Uganda: The ABC Strategy is Irrelevant to Children
By, Dr. Okuonzi Sam, New Vision (Kampala), December 17, 2006
THIS year's AIDS Day has come and gone. The passion behind "Unite for Children, Unite against AIDS", the theme for the celebrations, has not materialised into any concrete strategy or policy. With the chest-thumping by politicians and health officials about the miracle of the Abstinence, Be faithful, Condom use (ABC) strategy, the assumption is that this strategy also caters for AIDS in children.
But this is a mistaken assumption. While there has been some success in bringing down HIV/AIDS in Uganda among the adults, it is too simplistic to attribute this success to the ABC strategy alone.
Four key factors for the reduction of HIV/AIDS have been openness, the coherent and systematic approach for public mobilisation and education, multi-sectoral collaboration, and unparalled resource mobilisation. These factors are not captured by the ABC formula.
But the strategy, even with its expanded version, ABC-plus, remains largely irrelevant for the management of HIV/AIDS in children. Ten percent of people living with AIDS are children less than 12 years. The main route of transmission of the virus is from mother to child - in the womb, during birth or through breastfeeding. This route is now responsible for 22% of all new infections in Uganda. While the ABC strategy is concerned with preventing or restricting sex, major challenges of HIV/AIDS in children occur after the act of sex of their parents and are non-sexual.
At least 2.5 million children in Uganda are orphans infected or affected by AIDS. In addition to suffering from HIV/AIDS as a disease, these children are confronted with huge challenges of survival, growth and development. Their basic needs for health, nutrition, education, affection and protection are at stake. They experience rejection, fear, discrimination, loneliness and depression. Children infected or affected by HIV/AIDS are often more abused, and commonly disowned and dispossessed of family property.
Most children have no opportunity to test their sero-status and to be counselled. Only a few facilities are available for child counselling on HIV/AIDS. This service is fragmented, and not particularly highly valued by policy makers as a key service. It is not supervised and is often done by amateurs. The few child counsellors available frequently experience emotional stress or "burn out" and are not readily replaced by others. Other challenges facing counselling include lack of co-operation and fear of disclosure to health workers of children's HIV status by parents and caregivers, and lack of resources to establish and operate child-friendly counselling centres.
Therefore, the ABC strategy, even with some additions, will not do for HIV/AIDS in children. A comprehensive strategy to tackle HIV/AIDS in children should be six- pronged. First, the prevention of mother-to-child transmission (PMTCT) should be intensified and expanded so as to reach every pregnant mother. The coverage by PMTCT of 78% of pregnant mothers attending ante-natal clinics (ANCs) is a good starting point. But more needs to be done to reach those who are not attending ANCs. Also, only 56% of HIV positive pregnant mothers currently receive Nevirapine. This should be improved, in the short term, to 80%.
Second, it will be important to ensure routine screening for HIV of all children who visit or are taken to health facilities for health care. To support this, laboratory capacity, technology and systems need to be set up to provide timely and reliable diagnosis. Empowering lower level health care workers by training, technical and financial support to diagnose and manage HIV/AIDS infection will be critical. Clinical criteria for HIV/AIDS diagnosis need to be established and updated from time to time, guided by researched evidence. Even so, HIV infection in children can still be missed. In the absence of a definitive diagnosis, children with symptoms suggestive of HIV infection should be started on ARV until it is firmly excluded.
Third, counselling of children needs to be comprehensive. Children 0-12 years who are suspected to be infected or demand to be tested should be tested for HIV. They should be accompanied by a parent or guardian. But older children who demand to be tested may be allowed go unaccompanied, if they so wish. However, they should be counselled to seek approval from parents or guardians. Routine counselling and testing in health facilities need to be improved and made child-friendly. This requires some investment. Counselling should provide emotional and psychosocial support, advice on the adherence to ARV treatment, and on behaviour change.
Counselling should cover all important aspects such as coping with the consequences of the disease; stigma and discrimination; relationships with family, friends and community; the need of consent of older children (12 years and above) for testing; confidentiality of HIV results and privacy in counselling and medical examination. Counselling of a child on HIV/AIDS of necessity includes counselling of parents or guardians, teachers and other people who are close to the child. Counselling should be routine at health facilities. It should address the totality of a child's needs. Of particular importance is counselling on sexuality for adolescent children who are HIV positive, and who are thinking of getting partners and starting families. The training curriculum for child counsellors should be expanded to include all these issues. Teachers, the community and school children should be educated on how to treat and relate to HIV/AIDS affected children.
Fourth, at the earliest possible opportunity, children with HIV/AIDS should be started on ARVs. Early treatment results into better response and quick improvement. It also enables prevention and treatment of opportunistic and other coexisting infections. It enables timely parental education to take place, and facilitates easy and timely access to social and emotional support.
Fifth, a comprehensive programme of psychosocial, emotional and material support is necessary. HIV affected children should have access to routine counselling, protection and affection.They need clothes, food and schooling and scholastic requirements. The Orphans and Vulnerable Children programme is an attempt to meet these demands but is woefully inadequate and requires expansion. Finally, a programme to fight discrimination, stigma and abuse of children affected by HIV/AIDS needs to be established, intensified and expanded.
