Academic journal article Bulletin of the World Health Organization

Diagnosis of Paediatric HIV Infection in a Primary Health Care Setting with a Clinical Algorithm

Academic journal article Bulletin of the World Health Organization

Diagnosis of Paediatric HIV Infection in a Primary Health Care Setting with a Clinical Algorithm

Article excerpt


Over 10.9 million deaths occur annually in children aged <5 years in developing countries (1); most deaths are caused by preventable and easily treated childhood diseases (2). Appropriate management of these conditions is one of the most cost-effective interventions to reduce the global burden of disease (3). The Integrated Management of Childhood Illness (IMCI) was developed by WHO and United Nations Children's Fund (UNICEF) to improve survival rates in children (2); it uses an algorithmic approach to provide guidelines for the diagnosis and management of sick children at the primary care level (4). The clinical signs on which the IMCI guideline is based (5-8) and its ability to help health workers identify and appropriately treat sick children have been assessed previously (9-11). IMCI has been adopted as a worldwide strategy for improving paediatric care in resource-poor settings, and since its introduction in 1995, it has been implemented in 37 African countries and 102 countries worldwide (12).

The existing IMCI guideline recommends referral for children with severe or recurrent illnesses, such as those that are common in patients with HIV/AIDS; however, the specific identification and management of HIV/AIDS was not included in this guideline. In South Africa, HIV/AIDS is the leading cause of death in children, and it has reversed improvements in childhood mortality made over recent decades (13). Care for children with HIV/AIDS is putting a strain on health services (14) and increasingly is being shifted to the primary care level. Primary care health workers could provide the ongoing care that these children need, but such workers urgently need to gain appropriate skills. IMCI must now include the specific management of HIV infection as a major cause of morbidity and mortality in children (15).

In KwaZulu-Natal Province, South Africa, the prevalence of human immunodeficiency virus (HIV) is very high: 36.2% of women who attended government antenatal clinics in 2000 were HIV-positive (16). An algorithm for identification of children with HIV therefore was incorporated into IMCI. If a child is identified as possibly having HIV infection, IMCI includes guidelines for HIV serotesting and ongoing supportive management of paediatric HIV/AIDS. Antiretroviral drugs are not available currently for treatment of HIV infection in South Africa. This algorithm also has been adapted for use by several other African countries, but it was never evaluated formally. We report an evaluation of an HIV algorithm for identification of children with symptomatic HIV infection and show how data from this study was used to improve the algorithm.

Participants and methods IMCI/HIV algorithm

IMCI comprises a series of guidelines for assessment and treatment of common childhood conditions that are important causes of morbidity and mortality (2). The health worker assesses the child through history and examination and classifies the child as needing referral, specific medical treatment, or advice on home management.

Screening questions were added to the routine assessment of every child to alert the health worker on the fact that a child might be at risk of HIV infection, if any screening questions were answered positively, the child was also assessed for symptomatic HIV infection (Fig. 1). This assessment was based on local clinical experience (17-20) and WHO clinical case definitions for paediatric acquired immunodeficiency syndrome (AIDS) (21).


The study was carried out in the paediatric outpatient department at Ngwelezane hospital in KwaZulu-Natal from January to April 2001. This is a district hospital, and approximately 200 children are seen weekly in the outpatient department; most of these are referred by the 19 outlying clinics. HIV counselling and testing is available with routine hospital services and is requested by clinicians where indicated, but it may not be easily accessible because of a shortage of counsellors. …

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