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Background: Successful antiretroviral treatment programs in rural sub-Saharan Africa may face different challenges than programs in urban areas. The objective of this study was to identify patient characteristics, barriers to care, and treatment responses of HIV-infected children seeking care in rural Zambia. Methods: Cross-sectional analysis of HIV-infected children seeking care at Macha Hospital in rural southern Zambia. Information was collected from caretakers and medical records. Results: 192 HIV-infected children were enrolled from September 2007 through September 2008, 28% of whom were receiving antiretroviral therapy (ART) at enrollment. The median age was 3.3 years for children not receiving ART (IQR 1.8, 6.7) and 4.5 years for children receiving ART (IQR 2.7, 8.6). 91% travelled more than one hour to the clinic and 26% travelled more than 5 hours. Most participants (73%) reported difficulties accessing the clinic, including insufficient money (60%), lack of transportation (54%) and roads in poor condition (32%). The 54 children who were receiving ART at study enrollment had been on ART a median of 8.6 months (IQR: 2.7, 19.5). The median percentage of CD4+ T cells was 12.4 (IQR: 9.2, 18.6) at the start of ART, and increased to 28.6 (IQR: 23.5, 36.1) at the initial study visit. However, the proportion of children who were underweight decreased only slightly, from 70% at initiation of ART to 61% at the initial study visit. Conclusion: HIV-infected children in rural southern Zambia have long travel times to access care and may have poorer weight gain on ART than children in urban areas. Despite these barriers, these children had a substantial rise in CD4+ T cell counts in the first year of ART although longer follow-up may indicate these gains are not sustained. © 2009 van Dijk et al; licensee BioMed Central Ltd.
HIV-infected children younger than 16 years and attending the Antiretroviral Clinic at Macha Hospital in Macha, Zambia were eligible for enrollment. Macha is located in Southern Province, approximately 80 km from the nearest town of Choma. The catchment area of Macha Hospital is populated by traditional villagers living in small, scattered homesteads, with an estimated population density of 25 persons per km2 (P. Thuma, unpublished data). Macha Hospital is a 208-bed hospital administered by the Zambian Brethren in Christ Church that functions within the healthcare system of the Ministry of Health. The hospital serves as a district-level referral hospital for smaller hospitals and rural health centers within an 80 km radius, serving a population of over 150,000 persons. Macha Hospital provides care to approximately 4000 HIV-infected adults and children through the Government of Zambia’s antiretroviral treatment program, with additional support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the non governmental organization, AidsRelief. A program to prevent maternal-to-child HIV transmission began at Macha Hospital simultaneous with the implementation of the ART clinic in 2005. HIV-infected children are referred to the clinic from voluntary counseling and testing programs, outpatient clinics and hospitals. Since February 2008, children born to HIV-infected women are routinely tested for HIV infection at approximately 6 weeks of age, using dried blood spot samples and HIV DNA PCR performed in Lusaka, Zambia. Clinical care is provided without charge by medical doctors and clinical officers, and adherence counseling by nurses and trained counselors. Home visits are attempted for persons who fail to return for scheduled follow-up visits. Children were considered eligible for antiretroviral therapy if they had WHO stage 3 or 4 disease, or a CD4+ T cell percentage of <25% for children ≤ 11 months of age, < 20% for children 12-35 months of age, or <15% for children ≥ 36 months of age. The first-line antiretroviral treatment regimen consists of two nucleoside reverse transcriptase inhibitors (lamivudine plus zidovudine or stavudine) and a non-nucleoside reverse transcriptase inhibitor (efavirenz or nevirapine). This cross-sectional analysis was conducted within the context of an observational cohort study. HIV-infected children seeking outpatient care at Macha Mission Hospital, Choma, Zambia were prospectively enrolled into an observational cohort study beginning in September 2007 after written informed consent was obtained from a parent or guardian. The caretakers of all children who were asked to participate agreed to enroll in the study. A questionnaire developed by the study team was administered to the parent or guardian and the child was examined at the initial study visit and at each follow-up visit occurring approximately every three months. Blood specimens were collected in EDTA tubes as part of routine clinical care. Information from before study enrollment was abstracted from medical records. CD4+ T cell counts and percentages were measured using the Guava Easy CD4 system (Guava Technologies, Inc., Hayward, CA), and hemoglobin was measured using the ABX MICROS 60 (Hariba ABX, France). The study was approved by the Research Ethics Committee of the University of Zambia, the Ministry of Health, Republic of Zambia and the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health. For the present analysis, information was used from the initial study visit for HIV-infected children enrolled into the cohort study between September 2007 and September 2008. Children were classified as HIV-infected if they were older than 18 months with a positive serological test, younger than 18 months with confirmed infection by PCR either prior to or within 3 months of the initial study visit, or younger than 18 months with a positive serological test and either eligible for ART based on the 2006 WHO treatment guidelines or receiving ART at the initial study visit. Data were entered in duplicate using EpiInfo (Centers for Disease Control and Prevention) and analyses were conducted in SAS for Windows version 9.1 (SAS Institute Inc., Cary, NC). Proportions are reported for categorical variables and differences were tested using chi-square tests. Medians and interquartile ranges are reported for continuous variables and differences were tested using Wilcoxon rank sum tests. Children were categorized according to their use of ART at the time of the first study visit. Children who were not on ART were further categorized by eligibility for ART, as defined by the 2006 WHO treatment guidelines [21]. If laboratory results were not available at a specified clinic visit, results were used within a 3-month period (3 months prior for children initiating ART). Weight-for-age z-scores were calculated based on the WHO growth standards [22] and children with z-scores below -2 were defined as underweight. A measure of socio-economic status (SES) was calculated based on the Demographic and Health Survey SES scale used in Zambia [23]. SES percentiles were based on the predetermined cutoffs (75th = 19-24).
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