"Children and HIV/AIDS" presentation by Prof. Hoosen Coovadia

1. South Africa: a cocktail of
four colliding epidemics

2. South Africa: coping with a
very high burden of disease
Percentage of
total
22%
9%
6%
4%
4%
4%
3%
3%
3%
2%
2%
2%
2%
2%
2%
2%
1% Population: 45 M
Figure 2: National burden of disease
Data sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo.
DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.

3. South Africa: coping with a
very high burden of disease
Percentage of
total
22%
9%
6%
4%
4%
4%
3% Population: 153 M
3% Population: 48 M
3%
2%
2%
2%
2%
2%
2%
2%
1% Population: 45 M
Figure 2: National burden of disease
Data sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo.
DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.

4. South Africa: coping with a
very high burden of disease
Percentage of
total
22%
9%
6%
4%
4%
4%
3%
3% Population: 48 M
3%
2%
2%
2%
2%
2%
2%
2%
1% Population: 45 M
Population: 45 M
Figure 2: National burden of disease
Data sourced from WHO Global Burden of Disease (2002). DALYs=disability-adjusted life years. DR Congo=Democratic Republic of the Congo.
DTP=diphtheria, tetanus, and pertussis. *Low birthweight, birth asphyxia, and birth trauma.

5. Assessment of S. Africa’s
progress on 6 MDGs
MDG Progress in South Africa On track?
1. Eradicate extreme Underweight children < 5 years:12% Target ≤5% Reversal of
progress
poverty & hunger Mean reduction per year: –6% Target 2-6%
1. Achieve universal Enrolment in primary school: 87% Target 90% Insufficient
progress
primary education
1. Promote gender Gender parity ratio: 1·0 Target 1·0 On track
equality &
empower women
1. Reduce mortality of <5 mortality 1995-2005 - increasing Target -66% Reversal of
progress
children <5 years
1. Improve maternal Maternal mortality 1995-2005 – no Target -75% No progress
health reduction
1. Combat AIDS, HIV prev 1995-2005 - increasing Target -50% Insufficient
progress
malaria, etc

6. Potential for significant impact

7. A lack of health improvement
despite major investments
The paradox is poor health outcomes
despite good policies and relatively
high health expenditure
5 main areas where contradictions help explain the
discordance between high investments and poor outcomes

8. Avoidable Causes of Deaths
• Clinical Care:
poor quality
• Administrative Management:
shortcomings
• Community:
avoidable factors-awareness
and demand

9. Family and Managers and Healthcare
Community policy makers providers
44% of maternal deaths 32% of maternal deaths 54% of maternal deaths had a
had a modifiable factor had a modifiable factor modifiable factor related to
related to related to administrator healthcare provider action at
family/community action, action, e.g. lack of blood primary level; 48% at secondary
e.g. Inadequate or no for transfusion, lack of level; and 37% at tertiary level
antenatal care transport between health e.g. not adhering to standard
institutions protocols
38% of stillbirths and 19% of stillbirths and early 35% of stillbirths and early
early neonatal deaths had neonatal deaths had a neonatal deaths had a modifiable
a modifiable factor related modifiable factor related to factor related to healthcare
to family/community administrator action, e.g. provider action, e.g. fetal distress
action, e.g. delay in personnel not available or not identified in labour, poor
seeking care during not sufficiently trained response to maternal
labour hypertension
25% of all modifiable 22% of all modifiable 53% of all modifiable factors in
factors in child deaths factors in child deaths were child deaths were related to
were related to related to administrator healthcare provider action, e.g.
family/community action, action, e.g. lack of senior IMCI not used in clinics, and poor
e.g. caregiver did not doctors and nurses, and assessment and management in
recognise severity of the insufficient paedaitric beds hospitals
illness

