Is Kenya leaving her children behind in fight against HIV?

HIV response in Kenyan children is lagging behind despite the country being close to meeting the global target in addressing the virus in adults.

Year after year, Kenya is missing its target of eliminating new HIV infections among children, raising concerns that hundreds could be dying needlessly.

Kenya has received high praise for its fight against HIV, but there are challenges it has not overcome — including access to child-friendly medicine.

The latest report by the Joint United Nations Programme on HIV/Aids (UNaids) states there are about 6,800 new HIV infections in children in Kenya compared to 5,700 in Uganda and 8,600 in Tanzania.

HIV-FREE START TO LIFE

The report dubbed “Start free, stay free, Aids free” framework emphasised the need for every child to have a HIV-free start to life through prevention.

Those living with HIV should have access to antiretroviral (ARV) therapy to stay Aids-free and reduce the risk of onward transmission to uninfected persons.

The report released yesterday during a virtual international Aids conference revealed that only 58 per cent of children who are HIV positive are on treatment compared to 78 per cent of adults. Uganda leads in East Africa with 60 per cent of HIV-positive children on treatment as Tanzania lags behind with 57 per cent.

The data shows consistently lower viral load suppression among children than among adults.

CHILDREN ON TREATMENT

In Kenya, 77 per cent of children on treatment are virally suppressed followed by Uganda at 74 per cent and 72 per cent in Tanzania.

Highlighting the challenges hindering the retention of children in treatment, the study revealed lack of access and appropriate formulations specifically for children.

“Several countries have an ongoing shift to optimal formulations, but this needs to be supported with appropriate procurement and supply of optimal formulations (delays have occurred in some settings because of insufficient manufacturing capacity and supply security),” states the study.

CHILD-FRIENDLY TREATMENT

Poorer viral suppression among children is, at least partly, attributable to a lack of child-specific and child-friendly treatment options, which leads to inefficiency, side effects, non-adherence to treatment and dropping out of care.

Lack of knowledge and resources from caregivers affects children’s adherence and their retention on treatment, meaning, they’re not given drugs in the right proportion. Some vomit after taking the drugs, while there are caregivers who don’t know the correct dosage. With these treatment challenges, little wonder that children are lagging behind.

Highlighting the factors that have made it hard to suppress children’s viral load, Dr Justine Odionyi, Elizabeth Glaser Paediatric Aids Foundation Kenya (Egpaf) technical director, named three reasons — HIV factors, drug factors and patient factors.

VIRAL SUPPRESSION RATE

The viral suppression rate varies across regions, with Homa Bay doing best among counties at 85 per cent, above the national average of 82 per cent, according to the National Aids and STI Control Programme.

Arid and semi-arid counties have a much lower VLS due to myriad challenges in those regions.

For drug factors, children's medicine is in multiple formulations — syrups, pellets and tablets — that keep changing with a child’s age and weight. Newborns (3kg) are started on a syrup and a dispersible tablet. The drugs are also weight-dependent, so the dosage changes as the child grows.

Needs refrigeration

“The current drug for children, given to any child below 20kg, is a Lopinavir-based regimen of which the syrup formulation given to the very young is bitter, needs refrigeration, causes vomiting and nausea and some level of diarrhoea,” Dr Odionyi said.

The syrups can be switched to pellets of the same type of drug after three months. Younger children have even fewer treatment options.

Currently, Zidovudine, Lamivudine and Raltegravir are recommended for under-one-month-olds.

“The child, especially those below one year, often needs to go to the hospital to be weighed and their dose adjusted as per their weight,” she says.

“Our greatest issue is the unpalatability, storage and multiple formulations as opposed to older children above 35kg, who have just one tablet to take once a day,” she says.

NO FIXED-DOSE COMBINATIONS

Because of lack of fixed-dose combinations, children take their drugs twice daily (morning and evening), bringing about adherence issues.

She clarifies that patient factor is the most crucial determinant for adherence to ARV therapy. A caregiver can be given the best drugs, but if a child is not given every day at the right time, it interferes with adherence and effectiveness in the body.

“Children are dependent on caregivers for the administration of the drugs. How committed a caregiver is, how well educated and availability will determine how a child responds to medication,” she says.

Failure by caregivers and parents to give their children drugs on time is common.

 “Depending on their job, a parent can forget to give the drug in the morning and give it the evening or fail to observe time,” Dr Odionyi says. “We’re looking forward to the day we’ll have sweet drugs taken once daily, which will assure us of viral suppression among children.”

STRAWBERRY FLAVOURED HIV DRUG

However, the Drugs for Neglected Diseases Initiative (DNDI) are manufacturing a four-in-one strawberry flavoured paediatric HIV drug. The medicine is in the approval process by the World Health Organisation (WHO) as well as the US Food and Drug Administration (FDA).

The drug will boost Kenya’s ambitious 90-90-90 target, which seeks to have 90 per cent of all children with HIV diagnosed, 90 per cent of those diagnosed HIV positive receiving treatment and 90 per cent of those receiving treatment achieving viral load suppression by 2020.

“We cannot accept that tens of thousands of children still become infected with HIV and die from Aids-related illnesses every year. So many children living with HIV are doing well, but to see others missed and still left behind is a tragedy,” said Ms Winnie Byanyima, the executive director of UNaids.

REDOUBLE OUR EFFORTS

“As a global community, we’ve made remarkable progress toward controlling the HIV pandemic, yet we’re still missing far too many children, adolescents and young women,” says Ms Angeli Achrekar, Principal Deputy United States Global AIDS Coordinator, United States President’s Emergency Plan for AIDS Relief (Pepfar).

“We must all redouble our efforts to urgently reach these critical population,” she says, underlining Pepfar’s commitment.