Children account for around 350 of the 5,000 people living with HIV/AIDS who are receiving antiretroviral (ARV) treatment through Doctors Without Borders/Médecins Sans Frontières (MSF) in Chiradzulu, Malawi. Since last spring, children have had their own appointment day. Grouping the children in a pediatric clinic means that they receive more appropriate medical and psychological care. Ultimately, it may also offer a better understanding of how the AIDS virus develops in children and how to improve their treatment. UNAIDS estimates that more than 83,000 children in Malawi are living with HIV/AIDS.

The absence of a profitable market for pediatric antriretroviral medicines in Western countries leads to a limited number of treatment options specifically formulated for children in developing countries. © Pedro Violle

In Africa today, nearly half of all childrenwho are born HIV-positive die before the age of two. Only a very small number of those who survive and fall ill later receive treatment that can keep them alive.

"In Malawi, only a dozen medical facilities treat children," says Dr. Myrto Schaefer, a pediatrician with MSF's medical department. "Only four of them have more than 100 pediatric patients. It's a question of resources, organization, and political will."

Treatment adherence rates (that is, taking prescribed medicines appropriately) and effectiveness among children are equivalent to those obtained among adults. Treating children keeps them alive, but the cost is four times that of caring for an adult and treating children is more complicated.

"Putting a child on antiretroviral treatment is not a simple decision," says the Malawi program's medical coordinator, Dr. Laurent Hustache-Mathieu, who has just returned. "We don't have appropriate medicines or the experience to know how children will react to treatment."

Among infants, even diagnosing the illness is complicated because the mother's antibodies are present in the child's system until he or she reaches one-and-half years of age, which means that blood test results could be incorrect. Diagnosis must thus be based on clinical examination, the mother's and baby's health histories and the child's immune system. "There's still a margin of error, but we have no choice," says Dr. Hustache-Mathieu.

"The children help each other a lot"

Around 350 children–equally divided between boys and girls, with an average age of 7–are currently receiving ARV treatment in the Chiradzulu program. The "old-timer" has been receiving treatment for two-and-a-half years and is doing well. She takes her medicine every day and comes to the hospital once a month. There, she is with other children her age–always the same group–and they play while waiting to be seen.

Young patients in Chiradzulu perform plays, dances, and poems where the central theme is HIV/AIDS. © Didier Lefevre/Imagesandco.com

Tuesday appointments at the district hospital are reserved for children. Their parents or guardians come with them. The children play, cuddle stuffed animals, draw, and sing. In groups of five or six, all around the same age, the children can also talk to each other.

"You hear a child explain that he was sick, that he couldn't go to school and that he's taking medicine," says Dr. Schaefer, who has returned from Malawi. "Another will put an arm around him and explain his situation. They create real relationships, help each other a lot, and show affection for each other. They don't talk about problems. They want to see the positive and the improvements."

Counselors, whose role is to support patients in our program, have adapted their approach to these very young patients. Their goal is to support treatment adherence among children and help families answer any questions the child may have. During group play, they can watch the children. They spot possible problems that may be signaled by aggressive behavior, crying, or fear of coming to the hospital. They also see children on an individual basis with a parent. Unlike adults, many children take their medicine without knowing about their illness.

"Very often, parents tell the child to take the medicine without offering explanations or giving the child a choice," Dr. Hustache-Mathieu says. "And very few children ask questions." The counselor's role is not to reveal the child's illness but to evaluate treatment acceptance and create the conditions so that, one day, the young patient can be told of his or her status and take more responsibility for treatment.

Improving treatment of children

An MSF staff member counsels young patients on simple methods to organize their medication schedule. © Didier Lefevre/Imagesandco.com

The pediatric clinic opened last spring. "Previously, we monitored children like we do adults, even though their situation is very different, both medically and psychologically," says Dr. Hustache-Mathieu. "That's why we have now developed a specific approach."

Over time, the appointments set aside for children will be decentralized and held at the various health centers so that children living in rural areas do not have to come to the hospital in the city.

Ultimately, grouping children's medical visits may also help improve the understanding and treatment of children with AIDS. With that goal in mind, a physician-epidemiologist has been sent to join the team in Chiradzulu to collect and analyze pediatric medical data.