10. SPECIALIST OBSTETRIC AND GYNAECOLOGICAL SPECIALIST NEONATAL AND PAEDIATRIC CARE
Regional
hospital
CARE
Connecting places of caregiving
REPRODUCTIVE EMERGENCY PREGNANCY AND EMERGENCY NEWBORN AND CHILD CARE
CARE CHILDBIRTH CARE Care for sick children including those with HIV&AIDS, based
hospital
District
Termination of pregnancy Care for high risk pregnancies and
Post-abortion care
on Integrated Management of Childhood Illness principles
Treatment of complicated immediate newborn care including Extra care of preterm babies including kangaroo mother care
sexually transmitted resuscitation Emergency care for sick newborns
infections
REPRODUCTIVE ANTENATAL BASIC CHILDBIRTH POSTNATAL CARE CHILD CARE
HEALTH CARE CARE CARE •Early detection & Immunisations
•Family planning Basic antenatal Care for normal
referral of complications Growth monitoring and
Outpatient and
•Prevention and care care package with deliveries and immediate nutrition
maternity unit
•Support for infant
of sexually prevention of HIV newborn care including feeding choices Integrated Management of
transmitted infections mother-to child resuscitation •HIV testing for infants at Childhood Illness integrated
and HIV&AIDS transmission and prevention of mother- with care of children with HIV
6 weeks
•Preconception folic care for women to child transmission of including cotrimoxazole
acid HIV
•Adolescent and pre- •Healthy behaviours eg maternal nutrition, •Appropriate home care of babies: appropriate feeding, avoiding
pregnancy nutrition reduced work load hypothermia, hygienic cord/skin care, extra care for preterm babies
•Prevention of HIV •Danger sign recognition, and emergency •Good nutrition, including complementary feeding
•Demand for key preventive services such as immunisations
community
and sexually preparedness
Family and
transmitted infections •Recognition of danger signs and appropriate care-seeking
Intersectoral Improved living conditions – housing , water and sanitation, nutrition
Education and empowerment
Pre-pregnancy Pregnancy Birth Postnatal Childhood

11. Need to address key structural
and health systems bottlenecks
Improving capacity and stewardship of health system
to institute fundamental changes such as:
improving levels of morale and commitment amongst
health workers;
scaling up of mid-level workers;
task-shifting;
standardization, expansion and strengthening of
community health worker programmes;
and re-orientation of pre-service training, accelerated
production of such graduates and enhancing capacity
of public health managers.

12. Violence and injuries
Distribution of injury mortality by cause, 2000
(A) Worldwide. (B) South Africa.

13. Examples of innovation in the
system
Examples of innovation
Maternal, • Audits of deaths of mothers and children26;
Newborn and • Twinning of hospitals and clinics;
Child Health • On-site mentoring within health system27;
• Development of ‘mothers to mothers’ support groups28;
• Use of participatory research to improve malnutrition
management29
HIV/TB • Widespread implementation of lay counsellors and community
workers30;
• Universal use of rapid HIV test kits;
• Shift towards nurse driven treatment and care;
• Development and introduction of electronic clinical information
systems31
• Outreach support for nurses in TB programmes32
Chronic disease • Development of simplified clinical protocols33;
and mental health • Inclusion of adult health indicators in national health survey to monitor
the prevention and control of chronic diseases and their risk factors34
• Outreach support from hospital to clinics
Violence and • Development of Family Courts;
injury • Establishment of peace committees;
• Use of group interventions and micro-credit to reduce violence35 36;
• Settings based approach (schools and cities) towards improving
environmental determinants;

14. Key Messages
– HIV/AIDS and poor implementation of
existing packages of care are the
main reasons for the lack of progress
towards the MDGs on MNCH.
– Full coverage of key packages of
interventions would put South Africa
on track to achieve MDG 4 and make
substantial progress towards MDG 5.

15. Key messages
 High coverage of priority care for
MNCH is financially feasible,
requiring a 24% increase in
expenditure.
 Strengthening of leadership,
accountability mechanisms, and
high quality of care interventions
are required

16. 4 million
newborns die
annually within
the first month
of life, and their
fate is
intimately
linked to their
mothers’
health.

17. HIV AND MATERNALMORTALITY
King Edward Vlll Hospital, Durban., South Africa
Hypertension
Other Causes
(24%)
(35%)
AIDS
Pre-existing Med (15%)
Conditions
Pregnancy-related Haemorrhage
Sepsis (7%) Under-reporting of AIDS Deaths
HIV Status unknown in 75.8%

18. Why do mothers die in South Africa?
Other, 16% Non-
pregnancy
related
infections
Sepsis, 8% sucAIDS,
TB,
Pre-existing
pneumonia,
medical
38%
disease, 6%
Haemorrhag
e, 13%
Hypertensio
n, 19%
Source: Saving mothers report, DOH.

