Paediatric HIV management at primary care level: an evaluation of the integrated management of childhood illness (IMCI) guidelines for HIV

Developing and Validating an Effective Pediatric and Adolescent HIV Testing Eligibility Screening Tool for High-Volume Entry Points in Uganda

INTRODUCTION

Because of low pediatric HIV prevalence, more tests are needed to find 1 HIV-positive child compared with adults. In Uganda, the number needed to test (NNT) to find 1 new HIV-positive child was 64 in outpatient departments (OPDs) and 31 through index testing. We aimed to develop and validate a pediatric (1.5-14 years) screening tool to optimize testing approaches.

METHODS

Phase 1 evaluated the performance of 10 screening questions in 14 OPDs using a variable selection algorithm to evaluate combinations of screening questions. Using logistic regression, we identified the number of screening questions with the best predictive accuracy using the receiver operation characteristic curve. Phase 2 validated the proposed tool in 15 OPDs and 7 orphan and vulnerable children programs. We estimated sensitivity, specificity, and NNT accounting for intercluster correlations.

RESULTS

A total of 3482 children were enrolled. The optimal model included reported HIV-positive maternal status or 2/5 symptoms (sickly in the last 3 months, recurring skin problems, weight loss, not growing well, and history of tuberculosis). The proposed tool had sensitivity of 83.6% [95% confidence interval (CI): 68.1 to 92.4] and specificity of 62.5% (95% CI: 55.0 to 69.4). The tool was validated in a sample of 11,342 children; sensitivity was 87.8% (95% CI: 80.9 to 92.5) and specificity 62.6% (95% CI: 54.8 to 69.7) across OPDs and community sites. In OPDs, sensitivity was 88.1% (95% CI: 80.8 to 92.8) and specificity 69.0% (95% CI: 61.9 to 75.3). The NNT was 43 (95% CI: 28 to 67) across settings and 28 (95% CI: 20 to 38) for OPD.

CONCLUSIONS

This HIV screening tool has high sensitivity and reasonable specificity, increasing testing efficiency and yield for children and adolescents.

Screening Algorithms to Reduce Burden of Pediatric HIV Testing: A Systematic Review and Meta-analysis

BACKGROUND

The accuracy of symptom screening to identify children eligible for further HIV testing in generalized epidemics has been examined in several studies. We performed a systematic review and meta-analysis of these studies.

METHODS

We screened 5 databases and abstracts from 4 HIV/AIDS conferences. Studies were included if they were performed in clinical settings, included children of 0-15 years old, and used a signs/symptoms screen to determine eligibility for HIV testing. The primary outcomes were sensitivity and specificity of the screening tools. A meta-analysis was performed to evaluate the utility of a screening tool in the outpatient setting.

RESULTS

Our search returned 5529 database results and approximately 6700 conference abstracts, of which 36 articles were reviewed and 7 met criteria for inclusion. All were prospective or cross-sectional studies that developed and/or validated a screening tool to identify children at higher risk for being HIV infected. Sensitivity of the screening tools ranged from 71% to 96%, whereas specificity ranged from 25% to 99%. Meta-analysis of studies evaluating outpatient screening tools revealed a sensitivity of 81.4%, with a specificity of 69.4% for detecting HIV infection.

CONCLUSIONS

Few studies have evaluated the use of screening tools for HIV diagnosis in children. Screening tools that exist showed only moderate sensitivity and specificity and missed a substantial number of HIV-infected children in high-prevalence areas. In outpatient settings, the use of a screening tool may help reduce the number of HIV tests needed to identify an HIV-infected child, but at the cost of missed diagnoses. Further studies are needed to determine whether this represents a resource-saving mechanism.

Addition of Questions on Parental Factors to the WHO (Integrated Management of Childhood Illnesses) IMCI-HIV Algorithm Improves the Utility of the Algorithm for Diagnosis of HIV Infection in Children

The WHO Integrated Management of Childhood Illnesses-HIV (IMCI-HIV) algorithm and its regional adaptation have shown variable performance in clinically identifying HIV-infected children with lack of validation in low prevalence areas. Addition of certain 'parental factors' (proxy indicators of parental HIV) may improve its utility. In this study, children aged 2 months to 5 years were enrolled into Group A (n = 1000, 'suspected symptomatic HIV infected' children as per the IMNCI-HIV algorithm) and group B (n = 50, children newly diagnosed with HIV infection). Parental factors were asked and HIV infection was tested for in Group A. For Group B, retrospective data were collected regarding IMNCI-HIV algorithm signs and parental factors. Utility of individual and various combinations of IMNCI-HIV signs and parental factors to predict HIV status was evaluated. Results showed that incorporating parental factors to IMNCI-HIV algorithm improved its sensitivity and positive predictive value in identifying HIV-infected children while maintaining the same sensitivity.

