due to inadequate initial training, shortage of staff and insufficient supervision.…”

“…10,13 Ineffective implementation of IMCI due to poor adherence to the guideline recommendations, with incorrect or incomplete assessments of the child, has been identified as a critical factor in the poor quality of care for the sick child. 8,10 Previous studies indicate that adherence to the IMCI guidelines decreases over time due to inadequate initial training, shortage of staff and insufficient supervision. 8 Critical recommendations within the IMCI guideline may also be omitted due to lack of knowledge and skills.…”

Computer-Generated Reminders and Quality of Pediatric HIV Care in a Resource-Limited Setting

“…Care programs report difficulties in establishing systems for early infant diagnosis of HIV, initiating antiretroviral therapy (ART) promptly, ordering baseline and followup laboratory investigations, detecting tuberculosis, maintaining prophylaxis for opportunistic infections, and managing child malnutrition. [4][5][6][7][8] These challenges occur at multiple levels, ranging from individual clinical care systems to the country level.…”