By Joyce Chimbi

Nearly seven out of every 10 HIV positive children globally live in East and Southern Africa. Despite progress made to reduce new HIV infections in children, the region remains far behind the 95-95-95 fast-track global targets for ending pediatrics AIDS by 2030.

National AIDS and STI Control Programme (NASCOP) statistics show that out of 1.4 million people living with HIV in this East African nation in 2019, 90,000 were children under the age of 14 years.

An estimated 11% of these children were in Homabay County. The reality of HIV is well documented across the Lake Victoria region county which has a double digit HIV prevalence of 20.7%, more than four times the national prevalence of 4.8 %.

“The global community follows UNAIDS visionary goal, 95-95-95, that seeks to end four decades of the most dominant epidemic in living memory,” says Gideon Mikoye Libulele, a Senior Technical Officer in HIV care and treatment based in Homabay County.

“To do so, 95% of all people living with HIV should be aware of their positive status, 95% of all people diagnosed should receive sustained antiretroviral treatment (ART) care and treatment and 95% of all those on ART should be virally suppressed.”

Libulele says viral suppression or having a significantly reduced amount of HIV in the blood, is critical to treatment success and it also significantly reduces child illnesses and death.

As per NASCOP, out of an estimated 1,401,498 adults aged above 15 years living with HIV, approximately 1,164,753 or 83.1% are on ART.

As such, Kenya is not on track towards reaching the 95-95-95 target because children aged one to nine years have notably poor treatment outcomes.

Of all adults under ART coverage, 94.7% have achieved viral suppression. Currently, of all children living with HIV aged 0 to 14 years, 63.7% are on ART. Of all children receiving HIV care and treatment, 87.2% have achieved viral suppression.

HIV drugs

With studies in pediatrics HIV conducted by the Ministry of Health showing that in every three children who had a viral load test, one was virally unsuppressed, Kitare Health Center, a small rural clinic in Homabay County has found the silver bullet.

“Pediatrics suppression rate at the facility was 67% in 2019. We were struggling with many virally unsuppressed children. The more the amount of HIV in the body, the higher the chances of treatment failure,” says Jacob Ocholla, a clinical officer at Kitare Health Center.

“You may change the treatment regimen but at some point, there will be no other treatment option so the best treatment outcome means keeping our HIV client on a working HIV treatment regimen for as long as possible.”

*Stacy Akinyi’s two children struggled with viral suppression from 2016. Her records show that one of the children aged seven, had a viral load of 3,240 in 2016. Clinicians at Kitare Health Center attempted to intervene and the viral load fell to 124 in 2019.

Libulele says it is recommended that people living with HIV have a viral load of 400 and below. A viral load of 400 to 999 is acceptable but, he cautions, as numbers move towards the 1,000 mark, it is an indication that the individual is moving towards troubled waters.

Akinyi’s breakthrough did not last long, she says“the child’s viral load shot to 6,700 in 2019. The other sibling aged 10, had a viral load of 16,000 in 2018 that fell to 93 through intervention in the same year but then shot to 2,400 in 2019.|”

The scenario was not unique and this was the reality within the pediatrics cohort, says Collins Otieno Were, an adherence counsellor at the facility.

This, he says, necessitated consultations among HIV experts in the region and health organizations working in pediatrics HIV.

The consultations led to the introduction of Directly Witness Ingestion of Therapy (DWIT), whereby a witness ensures that medicine was in fact swallowed and not hidden inside the mouth to be spit later.

“I was very worried when doctors said that I would bring the children to the center every morning and evening for them to witness my children swallowing medication. This would be difficult for my school going children. I promised that I would witness every day without fail,” Akinyi says.

Directly Witness Ingestion of Therapy a game changer in the management of HIV pediatrics.

Confirming suspicions that where a primary caregiver is not virally suppressed the children are not likely to be suppressed, Akinyi’s viral load was at an alarming high of 35,200 and a very long way from the recommended 400 and below.

Akinyi was taken through adherence counselling for psychosocial support and, to identify and address other challenges that made it difficult for her children to have positive ART treatment outcomes.

Also in counseling was *Belinda Onyango, who discovered during the sessions that her turbulent marriage made it difficult for her to be an effective primary caregiver. She would leave her marital home and leave her children behind.

“The children would tell me they were taking their medicine but they were not because I was not there to witness,” she says.

Ocholla says that it is not enough for a primary caregiver to watch a child put the medicine in their mouth, the caregiver must ensure that the medicine is swallowed.

“Children will in many occasions take the sweet medicine and spit out the bitter pill. This is counterproductive and the results are the high cases we had of virally unsuppressed children,” he said.

A child can also forget to take medicine or completely pretend to have taken the medicine when in fact they have not, he says.

Adding that due to their young age, the seriousness of the situation there in is often not clear and they must be supported to stay on track. He stressed that DWIT is serving that purpose effectively.

Three months of using the intervention, Akinyi’s records show that both children had achieved an undetectable viral load and remain suppressed from 2019 to date. Similarly, the mother’s viral load dropped to 470 in 2020 and is now undetectable.

These are two of 32 children in pediatrics care at Kitare Health Center. Overall, 29 children have a viral load of below 400 copies, one has a viral load of between 400 and 999 and two have a viral load of beyond 1,000.

Through DWIT, a most cost effective intervention, Ocholla says that pediatrics suppression rate at the facility moved from 67% in 2019 to 88% in 2020, to the current 94%.

The intervention is however not without its share of challenges. Ocholla says that problems in the life of a primary caregiver can impact the intervention negatively.

He says a primary caregiver must have the presence of mind to consistently implement the intervention.

“Time is a factor and the caregiver must designate a time, day and night, to witness the ingestion. This is not always possible especially in a fisher folk community where men are out at dawn and women follow suit to buy the best fish,” Ocholla says.

The most important pillar of the intervention, Ocholla emphasizes, is consistency and adds that a change from one caregiver to another often disrupts implementation of intervention and produces negative treatment outcomes.

In a worst case scenario, more vulnerable children must rely on their health providers and will often go to the facility every day for the nurses or clinicians to witness the ingestion.

Despite these challenges, Were affirms that it has been done in Kitare Health Center and can be done elsewhere with similarly remarkable success.

*name hidden to cover identity

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