February 2005
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Treating HIV's youngest victims around the world
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It is not considered politically correct to call people with HIV "victims." Yet in the Third World, where AIDS is still a stigmatizing diagnosis and where treatment is scant, it is difficult to think of youngsters with the disease without that word coming to mind.
Yet through the diligent efforts of a team of pediatric professionals from Baylor College of Medicine in Houston and support from a variety of sources, a network to provide care to children around the world is growing in the areas hardest hit by the disease. It all began when Mark Kline, MD, visited Romania in 1996. There children with HIV were often orphaned and/or abandoned. They did not receive treatment in an era when cocktails of anti-retroviral medications were beginning to turn the tide of youngsters in the United States and Western Europe. Kline decided he could not let that situation continue without doing something.
That "something" has become the Baylor International Pediatric AIDS Initiative and the Children's Clinical Centers of Excellence Network, with clinical centers in Romania, Botswana, Mexico City, Kampala, Uganda, and Benghazi, Libya. By World AIDS Day 2005, Kline, a BCM professor of pediatrics, and his team hope to have completed clinics in Swaziland and Lesotho.
New nations, new challenges
Each nation presents its own challenges. Romania was a learning experience as Kline and his team navigated the bureaucracy to get the clinic in the port city of Constanta built, staffed and equipped. But when they began treating children with potent anti-viral medications, the effects were amazing.
In 1999, the death rate among children with HIV receiving care in Constanta was 16 percent. The center opened in April 2001 and in November of the same year, children were treated with anti-retroviral drugs. That year, the mortality rate dropped to 12 percent – a modest improvement. In 2002, it was 7 percent, in 2003, 3 percent and new statistics for 2004 indicate that the death rate is now just less than 1 percent.
"In absolute terms, there were 109 deaths in 1999 and 7 deaths in 2004, with the number of children in care remaining the same – about 700," said Kline. "If you just had one statistic that said what we are doing is producing the desired result, that would be it. It's really remarkable. A mortality rate of 1 percent or less is comparable to the best U.S. centers."
"Today we have more children with HIV on treatment than any other organization in the world," said Kline. It is a remarkable achievement, but it is also what drives him. "That tells you, in part, how little is being done for children."
One thing that makes the work of the Baylor International Pediatric AIDS Initiative possible is funding and support from a variety of sources. The Bristol-Myers Squibb Foundation's Secure the Future program for the Care and Support of Women and Children with HIV, the Abbott Laboratories Step Forward Program, AmeriCares, the United States Agency for International Development (USAID), the Sisters of Charity of the Incarnate Word, the U.S. Centers for Disease Control and Prevention and The Elizabeth Glaser Pediatric AIDS Foundation Project Heart have all provided important funding for many of the programs in the network and have committed to providing more.
For example, the Abbott Fund has supported the center in Romania since its inception. That center and its programs have served as a model for the others that have followed.
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The Botswana clinic at dusk |
The Bristol-Myers Squibb Foundation provided funds for the Botswana clinic as well as for the clinics under construction in Swaziland and Lesotho. The new clinics will mirror the design of the Botswana clinic. The two-story, 14,000-square-foot outpatient clinic has 10 examination rooms, two procedure rooms, a pharmacy, a laboratory and two conference rooms. While there will be local touches, the new clinics will be just as functional as the one in Botswana, and Kline and his team are eager for clinical care to begin.
Two clinics, two national firsts
The clinic in Mbabane, Swaziland, will be free-standing, located about 2 kilometers from the main public hospital. The one in Maseru, Lesotho, will be located southeast of the city center, immediately adjacent to a new government referral hospital. For both nations, these will be the first pediatric HIV treatment programs for children. For the first time, Kline and his team have been asked not only to set up a center but also to coordinate the scaling up of HIV treatment for the nation's youngsters.
"It's an interesting challenge," he said. "I've never had that experience before. These are small countries with small populations of about 1 million people each. We will have to devise a program plan for each country – not only for the centers but also for outreach to primary care facilities where care and treatment will be delivered."
Another unique experience
The Libyan connection began when the Qaddafi Foundation and the U.S. State Department asked Kline and his colleagues to consult on treatment of children with HIV there. For the youngsters, many of whom were infected in the hospital, the issues of stigma and discrimination mirrored those Kline found when he visited Romania in 1996.
"Children were being thrown out of schools; people were evicted from apartment buildings," he said.
Kline and his team worked with health professionals in that country and put together a proposal for a treatment program. Recently, Libyan professionals participated in a meeting of the Baylor network in Botswana.
In Uganda, Kline and his colleagues work in a small facility in Kampala. Funding for staff, medications and operations come from the CDC, but the numbers of children and families being served are growing rapidly.
"We have 600 children on treatment there and hope to have 2,000 by the end of the year," he said. Preliminary plans are being made for construction of a large children's center similar to the Botswana center.
Currently, plans also are being developed for a Baylor center in Malawi, an East African nation with severe resource and human capacity constraints. The Baylor team hopes to continue to grow the children's centers network across Africa and around the world to transform the ways in which children with HIV are perceived and treated.
Kline's greatest concern is finding enough health professionals to provide staffing. An African brain drain has depleted the supply of health care professionals there.
"We are going to have to be creative about attracting and retaining good people," he said.
Funding the network
The Abbott Fund has also given Kline's network a large grant to funds its operations, meetings, training and fellowship exchanges to BCM in Houston. Kline would like to bring professionals to BCM and Texas Children's Hospital for advanced training.
"We just appointed our first African fellow under the Abbott program," he said. "He is getting a PhD at The University of Texas School of Public Health at Houston, working primarily in HIV and sexually transmitted disease program management."
Such programs build the capacity of nations to care for children, and that's a major goal of the Baylor team. Five fellows from Africa, Romania and Mexico are obtaining advanced degrees at Baylor under BCM's NIH/Fogarty International Center-funded AIDS International Training and Research Program. Kline and his team see these individuals as the future leaders in the fight against pediatric HIV/AIDS globally.
Gaining support
Kline has seen his dreams realized and he hopes that more can be done.
"The concept of networking centers to catalyze access to treatment for children is something people immediately understand," he said. "No one has to be convinced of its importance."
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