Van Winghem J, Telfer B, Reid T, et al. Implementation of a comprehensive program including psycho-social and treatment literacy activities to improve adherence to HIV care and treatment for a pediatric population in Kenya. BMC Pediatr. 2008 Nov 21;8:52.
Antiretroviral therapy (ART) in resource-constrained areas has been shown to decrease mortality in children.(1,2,3,4,5) Since 2006, ART has been available for HIV-infected children in Kenya and has reduced mortality.(6) Adherence to ART is essential for good clinical outcomes. Previous studies have documented several factors that affect adherence, including patient and medication factors, the relation between the health care provider and patient, and the health care system.(7) Detailed descriptions of programs successful at promoting ART adherence are not widely available, thereby limiting programs from adopting well-evaluated and successful programs.
To describe the components of the MSF-Belgium HIV care and treatment program in Kenya designed to promote ART adherence
Kibera settlement, Nairobi, Kenya
A total of 1205 HIV-infected, ART-naïve children under 15 years of age
Survival and program description
Methods Used in The Survival Analysis
Survival from date of ART initiation to death was estimated using the Kaplan-Meier method. Patients were considered lost to follow-up if they were not known to have died, had not transferred care, and had not attended the clinic in the 4 months prior to data analysis. Patients were censored at their last clinic visit up to November 30, 2007.
Results from Survival Analysis
Of the 1205 children under care, 657 (55%) initiated ART. Between January 1, 2003 and November 30, 2007, 452 (69%) were still on ART, 32 (5%) had died, 106 (16%) had transferred out, and 67 (10%) were lost to follow-up. The regimen of 7 children was switched to second-line therapy. The 12-month survival was 95.3% (95% confidence interval [CI]: 93.2-96.7) and the 24-month survival was 94.3% (95% CI: 91.9-96.1)
A range of interventions were developed to promote ART adherence, including a child-friendly clinic environment, with toys, games, videos, and so on. Children were seen on a day dedicated to pediatric care. A pediatrician was available to attend to patients with complicated conditions, and group activities were provided for the children.
Care of the entire family was provided at the same clinic. Group discussions regarding topics relevant to the parents or other adult care givers were held on the days that children were seen at the clinic. Support also was enhanced by coordinating services with non-governmental organizations that could provide shelter or address other needs. Patients who missed appointments were contacted by phone or by a home or hospital visit.
Special "fun days" were created in which staff, providers, care givers, and children spent a day out together at child-friendly sites. This day of enjoyment served to strengthen the relationships between staff and patients/families. Support groups were established for children, teens, and caregivers to address the psychosocial concerns and needs of each group. Structural aids for enhancing adherence included pillboxes and tick sheets
Additional psychosocial support activities and tools were created, including a fairytale that was used as a communication tool to create a positive understanding of HIV disease and treatment. The story is read by a counselor to the child, who then takes the storybook home. Future visits are used for the counselor to address questions that the child may have. A booklet aimed at teens provided basic information about HIV/AIDS, opportunistic illnesses, treatment, nutrition, and positive-living attitudes. Pictures and stories are used to provide information about the disease process. Individual therapy for adults, teens, and children was available. Small groups for care givers were also available.
Capacity-building interventions included treatment literacy trainings conducted over a few days and led by two counselors and attended by 10-15 participants. Separate groups were held for children, teens, and care givers. The trainings for children and teens were designed to provide knowledge and skills so that they could understand and manage their disease. The aim for care givers was to provide knowledge and skills to better understand the disease process. Topics included beliefs towards HIV status, disclosure, treatment, care, opportunistic illnesses, nutrition, and home-based care, and the development of communication skills. For the HIV-infected caregivers, treatment literacy was included in the training.
The "hero book" was a memory book in which the child/teen was the hero and author. It included a series of drawing exercises designed to assist children to think about and express their problems and challenges. Hero book-training consisted of a week of group sessions with a maximum of 10 participants of similar ages. Trainings were led by artists and counselors.
Staff all received training on a broad range of topics, including HIV medicine, pediatric ART, treatment literacy, and psychosocial issues, such as communication skills. Counseling for staff to address personal matters also was available.
There also were efforts to increase involvement of patients and others living with HIV. Four patients were trained as peer educators and counselors and worked within the program. There were also courses designed to teach additional trainers for the treatment literacy component of the program.
Conclusions and Programmatic Implications
Development and implementation of a child-centered approach to care and treatment of children and teens living with HIV is an important mechanism for improving adherence to ART and other aspects necessary for good clinical management of HIV disease. The program demonstrates the feasibility of implementing such a program in resource-constrained areas.
- O'Brien DP, Sauvageot D, Zachariah R, Humblet P. In resource-limited settings good early outcomes can be achieved in children using adult fixed-dose combination antiretroviral therapy. AIDS 2006;20:1955-60.
- Reddi A, Leeper SC, Grobler AC, et al. Preliminary outcomes of a paediatric highly active antiretroviral therapy cohort from KwaZulu-Natal, South Africa. BMC Pediatrics 2007;7:13.
- George E, Noël F, Bois G, et al. Antiretroviral therapy for HIV-1 Infected Children in Haiti. J Infect Dis 2007;195:1411-8.
- The Malawi Paediatric Antiretroviral Treatment Group: Antiretroviral therapy for children in the routine setting in Malawi. Trans Royal Soc Trop Med Hygiene 2007;101(5):511-6.
- Kline MW, Matusa RF, Copaciu L, Calles NR, Kline NE, Schwarzwald HL. Comprehensive pediatric human immunodeficiency virus care and treatment in Constanta, Romania: implementation of a program of highly active antiretroviral therapy in a resource-poor setting. Pediatrc Infect Dis J 2004;23(8):695-700.
- HIV AND AIDS SITUATION IN KENYA BASED ON FACTS AND FIGURES FOR 2006.
- World Health Organisation. Adherence to long-term therapies: evidence for action. WHO, Geneva; 2003. No abstract available.