19. Why do newborns and
children die in South Africa?
Pneumonia, 1% Other child,
2% Injuries, 5%
Diarrhoea, 1%
Neonatal
infections, 7%
Preterm, 13%
Neonatal
HIV & Birth asphyxia,
AIDS, 8%
35% Congential, 4%
Other neonatal,
2%
Source: UN estimates and South African data for 2008

20. WHY DO WHY DO AFRICAN
NEWBORNS AND CHILDREN UNDER
CHILDREN DIE IN THE AGE OF 5
SOUTH AFRICA? YEARS DIE?
Pneumonia, 1% Other child,
2% Injuries, 5%
Diarrhoea, 1%
Neonatal
infections, 7%
Preterm, 13%
Neonatal
HIV & Birth asphyxia,
AIDS, 8%
35% Congential, 4%
Other neonatal,
2%
Source: UN estimates and South African data for 2008

21. Number of Children on Comprehensive HIV and AIDS Treatment Plan
Source of data: Monitoring and Evaluation, DoH, SA
21

23. Mortality trend in selected countries
Brazil
*
56
46
21
17
IMR U5MR
1990 2009
South Africa
*
62 62
48
43
IMR U5MR
1990 2009
Source: : UN Inter-agency Group for Child Mortality Estimation,2010 23

24. WHY DO WHY DO
AFRICAN MOTHERS DIE
MOTHERS IN SOUTH
DIE? AFRICA?
Why
do mothers die in South Africa?
Other, 16%
Other, 16% Non-
pregnan
related
infectio
Sepsis, 8%
Sepsis, 8% Non-
sucAID
pregnancy
TB,
related
infections
Pre-existing
pneumon
sucAIDS, TB,
pneumonia,
medical
Pre-existing medical
disease, 6% 38%
38%
disease, 6%
Haemorrhag
Haemorrhage, 13%
e, 13%
Hypertension, 19%
Hypertensio
n, 19%
Source: Saving mothers report,
Source: Khan KS et al. Lancet 2006 Source: Saving mothers report. DoH.

25. TOTAL MATERNAL
POPULATION MORTALITY
BURDEN
SASI Group and M. Newman 2006

26. HIV/AIDS BURDEN
Source: SASI Group and M. Newman 2006

27. MORTALITY: 1-4 YEAR OLDS

28. Family and HIV
First steps to healing the South African Family.
Lucy Holborn and Gail Eddy. SAIRR
Fractured families: a crisis for South Africa
“In South Africa, the “typical” child is raised by their
mother in a single-parent household. Most children
live in households with unemployed adults”

29. Orphans and child-headed households:
There are 860 000 double-orphans in this country, 624 000
maternal orphans and 2 400 000 paternal orphans. More than
half had lost parents due to AIDS.
Single-parent households:
23% of children were living with neither biological parent; 35%
were living with both biological parents.
Absent fathers:
Living but absent fathers 48% and present 36% in 2009.

31. Broken families breaking
youth.
Family breakdown impacts
on: education, employment
opportunities, teenage
pregnancies, attitudes to sex,
HIV, violence and crime,
mental health

32. WHAT NEEDS TO BE DONE AT
FAMILY LEVEL?
NOW!
1. Support children through families
2. Develop comprehensive & integrated
family-centered services
3. Create social protection for the
poorest families
4. Expand income transfers to poor
families
Linda Richter. Mexico IAS Conference 2008

33. NOT ONLY ORPHANS ARE
AFFECTED
• AIDS Orphans ??
• Children infected and affected
• Few differences between “orphans”
and very poor children
• A massive social problem
<10% of children orphaned or made vulnerable by AIDS currently receive
public support and services. UNAIDS . 2007 AIDS EPIDEMIC UPDATE

34. TREATMENT: WAYS FORWARD
• Each infection can and should be
prevented
• Early diagnosis prior to disease
progression
• Earlier initiation of ART
• Expand screening for HIV in health care
facilities

35. TREATMENT:
IMPROVING EFFECTIVENESS OF ARV
THERAPY AMONG HIV-INFECTED
CHILDREN IN SUB-SAHARAN AFRICA
“..findings emphasise the need for:
**low-cost diagnostic tests that allow for earlier
identification of HIV infection in infants
**improved access to antiretrovirals, including
expansion into rural areas
**integration of antiretroviral treatment
programmes with other health-care services,
such as nutritional support”.
Sutcliffe et al, Lancet Infectious Diseases, 2008; 8:477-89

36. All children, including those
affected by HIV and AIDS are
best cared for in functional
families with basic income
security, access to health care
and education, and support
from kin and community
Our work is to ensure these conditions
for children and families