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therefore, provides an important link to PMTCT and ART programmes within a well-established, integrated child health programme.
There has been no formal evaluation of implementation of the HIV component in routine practise, but in 2001, a small-scale health facility survey (HFS) was conducted in four provinces in South Africa, using the standard WHO HFS methodology, with the addition of a single indicator relating to HIV classification. The findings showed that only one of 18 children identified as SUSPECTED SYMPTOMATIC HIV by the IMCI expert was correctly classified by the observed health worker. Although the numbers of observed children in this review were small, the findings suggest poor implementation of the HIV component by IMCI trained health workers (85).
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IF THE CHILD-
has a classification today of PNEUMONIA or PERSISTENT DIARRHOEA or NOT GROWING WELL OR
Has had an episode of persistent diarrhoea in the past three months OR
Has had a discharging ear at any time OR
If the mother is known to be HIV positive*
ASSESS FOR SYMPTOMATIC HIV INFECTION *:
Discuss reasons for classification w ith mother and advise her to take the child for HIV testing
Arrange pre-test counselling and HIV testing
Assess feeding and counsel (p.21)
Counsel mother about her ow n health
Follow -up in 14 days as follow s:
- if mother agrees to have the child tested, discuss the result and arrange regular follow up if positive (p.20) - if mother refuses testing, review the child and for
further discussion. Offer treatment to the child including regular follow -up and co-trimoxazole prophylaxis if HIV testing is refused (p.20).
three or more
positive findings SUSPECT ED SYMPTOMATIC
HIV
If the mother is know n HIV positive:
- give appropriate feeding advice (p. 23)
- if the child is under one year start co-trimoxazole prophylaxis (p. 9) and test to determine w hether the child is infected at age 12 months
- if the child is over one year arrange testing to determine if the child is infected
Counsel mother about her ow n health and about prevention of HIV infection
If breastfeeding counsel about importance of safe sex during breastfeeding to prevent HIV transmission to the baby if the mother becomes infected w hile breastfeeding
KZN IMCI guideline September 2002
*If the child has been classified as symptomatic HIV in the past and had a positive HIV test, do not assess again - give follow-up care for confirmed symptomatic HIV (p. 20)
less than three
positive findings SYMPTOMATIC HIV UNLIKELY NOTE (a s above):
Does the child have
any PNEUMONIA now?
ear discharge now OR in the past?
low weight for age?
poor weight gain or weight loss?
An y episode of persistent diar- rhoea in the past three months?
LOOK AND FEEL FOR:
enlarged lymph glands in two or more of the following sites:
neck, a xilla or groin?
oral thrush?
parotid gland enlargement?
CLASSIFY by counting the number of positive findings
Symptomatic HIV Assess and classify
Figure 4: KZN HIV algorithm (2002 version)
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Figure 5: WHO generic HIV algorithm for high HIV prevalence countries (current version 2008)
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Chapter Three: Rationale for South African HIV/IMCI effectiveness
study
The SA HIV/IMCI Effectiveness Study, presented in this thesis, is a continuation of work that started in 1998 with the development of an HIV component for IMCI, and led to the publication of the WHO generic IMCI guideline for high HIV prevalence areas (84). The aim of this study was to evaluate the effectiveness of IMCI implementation, with particular focus on the HIV component, in routine practise in a high HIV prevalence area in two provinces of South Africa. The study was conducted to determine whether the IMCI programme, a complex public health programme widely adopted in South Africa, is achieving the levels of effective implementation required to reach high coverage of interventions among children attending PHC facilities, in the ‘real-life’
situation. The study also sought to identify barriers and enablers to implementation of IMCI, particularly the HIV component, to provide an evidence-base to improve IMCI implementation, and provide additional information about the sustainability of IMCI.
This study was designed with a focus on the implementation of the HIV component of IMCI, particularly to investigate determinants of health workers ability and willingness to take every opportunity, during the course of routine care, to identify HIV infected and exposed children and deliver appropriate interventions. This was because there are unique challenges involved in caring for HIV infected patients, and implementation of the HIV component is fundamental to overall success of IMCI in high HIV prevalence settings. Although the African countries participating in IMCI-MCE had a relatively high HIV prevalence (5.4% and 6.2% in Uganda and Tanzania,
respectively, in 2007), and both countries had adapted IMCI guidelines to include HIV, there has been no previous large-scale evaluation of IMCI implementation conducted in a high HIV prevalence setting, and no effectiveness study of the HIV component. Apart from a small preliminary study conducted by the author to evaluate the efficacy of the HIV algorithm (82), no research has been conducted to assess the sensitivity, specificity and positive predictive value of the HIV algorithm in routine practise, or the coverage of HIV interventions recommended by the IMCI guidelines at operational PHC level.
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