Transitions to adulthoodOpportunities and Challenges for Children with HIV6 August 2008
By Mutsa F Bwakura-Dangarembizi
OutlineHIV Epidemic in ZimbabweAdolescenceChallenges facedModels of careOpportunitiesConclusion
ZimbabwePopulation 12 million22% aged between 10-19 years
Early and severe adult HIV epidemic Peak HIV prevalence 1997 (29%)Current prevalence 15.6 %
1,265,473 orphans (77.1% are HIV/AIDS)54% are adolescents (10-18yr)
Life expectancy 33 years HIV prevalence among 15-49 yr olds in Africa in 1990 (UNAIDS)Ministry of Health and Child Welfare. Zimbabwe National HIV and AIDS Estimates 2007, final draft report
Trends in the number of Children Living with HIV and AIDS Source: Ministry of Health and Child Welfare. Zimbabwe National HIV and AIDS Estimates 2007, final draft report
Orphan-hood trendsSource: Ministry of Health and Child Welfare. Zimbabwe National HIV and AIDS Estimates 2007, final draft report
Adolescence a period of transition
The HIV-infected adolescent has walked a journey from childhood survived the more than 50% early mortality associated with vertical HIV transmission survived recurrent opportunistic infections survived years of under-nutritionis likely to have survived parental losshas lived in more than 3 or 4 householdsis behind with his/her schooling for various reasonsmay even be the head of a household
Now he/she must become an adult.What are the challenges?
Education related challengesEducationContinuity in the context of chronic ill healthPotential for stigma and discrimination
When I get an answer wrong in class my teacher makes fun of me-she tells everyone I must have forgotten to take my drugs in the morning (Samuel aged 14yr)
Health related challenges Chronic conditionsRespiratoryCor-pulmonaleSkin (self-image)Pubertal delay
We cant play with you because you are always coughing
Health related challenges cont.StuntingHi I am 18yr old, will I grow taller if I take ARVs?
Psychosocial challengesLove and securityAcceptancePeer pressureAdult role modelsCoping with loss of loved ones Hope for a futureChild headed householdsWill I be able to get married and have children?
Models of CarePublic sectorPaediatric clinics in the large cities Specialized Adolescent clinics in a few hospitalsFamily clinics in most district hospitalsPrivate sector One NGO-funded nurse run family clinic with dedicated adolescent services
Models of Psychosocial Support
Hospital basedChiedza Support Group
Community based: AfricaidMission: ..to equip children and teenagers living with HIV with essential skills and confidence to cope better with the events in their lives, to pursue their hopes and dreams and to enjoy happy, fulfilled lives
Africaid activitiesProvision of counseling, training, skills building, recreational activities and educational supportEnsure access to appropriate information through the development of information, materials in partnership with the support groups
OpportunitiesBiologyGrowth and pubertyLong term ART and adherence Long-term non progressors
Opportunities cont.PsychosocialDeveloping appropriate models of careCommunity support for adherence Raising community awareness and acceptance of this generation Integrating adolescent HIV care in the community
In ConclusionAdolescence--- for some a time of play, for some a time of work, for most a period of optimism, but for some a time of dashed hopesAdolescent-friendly health services as well as communities and societies that provide love, acceptance and support will assist HIV-infected children make that transition to adulthood
AcknowledgementsMinistry of Health and Child Welfare ZimbabweNewlands ClinicAfricaidDr Rashida FerrandDr Frances CowanParirenyatwa Hospital Family Care CentreChiedza Support GroupThe Children
***Subtype b*Number of new infections in children peaked in 2003 at 125,161 and declined to 115,147 in 2006 and dramatically increased to 132,938 in 2007. This may reflect use of CTX and improved survival**Change coloursAdolescence is a time of rapid physical psychological, cognitive and social changes that influence prevention strategies, disease progression and going care*Who is the HIV-infected adolescent many have walked a journey many of us would rather not talk about**Every HIV-infected child you meet in the clinic wants to be something when they grow up and they realize Education is keyralShelterOrphan-hood and being in the custody of relativesChild-headed householdsShelterOrphan-hood and being in the custody of relatives
*No adolescent subspeciality, cared for by either adult physicians or paediatricians in large hospitalsOtherwise mix with rest of population elsewhere. A study by Dr Ferrand in Harare showed that HIV infected adolescents were more likely to suffer fromSkin conditions tend to tell a story are disfiguring and stigmatisingLung conditions Cor pulmonale poor exercise tolerance*Stunting is significant in vertically infected children even after starting ARVsIt becomes stigmatizing: left out of games, considered younger than they really are
Bullet for delayed puberty*There are Different ways to meet the needs of this generation their needs are varied from education, health, psychosocial and there are models of acre which all try to meet the needs of the chn*When the epidemic started most of the infants were dying, ARV roll out saw older children being treated with adult FDCs. This lot together with the long term non progressors now form a the ever increasing group of adolescence3 hospitals remove figures**Hospital based. Typical Saturday starts with an ice-breaker, some clinical topics eg adherence, play, team building and general discussions guided by the childrenThis provides an opportunity for the chn to be themselves and open up to share their lives past, present and future*Community based in partnership with other service organizations ensures sustainability*Produced material on adolescence growing up, disclosure to partners, reproductive health: respond to the needs of the children*There is a lot we still need to learn about this group of children in terms of growth, puberty etc**Support groups have become a safe havenThe challenge now is for the community: family, education system, health sector and society to make room and accept this generation.