The writers, Dr Sam Okuonzi and Dr Edison Muhwezi, are the director and programme officer, respectively, at the Regional Centre for Quality of Health Care, Makerere University School of Public Health
Source: http://allafrica.com/stories/200612180265.html
THIS year's AIDS Day has come and gone. The passion behind "Unite for Children, Unite against AIDS", the theme for the celebrations, has not materialised into any concrete strategy or policy. With the chest-thumping by politicians and health officials about the miracle of the Abstinence, Be faithful, Condom use (ABC) strategy, the assumption is that this strategy also caters for AIDS in children.
But this is a mistaken assumption. While there has been some success in bringing down HIV/AIDS in Uganda among the adults, it is too simplistic to attribute this success to the ABC strategy alone.
Four key factors for the reduction of HIV/AIDS have been openness, the coherent and systematic approach for public mobilisation and education, multi-sectoral collaboration, and unparalled resource mobilisation. These factors are not captured by the ABC formula.
But the strategy, even with its expanded version, ABC-plus, remains largely irrelevant for the management of HIV/AIDS in children. Ten percent of people living with AIDS are children less than 12 years. The main route of transmission of the virus is from mother to child - in the womb, during birth or through breastfeeding. This route is now responsible for 22% of all new infections in Uganda. While the ABC strategy is concerned with preventing or restricting sex, major challenges of HIV/AIDS in children occur after the act of sex of their parents and are non-sexual.
At least 2.5 million children in Uganda are orphans infected or affected by AIDS. In addition to suffering from HIV/AIDS as a disease, these children are confronted with huge challenges of survival, growth and development. Their basic needs for health, nutrition, education, affection and protection are at stake. They experience rejection, fear, discrimination, loneliness and depression. Children infected or affected by HIV/AIDS are often more abused, and commonly disowned and dispossessed of family property.
Most children have no opportunity to test their sero-status and to be counselled. Only a few facilities are available for child counselling on HIV/AIDS. This service is fragmented, and not particularly highly valued by policy makers as a key service. It is not supervised and is often done by amateurs. The few child counsellors available frequently experience emotional stress or "burn out" and are not readily replaced by others. Other challenges facing counselling include lack of co-operation and fear of disclosure to health workers of children's HIV status by parents and caregivers, and lack of resources to establish and operate child-friendly counselling centres.
Therefore, the ABC strategy, even with some additions, will not do for HIV/AIDS in children. A comprehensive strategy to tackle HIV/AIDS in children should be six- pronged. First, the prevention of mother-to-child transmission (PMTCT) should be intensified and expanded so as to reach every pregnant mother. The coverage by PMTCT of 78% of pregnant mothers attending ante-natal clinics (ANCs) is a good starting point. But more needs to be done to reach those who are not attending ANCs. Also, only 56% of HIV positive pregnant mothers currently receive Nevirapine. This should be improved, in the short term, to 80%.
Second, it will be important to ensure routine screening for HIV of all children who visit or are taken to health facilities for health care. To support this, laboratory capacity, technology and systems need to be set up to provide timely and reliable diagnosis. Empowering lower level health care workers by training, technical and financial support to diagnose and manage HIV/AIDS infection will be critical. Clinical criteria for HIV/AIDS diagnosis need to be established and updated from time to time, guided by researched evidence. Even so, HIV infection in children can still be missed. In the absence of a definitive diagnosis, children with symptoms suggestive of HIV infection should be started on ARV until it is firmly excluded.
Third, counselling of children needs to be comprehensive. Children 0-12 years who are suspected to be infected or demand to be tested should be tested for HIV. They should be accompanied by a parent or guardian. But older children who demand to be tested may be allowed go unaccompanied, if they so wish. However, they should be counselled to seek approval from parents or guardians. Routine counselling and testing in health facilities need to be improved and made child-friendly. This requires some investment. Counselling should provide emotional and psychosocial support, advice on the adherence to ARV treatment, and on behaviour change.
Counselling should cover all important aspects such as coping with the consequences of the disease; stigma and discrimination; relationships with family, friends and community; the need of consent of older children (12 years and above) for testing; confidentiality of HIV results and privacy in counselling and medical examination. Counselling of a child on HIV/AIDS of necessity includes counselling of parents or guardians, teachers and other people who are close to the child. Counselling should be routine at health facilities. It should address the totality of a child's needs. Of particular importance is counselling on sexuality for adolescent children who are HIV positive, and who are thinking of getting partners and starting families. The training curriculum for child counsellors should be expanded to include all these issues. Teachers, the community and school children should be educated on how to treat and relate to HIV/AIDS affected children.
Fourth, at the earliest possible opportunity, children with HIV/AIDS should be started on ARVs. Early treatment results into better response and quick improvement. It also enables prevention and treatment of opportunistic and other coexisting infections. It enables timely parental education to take place, and facilitates easy and timely access to social and emotional support.
Fifth, a comprehensive programme of psychosocial, emotional and material support is necessary. HIV affected children should have access to routine counselling, protection and affection.They need clothes, food and schooling and scholastic requirements. The Orphans and Vulnerable Children programme is an attempt to meet these demands but is woefully inadequate and requires expansion. Finally, a programme to fight discrimination, stigma and abuse of children affected by HIV/AIDS needs to be established, intensified and expanded.
The writers, Dr Sam Okuonzi and Dr Edison Muhwezi, are the director and programme officer, respectively, at the Regional Centre for Quality of Health Care, Makerere University School of Public Health
Source: http://allafrica.com/stories/200612180265.html
posted by AIDS-Care-Watch at 9:33 am
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