Health system factors affecting implementation of integrated management of childhood illness (IMCI): qualitative insights from a South African province

The Integrated Management of Childhood Illness (IMCI) strategy has been adopted by 102 countries including South Africa, as the preferred primary health care (PHC) delivery strategy for sick children under 5 years. Despite substantial investment to support IMCI in South Africa, its delivery remains sub-optimal, with varied implementation in different settings. There is scarce research globally, and in the local context, examining the effects of health system characteristics on IMCI implementation. This study explored key determinants of IMCI delivery in a South African province, with a specific focus on health system building blocks using a health system dynamics framework. In-depth interviews were conducted with 38 districts, provincial and national respondents involved with IMCI co-ordination and delivery, exploring their involvement in, and perceptions of, IMCI strategy implementation. Identified barriers included poor definition of elements of a service package for children and how IMCI aligned with this, incompetence of trained nurses exacerbated by inappropriate rotation practices, use of inappropriate indicators to track progress, multiple cadres coordinating similar activities with poor role delineation, and fragmented, vertical governance of programmes included within IMCI, such as immunization. Enabling practices in one district included the use of standardized child health records incorporating IMCI activities and stringent practice monitoring through record audits. Using IMCI as a case study, our work highlights critical health system deficiencies affecting service delivery for young children which need to be resolved to reposition IMCI within the broader child 'survive, thrive and transform' agenda. Recommendations for appropriate health system strengthening include the need for redefining IMCI within a broader PHC service package for children, prioritizing post-training supervision and mentoring of practitioners through appropriate duty allocation and rotation policies, strengthening IMCI monitoring with a specific focus on quality of care and building stronger clinical governance through workforce allocation, role delineation and improved accountability.

Fragmentation of maternal, child and HIV services: A missed opportunity to provide comprehensive care

Background

In South Africa, coverage of services for mothers and babies in the first year of life is suboptimal despite high immunisation coverage over the same time period. Integration of services could improve accessibility of services, uptake of interventions and retention in care.

Aim

This study describes provision of services for mothers and babies aged under 1 year.

Setting

Primary healthcare clinics in one rural district in KwaZulu-Natal, South Africa.

Methods

All healthcare workers on duty and mothers exiting the clinic after attending well-child services were interviewed. Clinics were mapped to show the route through the clinic taken by mother–baby pairs receiving well-child services, where these services were provided and by whom.

Results

Twelve clinics were visited; 116 health workers and 211 mothers were interviewed. Most clinics did not provide comprehensive services for mothers and children. Challenges of structural layout and deployment of equipment led to fragmented services provided by several different health workers in different rooms. Well-child services were frequently provided in public areas of the clinic or with other mothers present. In some clinics mothers and babies did not routinely see a professional nurse. In all clinics HIV-positive mothers followed a different route. Enrolled nurses led the provision of well-child services but did not have skills and training to provide comprehensive care.

Conclusions

Fragmentation of clinic services created barriers in accessing a comprehensive package of care resulting in missed opportunities to provide services. Greater integration of services alongside immunisation services is needed.

Scoping review: strategies of providing care for children with chronic health conditions in low- and middle-income countries

OBJECTIVES

To identify and review strategies of providing care for children living with chronic health conditions in low- and middle-income countries.

METHODS

We searched MEDLINE and Cochrane EPOC databases for papers evaluating strategies of providing care for children with chronic health conditions in low- or middle-income countries. Data were systematically extracted using a standardised data charting form, and analysed according to Arksey and O'Malley's 'descriptive analytical method' for scoping reviews.

RESULTS

Our search identified 71 papers addressing eight chronic conditions; two chronic communicable diseases (HIV and TB) accounted for the majority of papers (n = 37, 52%). Nine (13%) papers reported the use of a package of care provision strategies (mostly related to HIV and/or TB in sub-Saharan Africa). Most papers addressed a narrow aspect of clinical care provision, such as patient education (n = 23) or task-shifting (n = 15). Few papers addressed the strategies for providing care at the community (n = 10, 15%) or policy (n = 6, 9%) level. Low-income countries were under-represented (n = 24, 34%), almost exclusively involving HIV interventions in sub-Saharan Africa (n = 21). Strategies and summary findings are described and components of future models of care proposed.

CONCLUSIONS

Strategies that have been effective in reducing child mortality globally are unlikely to adequately address the needs of children with chronic health conditions in low- and middle-income settings. Current evidence mostly relates to disease-specific, narrow strategies, and more research is required to develop and evaluate the integrated models of care, which may be effective in improving the outcomes for these children.

