Survey of Children Accessing HIV Services in a High Prevalence Setting: Time for Adolescents to count?/Enquete Sur I'acces Des Enfants Aux Services Lies Au VIH Dans Un Pays De Forte Prevalence De Ce Virus : Les Adolescents Vont-Ils Enfin compter?/Encuesta Sobre Los Ninos Que Acceden a Los Servicios De VIH En Un Entorno De Alta Prevalencia: ?Deberiamos Pensar Mas En Los Adolescentes?

Introduction Infection with human immunodeficiency virus (HIV) is the leading cause of death in southern Africa, which has the highest prevalence of HIV infection in the world. (1) Without interventions, the risk of mother-to-child transmission (MTCT) of HIV is common; (2) thus, the adult HIV epidemic in the region has been followed by an epidemic of vertically-acquired HIV infection among children. (1) The health-care needs of children are poorly served in most low-income countries, (3-5) and adults have been the main targets of HIV-care programmes. However, there is growing recognition of the need for equitable access to antiretroviral therapy (ART) for HIV-infected children as well. As HIV epidemics in Africa mature, the age profile of children in need of HIV care is changing. The infection appears to progress slowly in one-quarter to one-third of HIV-infected infants. These slow progressors may have a median life-expectancy as high as 14-16 years, even without ART. (6,7) In countries with severe epidemics of early-onset HIV infection, more and more cases are presenting with clinical symptoms in late childhood or adolescence. (8,9) Furthermore, as access to ART and provision of HIV care improve, a greater proportion of HIV-infected infants is likely to survive to adolescence. (10) Despite the growing numbers of older children and adolescents who develop symptoms, there has been little focus on providing this group with specialized HIV In industrialized countries, adolescent medicine is a distinct clinical speciality. However, in resource-poor settings, dedicated health-care services for adolescents are few, and children generally move from paediatric to adult care services at 8-12 years of age. Zimbabwe has experienced a severe and early-onset HIV epidemic, with the prevalence of HIV infection in adults peaking at 30% in 1997 and subsequently declining to below 15% by 2007. In 2007, an estimated 120 000 children were living with HIV (1) and 3.4% of children aged 10 years were HIV-infected long-term survivors following MTCT. (12) Within a few years, HIV-related deaths among adolescent long-term survivors are likely to outnumber those among infants. (12) However, as is typical for the region, HIV-care programmes routinely report data for only three age categories: 0-4, 5-14 and 15-49 years. Thus, there is no clear age profile of the older children receiving HIV care. We investigated the number of children receiving HIV care in Zimbabwe to establish the proportion of adolescents (10-19 years of age). We also ascertained clinic staff perceptions of the main problems faced by HIV-infected younger children and adolescents. Methods Setting Zimbabwe is divided into eight provinces and has two major cities--Harare and Bulawayo. ART first became available in the public health sector in 2004 and is now accessible through both primary care and hospital-based HIV services. The therapy is initiated in hospital HIV services, with continuing care decentralized, where possible, to the local primary care level. All clinics providing HIV care are registered with Zimbabwe's Ministry of Health and Child Welfare and issue a quarterly report of the number of patients registered on ART. Facility engagement The Ministry of Health and Child Welfare provided a list of all health-care facilities offering HIV treatment. Permission to conduct a survey was obtained from the Ministry of Health and Child Welfare and from the medical director of each province. No ethical approval was required because the data gathered did not report on individual patients and were considered to be an audit of HIV clinical services. Each patient who registers at an HIV care service is serially recorded in numbered paper registers. The sex, age and date of registration are recorded at the time of enrolment, and a record of every clinic attendance or death is maintained in the register. …