In 1997, as the IMCI guidelines were being adapted, HIV prevalence among pregnant women in South Africa was increasing rapidly, with the highest HIV prevalence in KZN (78). However,
management of HIV-infected children by primary health care workers was not specifically addressed in the generic IMCI case management guidelines. There were several reasons for this: at that time no specific treatment was available for HIV infected children, management of children with HIV was primarily hospital-based, and most HIV-infected children presented with conditions addressed by IMCI (79). In addition, IMCI guidelines already recommend that any child with a severe illness, or whose condition did not improve with routine treatment, should be referred to the district hospital for further management.
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However, the IMCI technical task team responsible for adapting the IMCI guidelines in KZN made the decision that a child survival strategy, being introduced in a setting where antenatal HIV
prevalence was among the highest in the world, should specifically and directly address HIV/AIDS.
Even in the absence of specific HIV treatment, health workers at PHC clinics, with support from referral services, were in the best position to identify and offer continued support to HIV-infected children, and their families, in the community. As a result, an HIV component was developed and added to the IMCI case management guidelines in South Africa. The aim of this IMCI/HIV component was to provide health workers with tools to counsel mothers about HIV and identify children at-risk of HIV infection, and to provide guidelines for HIV testing of children and for management of HIV infected children. Treatments available at that time included co-trimoxazole prophylaxis, and pain control where indicated. Implementation of these HIV guidelines would provide mothers and health workers with information about the child’s illness, and assist them to provide appropriate care.
Another anticipated benefit was that mothers receiving on-going treatment and support for their child at the local clinic, could also access health care for themselves, particularly counselling about safer sexual behaviour and contraceptive use.
The first version of the HIV algorithm, developed in KZN in 1998 (Figure 2), was based on local clinical experience and WHO clinical case definitions for paediatric AIDS (80). This HIV algorithm was integrated into the IMCI clinical guidelines such that IMCI trained health workers asked a series of
‘HIV questions’ during the routine assessment of every child. A single question was added to the assessment of each of the four main symptoms for this purpose. If there was a positive answer to any of the HIV questions, the health worker would undertake an additional assessment of the child, according to the HIV algorithm (Figure 2), to look for other symptoms or signs suggesting HIV infection. If the child was found to have three signs or symptoms suggestive of symptomatic HIV infection, the health worker would make a classification of SUSPECTED SYMPTOMATIC HIV, and the mother was advised to attend for counselling and HIV testing of the child. If the HIV test was positive, the child would receive on-going care at primary level. The aim of the HIV algorithm was to be a screening tool to identify high-risk children who would benefit from HIV testing, rather than to accurately diagnose HIV positive children.
This HIV algorithm was subsequently adopted throughout South Africa. As a result, WHO held an expert consultative meeting in Durban in 2000 (81), where a draft generic HIV component based on the algorithm shown in Figure 2 was accepted and recommended for implementation in high HIV prevalence countries (79). At this meeting, it was proposed that the HIV algorithm should be formally evaluated in KZN.
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Figure 3: KZN HIV algorithm (1998)
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2.2.1 Evaluation of the HIV algorithm
The initial HIV algorithm shown in Figure 2 was evaluated in KZN in 2001, by Horwood and colleagues, with funding support from WHO (Appendix 1). In total, 690 consecutive children aged 2-59 months attending the paediatric outpatient department in a district hospital in KZN were enrolled in the study. Each child had a standardised detailed clinical examination by a
paediatrician, and was then separately assessed by an expert IMCI practitioner for SUSPECTED SYMPTOMATIC HIV using the HIV algorithm. All enrolled children were then tested for HIV.
198/690 (28.7%) children tested HIV positive, 56.1% of whom were classified as SUSPECTED SYMPTOMATIC HIV by the IMCI expert. The specificity of the HIV algorithm was 85.0%, and the positive predictive value (PPV) was 60.0% (82).
A statistical model was developed based on the significant predictors of HIV infection
identified among children in the study population. Different combinations of clinical features were tested, using this model to maximise the sensitivity and specificity of the algorithm, and a revised and simplified HIV algorithm was developed (Figure 3). This algorithm had a sensitivity of 70.1%
and specificity of 80.1% when applied to the KZN study sample (82), and was the basis for a generic WHO HIV algorithm, recommended for IMCI implementation in high HIV prevalence countries. As a result, in 2002, WHO revised the IMCI adaptation materials to include management of children with symptomatic HIV, for those countries wishing to include HIV management in their IMCI materials (79). To ensure that the KZN study findings could be replicated in other high HIV prevalence settings, where childhood illnesses like diarrhoea and malnutrition may be more common in HIV uninfected children, the KZN study methodology was repeated in Ethiopia (83) and in Uganda (unpublished) with funding support from WHO.
However, the algorithm soon required further revisions as PMTCT programmes became available in high HIV prevalence countries, and HIV testing for mothers and HIV PCR testing for infants became more widespread at primary care level. An updated HIV algorithm was developed, taking into account HIV test results of the mother and child, if available, and included an additional classification for HIV exposure. In 2008, WHO published a revised algorithm (Figure 4) and chart booklet. The revised algorithm includes more detailed information on ART for children, treatment of mouth and skin lesions, and opportunistic infections. It is currently recommended for IMCI implementation in high HIV prevalence countries (84). Although, this current version of the algorithm still includes an assessment of signs of symptomatic HIV for children who not been tested for HIV, much more emphasis is placed on ensuring that mothers receive HIV test results for their children and appropriate care and treatment thereafter. The IMCI/HIV algorithm,
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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).