Barriers to the care of HIV-infected children in rural Zambia: a cross-sectional analysis

Abstract

BackgroundSuccessful 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.MethodsCross-sectional analysis of HIV-infected children seeking care at Macha Hospital in rural southern Zambia. Information was collected from caretakers and medical records.Results192 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.ConclusionHIV-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.

Impact of Geographic and Transportation-Related Barriers on HIV Outcomes in Sub-Saharan Africa: A Systematic Review

“…In these studies, prominent themes included lack of money to pay for transportation to clinic [24, 49–54, 57, 59], being forced to decide between paying for transportation to clinic and basic necessities such as feeding one’s family or purchasing medications for opportunistic infection prophylaxis [52, 63], and the need to draw on social supports to overcome transportation barriers [62]. Poor road conditions [46], difficulty accessing reliable transportation [24], and the inability to take time off from work to travel long distances to clinic [51], were also described as factors that contributed to transportation difficulties. These studies represented at least 5,373 participants in ten countries: Botswana, Ethiopia, the Gambia, Kenya, Malawi, Namibia, Nigeria, South Africa, Tanzania, and Uganda.…”

Measles and Rubella Seroprevalence Among HIV–infected and Uninfected Zambian Youth

“…36,37 After obtaining written informed consent from a parent or guardian and assent from children 8–15 years of age, children were seen at study visits every three months, at which time a questionnaire was administered, the child was examined and a blood sample was collected. Beginning in 2009, blood spots were collected on filter paper (Whatman, Protein Saver card 903) at enrollment and after ART initiation.…”

Feasibility and Challenges in Providing Antiretroviral Treatment to Children in Sub-Saharan Africa

“…While caregivers generally report that the optimal age for disclosure is 11 or 12 years [60], only 17-38% of adolescents in Cote d'Ivoire and Zambia were aware of their HIV infection status [53,58,59], and many caregivers felt that their children were too young to be told [58]. Significantly more children receiving ART in these studies were aware of their status, as initiating and adhering to treatment often motivate disclosure.…”

“…Research on disclosure in sub-Saharan Africa is increasing and indicates that disclosure is not common, even among older children [53,[58][59][60]. While caregivers generally report that the optimal age for disclosure is 11 or 12 years [60], only 17-38% of adolescents in Cote d'Ivoire and Zambia were aware of their HIV infection status [53,58,59], and many caregivers felt that their children were too young to be told [58].…”

“…In the same study population, distance to the clinic was negatively associated with viral suppression [68]. Both direct and indirect costs of transportation have been identified as barriers to adherence in adult and pediatric populations, particularly in rural areas where distances travelled may be substantial [58,[69][70][71][72][73].…”