EVALUATION OF HIV ADAPTATIONS TO IMCI

Integrated Management of Childhood Illnesses (IMCI) is a WHO/UNICEF strategy aimed at reducing mortality in children under five years by improving health care at a primary level.

In South Africa, IMCI was adapted to include an algorithm to identify children with symptomatic HIV infection, and guidelines for the management of these children. These HIV guidelines have been widely implemented in South Africa and evaluated. However, there had been no research to determine the extent to which all the aspects of the HIV adaptations are being implemented, neither had the effect of the adaptations on the workload of health care providers been investigated. The sensitivity, specificity and positive predictive value of the HIV algorithm during routine use had also not been evaluated.

Consequently, research was commissioned by the National Department of Health, in partnership with the Kwazulu-Natal Department of Health, Limpopo Department of Health and the World Health Organisation, to evaluate the HIV guidelines and their effectiveness during routine care by IMCI trained health workers. The research was implemented by CRH, and the project started in November 2005 and will be completed in 2007.

The study employed a two-phase field evaluation approach, conducting research at clinics in two provinces in South Africa: KwaZulu-Natal and Limpopo.

Phase one was a qualitative assessment to determine the attitudes and experiences of child carers and health care providers with regard to the HIV algorithm and its implementation. This was done using focus group discussions, with two discussions for carers and two for health care providers being held in each province. In this way a rich yield of information regarding experiences and attitudes relating to the HIV-adapted IMCI training materials was gathered. This phase also assisted in determining possible barriers to implementation of IMCI from the perspective of both health care providers and carers, as well as carers' attitudes to and experiences of the inclusion of HIV-related questions and issues in the routine management of children at a primary health level.

Phase two made use of observed consultations and data collection and was quantitative in approach. Thirty-one IMCI trained health care providers from each province were observed doing twenty consultations with sick children. All findings were checked by an expert IMCI practitioner who determined whether the children were assessed and managed correctly according to all the aspects of the adapted IMCI guidelines.

Carers of the children then received HIV counselling and, where consent was obtained, the child was tested for HIV. Children below eighteen months who had a positive HIV rapidtest had their status confirmed with PCR testing, whilst above the age of eighteen months the confirmatory test was a second rapidtest. In this way the effectiveness of the IMCI algorithm was determined as compared to an HIV test. Observed children who were confirmed as HIV positive or where a confirmatory test was still awaited, were then examined for signs of HIV infection according to the WHO revised Clinical Staging of HIV and Aids in Infants and Children, simplified for use in primary care.

Lastly, observers did a clinic review to look at the availability of resources required for implementing care for HIV infected children. They also reviewed clinic-based records to determine whether children are tested and followed up properly.

As treatments become available for HIV infected children, it is important that guidelines are available for health care providers at a primary level to be able to identify and manage sick children appropriately. IMCI is a tool which will make treatment accessible to children with HIV in many countries, and this study will help to ensure that effective guidelines are being implemented.