Treating Pediatric AIDS Globally: Mark Kline, MD and BIPAI
On April 28, 2008, a large crowd came for a groundbreaking ceremony for the Satellite Children's Center of Excellence in Butha-Buthe, Lesotho. The Baylor International Pediatric Aids Initiative (BIPAI), represented by Dr. Mark Kline, and about 3000 people, including the Prime Minister of Lesotho, cabinet members, members of Parliament, the chief justice of the Supreme Court, local chiefs, and men, women, and children from the district converged to mark the occasion.
The satellite children's center is one of the latest accomplishments of BIPAI, a nonprofit organization dedicated to providing high quality pediatric and family HIV/AIDS care and treatment. It operates in Romania, Africa, Mexico, and Houston, Texas.
Romania: Where It Began
The program involving the Clinical Centers of Excellence, centers for the care and treatment of children with HIV, started in 1996 in Romania, where half of Europe's pediatric AIDS cases are located. BIPAI opened a children's center in Constanta, which today is the largest pediatric and adolescent treatment center in Europe. This clinic, originally named the Romanian American Children's Center, initially enrolled 430 children.
"[We] began to see a dramatic improvement in the health of children, who literally were dying. The death rate for HIV-infected children in Constanta plummeted from 13% per year to less than 1% per year," said Dr. Mark Kline, president of BIPAI, pediatrics professor at Baylor College of Medicine, and chief of the retrovirology clinic at Texas Children's Hospital.
In partnership with the Romanian government and the Constanta Infectious Disease Hospital, the center is staffed by Romanian and American medical professionals. It provides primary and specialty care and treatment to over 600 infants and children infected with HIV. Clinical research is conducted on the site, and the center has developed to provide for a range of needs, including housing, education, and job training for young adults.
Africa: Expanding the Network
Dr. Kline said Romania "demonstrated that antiretroviral therapy was feasible in a resource-poor area." BIPAI then began working in African countries such as Botswana, Lesotho, and Swaziland in southern Africa, countries with some of the world's highest incidence of HIV/AIDS, to replicate the concept of the children's clinics.
BIPAI first approached the Botswana Ministry of Health, which agreed to partner with BIPAI and donated a piece of land. When the clinic was built, 200 children were already in treatment. In its first year, 4000 children were brought to the center for HIV testing. Today, more than 2000 children are in treatment, and the mortality rate is down to 0.3%. The Botswana center has grown to be one of the largest pediatric AIDS treatment centers in the world.
With two million children with AIDS living in Africa and local public health infrastructures overwhelmed, it was decided to build other centers in Africa, and today a network of centers operates in Swaziland, Lesotho, Malawi, Tanzania, Uganda, and Burkina Faso.
The centers are staffed by American doctors trained in an intensive, one month course on tropical medicine and pediatric HIV. They work for a year or more in the centers. In addition to providing care for HIV infected children, they also provide training for local health professionals, who then take over. The centers currently enroll about 1000 children a month into care.
Dr. Michael Tolle and PAC in Lesotho
In 2006, The Pediatric AIDS Corps (PAC) came into being. Dr. Michael Tolle, who wanted to work in Africa, enrolled in the month-long training program with the first group. He spent over a year in Lesotho, a mountainous, highland country. He and his fellow doctors started with a large volume of very sick kids.
"That was certainly very hard for me, and I think a lot of my colleagues, to see that sick of a group of kids that quickly," Dr. Tolle said. Lesotho has a very high prevalence of AIDS, and it is the leading cause of death after malnutrition. More than 20% of women are infected, and mother-to-child transmission is the most common cause of infection.
A typical day at the clinic for Dr. Tolle and the other doctors involved working from 7:30 a.m. until sundown. There were usually three or four doctors available for patients. Dr. Tolle, a family practitioner by training, saw adults and pregnant women as well as children. During the visit, the doctors also went into adherence counseling and education. A high volume of patients were seen everyday.
