The Baylor-Bristol-Myers Squibb Children's Clinical Center of Excellence in Mbabane, Swaziland is open and thriving. Care and treatment services are provided to over 4,000 HIV-infected Swazi children and their families at this site and its affiliated clinics.

Program Update

9.25.08 Satellite Centers of Excellence are under construction at two sites in Swaziland. Based in Manzini and Hlatikulu, these satellite centers will expand the reach of services provided by BIPAI to HIV-infected children and families in Swaziland.

Background

Baylor College of Medicine Children's Foundation-Swaziland is an international non-profit non-governmental organization founded as a partnership between Baylor International Pediatric AIDS Initiative (BIPAI) and the government of Swaziland in 2005. The Baylor College of Medicine Bristol Myers-Squibb Children's Clinical Centre of Excellence-Swaziland (COE) was established under the aegis of the Foundation in partnership with Bristol Myers-Squibb, the Baylor International Pediatric AIDS Initiative (BIPAI) and the government of Swaziland. The COE was officially opened by His Majesty King Mswati III on 24th February 2006.

Objectives

The objectives of the Baylor College of Medicine Children's Foundation-Swaziland are as follows:

• To increase the number of HIV/AIDS children receiving antiretroviral therapy and provide regular follow up at the clinical care center of excellence through provision of a comprehensive, compassionate, and professional service to children, parents and siblings at the COE
• To build capacity of local clinicians (pediatricians, general practitioners, nurses, and counselors) to provide high quality care and treatment to HIV/AIDS patients through continuous didactic training and clinical mentorship.
• To establish an outreach pediatric HIV/AIDS care that is integrated to the health care needs in Swaziland
• To conduct and utilize relevant clinical and operational research in pediatric care and treatment of HIV/AIDS in collaboration with The Ministry of Health and Social Welfare.

Services provided at the COE

1. Diagnosis of HIV infection
2. Early infant diagnosis of HIV using the DNA PCR dried blood spots
3. Provision of laboratory services - CD4, FBC, Chemistry etc. There is a CD4 machine on site for running specimens at the clinic and outreach sites.
4. Initiation of HAART for qualifying patients
5. Refill of ARVs and follow up of patients on ARVs
6. Provision of TB services including sputum collection and dispensing of TB drugs
7. Active TB case finding
8. Provision of isoniazid preventive therapy to HIV infected patients without active TB
9. PMTCT services including antenatal and postnatal services.
10. Follow up of HIV exposed infants
11. Family planning services by providing injectible and oral contraceptives and condoms
12. Pap smears for HIV infected sexually active women
13. Provision of outpatient therapeutic feeds (Plumpy Nut)
14. Provision of emergency services for the critically ill patients
15. Attending to complex pediatric cases referred from all over the country
16. Helping at the MGH in the pediatric ward to increase inpatient testing and management of the severely malnourished children
17. On site mentoring of nurses in order for them to consult independently(task-shifting)
18. Weekly clinical meetings

Outreach services

Pediatric outreach services help to bring services through:

1. Provision of care and treatment at various clinics, health centers and hospitals
2. Mentoring visits to nurses at the various clinics, health centers, and hospitals
3. Helping with the roll out of early infant diagnosis through Dried Blood Spot DNA PCR and therapeutic feeding using Plumpy Nut
4. Collection of data on key indicators and appropriated feedback to site staff.

PMTCT Scale Up: Northern Hhohho

The project has four main components: 1) community mobilization, 2) HIV testing and counseling of all pregnant mothers and provision of appropriate clinical care, 3) comprehensive antenatal care including provision of antiretroviral therapy where indicated, and ARV prophylaxis for prevention of mother to child transmission where the mothers' CD4 is more than 350 cells/uL, 4) postnatal care of the mother and infant, including follow up of HIV exposed infants for at least one year, and continuous psychosocial and nutritional counseling.

The specific services offered include:

• HIV Testing and Counseling (HTC) at ANC,
• Referral of pregnant, HIV positive women for PMTCT services at a special PMTCT clinic (PORECO clinic),
• Clinical assessment of the pregnant client; clinical staging, CD4 count, etc.
• Comprehensive antenatal care
• Initiation of ART in women with CD4 <350 cells/uL or WHO stage III or IV (1st line regimen; AZT, 3TC, NVP)
• Regular clinical monitoring of clients with CD4 >350 cells/uL
• ARV prophylaxis regimen, for preventing transmission among women who do not have indications for ART ,i.e. CD4>350,
• Treatment of opportunistic infections, STI's, TB
• Education on:
  - Nutritional Support
  - Counseling and psychosocial support, (support groups)
  - Safe Labour and Delivery practices
  - Postnatal care of mother and infant
  - Counseling and support on infant feeding options
  - Family Planning
  - Involvement of partner
  - Follow-up of infant - DNA PCR at 6 weeks and after weaning, and at 12 months
  - Management of HIV Positive and Negative infant
• Home visit

Community Support

Community outreach is a cross-cutting theme in our entire range of services. PMTCT PLUS is involved community mobilization to ensure community participation. This entails organizing meetings with community stakeholders and community based organizations e.g. neighborhood care points, orphanages. A number of these meetings have been held with the chiefdoms, regional health management teams, non-governmental and mission organizations, and schools. In addition, patients receiving antiretroviral therapy are encouraged to join support groups which meet once a month.

Adolescent Group

An adolescent support group meets regularly to encourage peer support. Topics discussed during the adolescent support group meeting are selected by the teenagers themselves. These topics vary, and have included: how HIV is transmitted, and how it can be prevented; how we can live positively with HIV; how to disclose to friends and peers; how to empower others living with HIV who are too afraid to test; nutrition and HIV (what are good foods and bad foods?); how alternative medicines can be harmful or helpful in the era of HIV; how to stay focused on your dreams.

These discussions were very fruitful for the children. At every meeting participants are reminded about the importance of confidentiality as a marker of the integrity of the COE. This ensures that adolescents feel free to express themselves and voice their opinions in a safe environment. We also use referral centers to further manage children whose needs exceed the provisions of the COE. Such referral sites provide child counseling, education on income generation and adolescent information and resource centers.

Health care provider Training and Clinical Mentoring

Provision of ART calls for specific skills and health care providers require training to acquire these skills. The COE has therefore taken the lead in pediatric HIV training for the country. We accomplish first through didactic training of health care providers and thereafter follow-up clinical mentoring at their respective health care facilities. Pre- and post-tests are given to evaluate the effectiveness of the training in imparting skill and knowledge to the trainees. The trainers are also evaluated by the trainees on their effectiveness in delivery of the training. The evaluation tools are also constantly being improved on the basis of the ongoing evaluation.

The training covers the following areas: basic pediatric HIV training for physicians, HIV training for nurses, laypersons training, DNA PCR DBS training for health professionals, private physicians weekend pediatric HIV trainings, trainings for nurses working in private surgeries, one or two day refresher trainings for various groupings of health care professionals, PMTCT trainings, severe acute malnutrition management trainings, training of trainers workshops.