Rapid appraisal of primary level health care services for HIV-positive children at public sector clinics in South Africa

South Africa has a large and growing number of HIV-infected children. While no policy exists to provide anti retroviral therapy to these children, several other effective health and social interventions are available which have been shown to improve life expectancy and quality of life in HIV-infected children. This study was undertaken to ascertain the extent to which some of these interventions are currently available to children attending public sector clinics in all 9 provinces of South Africa. The research was conducted as a rapid appraisal of services and information was collected through brief telephonic interviews with clinic managers at 11% of the public sector clinics in South Africa.

The study looked at whether the following five interventions were available:

• Cotrimoxazole as a prophylaxis to prevent pneumocystis carinii pneumonia (PCP) in children
• Vitamin A supplementation
• Tuberculosis (TB) contact tracing for children
• Nutritional supplementation through the Protein Energy Malnutrition (PEM) Scheme
• Social assistance grants

Several policies and guidelines exist which provide health staff with information on the administration of one or more of these interventions. A set of comprehensive guidelines entitled Managing HIV in Children was released by the National Department of Health in March 2000. This booklet was intended as a guide for primary health care staff. This study also looked at the extent to which these guidelines were available to clinics and used by health care staff.

The results indicate that the guidelines are not widely accessible but that they are urgently required. Only 20% of the clinics had knowledge of the guidelines. Over 30% of the clinics reported that HIV-positive children are referred elsewhere for treatment.

It was not clear from the study whether this included long-term management. Only one third of the clinics had a policy in place for the administration of prophylactic cotrimoxazole to HIV-infected children and most of these clinics were prescribing the drug incorrectly. Clinics were also found to be administering cotrimoxazole inappropriately as a treatment.

Nationally, 35% of the clinics reported administering vitamin A to HIV-positive children. The administration of both vitamin A and cotrimoxazole was impeded by their availability at clinics.

Most of the clinics reported some system for following up on child contacts of adult cases of TB. 57% of the clinics reported administering prophylatic TB treatment for child contacts as part of their contact tracing. Of the clinics that provided details on the specific prophylatic agent used, only 19% were providing the correct regimen according to the National TB Control Programme recommendations.

The majority of the clinics (75%) reported that HIV-positive children were included on the clinics PEM scheme. 53% of these clinics reported however that the child had to be underweight or malnourished in order to qualify. Irregular supplies of milk formula and PVM porridge were cited as the major problems with the implementation of the scheme.

The vast majority of the clinics (73%) reported that they refer clients elsewhere for advice and assistance with accessing a social security grant.

The study highlights the need for monitoring and evaluation of the implementation of existing policies/guidelines and for training of primary health care staff on the appropriate management of HIV in children. The results also indicate the need for greater inter-sectoral collaboration and for clear directives on certain interventions for HIV-infected children, such as the inclusion of all HIV-infected children on the PEM scheme.

Finally, the regular supply of necessary drugs and supplements are essential for the successful implementation of existing policy and guidelines.