"It's just a constant flow of people in and out of the building," Dr. Tolle said. "It was quite amazing to see...Watching the system grow to where it could handle a high volume of patients at a pretty good quality and good outcomes and levels was quite gratifying to see. It was a hardworking working day at the clinic."
The children would typically be brought in wrapped in blankets that covered their wasted bodies, near death, malnourished and needing medical attention immediately. They were treated in the hospital for two weeks, survived, got started on treatment, and six months later would be doing well.
Parents who were asked what made them happiest about their children recuperating usually cite school attendance. "The number one comment from parents that really stuck with me...is that the children are back in school. Education is prized beyond belief by the poorest people in Lesotho," says Dr.Tolle.
Another aspect of care is prevention. This consists of the prevention of transmission from mother to child. In Lesotho, BIPAI has a program to treat pregnant, infected women with antiretroviral therapy. The babies are followed up at the clinic. Dr. Tolle stated that "the essential, key part of all of it is making sure mom could be diagnosed, that mom can have antiretroviral treatment while she's pregnant." Prevention -- receiving highly active treatment to control the virus prior to or during delivery by caesarean section -- has led to lower numbers of infected kids.
The clinics follow a family model and BIPAI focuses on treating the family unit, as many Africans live in extended families. Families of infected children get a full range of services, from education on how to avoid transmitting the infection and safe sex practices to treatment for adults. From Dr. Tolle's viewpoint, this kind of integrated treatment leads to families getting seen more at the clinic and improves their chances of adhering to their regimen and thus getting better. Dr. Tolle sees the gains of BIPAI's work as being "substantial."
Dr. Monica McGrann and PAC in Botswana
What stimulated the formation of BIPAI and PAC were the large numbers of children and babies being infected and dying. Local resources were unable to handle the magnitude of the problem. Botswana, for instance, had a high death rate six years ago. Today, most infected children are identified early, and treatment is started early. In Gaborone, Botswana's capital, thousands of infected children have a death rate of less than 1% per year. This is the lowest death rate reported in any setting. Other countries have gone now from identifying no kids with HIV to identifying more kids in their populations, and prevention of HIV has greatly improved.
As can be seen in the growing numbers of children being enrolled for treatment, public reception of BIPAI's clinics has been very good. Prior to the establishment of the Botswana clinic, a media source had reported that the clinic would not be received well. However, the clinic now overflows with patients, and BIPAI has been tremendously well-received.
Dr. Monica McGrann worked for two years in the clinic at Gabarone; she was one of the first PAC members to go to Africa. Her interest in international health led to her joining PAC, and she chose Botswana because of governmental support for the treatment of HIV. (The Bostwanan government finances HIV care for all of its infected citizens and has its own structure for providing care.)
Among the things Dr. McGrann found fascinating were the cultural differences between patients she saw in Botswana and those she treats in the United States. In Africa, the PAC treats families, and sometimes the child, the mother, and the grandmother were all on medication. Also, in contrast to children she treats in the United States, the Botswanan children had no problems taking the medication in pill form. According to Dr. McGrann, "That psychological impediment to swallowing wasn't what we faced when it came to the children not [taking] their medicines."
Dr. McGrann also found that HIV is highly stigmatized in Botswana, even though 50% of the urban population has it. The psychological impact is most noticeable among the adolescents than children, and she believes that the later the child is educated about the virus, the more difficult it is to have them committed to the medicines.
As at BIPAI's other's sites, Dr. McGrann saw the death rates drop after the implementation of treatment. She says that, in the two years of her tenure in Botswana, she saw "a dramatic decrease in the severity of the illnesses the children were having....Even after just a few weeks on the medicine, you see a big difference."
In addition to providing high-quality treatment and care at its established facilities, BIPAI's future plans include more outreach and satellite services, such as the one in Butha-Buthe, so that treatment is made available to HIV infected children and their families living in isolated and rural areas.
About the Author
Shyla Nambiar is a freelance writer based in Atlanta, Georgia.
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