Reasons for hospitalization in HIV-infected children in West Africa

INTRODUCTION

Current knowledge on morbidity and mortality in HIV-infected children comes from data collected in specific research programmes, which may offer a different standard of care compared to routine care. We described hospitalization data within a large observational cohort of HIV-infected children in West Africa (IeDEA West Africa collaboration).

METHODS

We performed a six-month prospective multicentre survey from April to October 2010 in five HIV-specialized paediatric hospital wards in Ouagadougou, Accra, Cotonou, Dakar and Bamako. Baseline and follow-up data during hospitalization were recorded using a standardized clinical form, and extracted from hospitalization files and local databases. Event validation committees reviewed diagnoses within each centre. HIV-related events were defined according to the WHO definitions.

RESULTS

From April to October 2010, 155 HIV-infected children were hospitalized; median age was 3 years [1-8]. Among them, 90 (58%) were confirmed for HIV infection during their stay; 138 (89%) were already receiving cotrimoxazole prophylaxis and 64 children (40%) had initiated antiretroviral therapy (ART). The median length of stay was 13 days (IQR: 7-23); 25 children (16%) died during hospitalization and four (3%) were transferred out. The leading causes of hospitalization were WHO stage 3 opportunistic infections (37%), non-AIDS-defining events (28%), cachexia and other WHO stage 4 events (25%).

CONCLUSIONS

Overall, most causes of hospitalizations were HIV related but one hospitalization in three was caused by a non-AIDS-defining event, mostly in children on ART. HIV-related fatality is also high despite the scaling-up of access to ART in resource-limited settings.

The acceptability and feasibility of routine pediatric HIV testing in an outpatient clinic in Durban, South Africa

BACKGROUND

Limited access to HIV testing of children impedes early diagnosis and access to antiretroviral therapy. Our objective was to evaluate the feasibility and acceptability of routine pediatric HIV testing in an urban, fee-for-service, outpatient clinic in Durban, South Africa.

METHODS

We assessed the number of patients (0-15 years) who underwent HIV testing upon physician referral during a baseline period. We then established a routine, voluntary HIV testing study for pediatric patients, regardless of symptoms. Parents/caretakers were offered free rapid fingerstick HIV testing of their child. For patients <18 months, the biological mother was offered HIV testing and HIV DNA polymerase chain reaction was used to confirm the infant's status. The primary outcome was the HIV testing yield, defined as the average number of positive tests per month during the routine compared with the baseline period.

RESULTS

Over a 5-month baseline testing period, 931 pediatric patients registered for outpatient care. Of the 124 (13%) patients who underwent testing on physician referral, 21 (17%, 95% confidence interval: 11-25%) were HIV infected. During a 13-month routine testing period, 2790 patients registered for care and 2106 (75%) were approached for participation. Of these, 1234 were eligible and 771 (62%) enrolled. Among those eligible, 637 (52%, 95% confidence interval: 49-54%) accepted testing of their child or themselves (biological mothers of infants <18 months). There was an increase in the average number of HIV tests during the routine compared with the baseline HIV testing periods (49 versus 25 tests/month, P = 0.001) but no difference in the HIV testing yield during the testing periods (3 versus 4 positive HIV tests/month, P = 0.06). However, during the routine testing period, HIV prevalence remains extraordinarily high with 39 (6%, 95% confidence interval: 4-8%) newly diagnosed HIV-infected children (median 7 years, 56% female).

CONCLUSIONS

Targeted and symptom-based testing referral identifies an equivalent number of HIV-infected children as routine HIV testing. Routine HIV testing identifies a high burden of HIV and is a feasible and moderately acceptable strategy in an outpatient clinic in a high prevalence area.

Understanding the contribution of common childhood illnesses and opportunistic infections to morbidity and mortality in children living with HIV in resource-limited settings

OBJECTIVE

Although antiretroviral treatment (ART) has reduced the incidence of HIV-related opportunistic infections among children living with HIV, access to ART remains limited for children, especially in resource-limited settings. This paper reviews current knowledge on the contribution of opportunistic infections and common childhood illnesses to morbidity and mortality in children living with HIV, highlights interventions known to improve the health of children, and identifies research gaps for further exploration.

DESIGN AND METHODS

Literature review of peer-reviewed articles and abstracts combined with expert opinion and operational experience.

RESULTS

Morbidity and mortality due to opportunistic infections has decreased in both developed and resource-limited countries. However, the burden of HIV-related infections remains high, especially in sub-Saharan Africa, where the majority of HIV-infected children live. Limitations in diagnostic capacity in resource-limited settings have resulted in a relative paucity of data on opportunistic infections in children. Additionally, the reliance on clinical diagnosis means that opportunistic infections are often confused with common childhood illnesseswhich also contribute to excess morbidity and mortality in these children. Although several preventive interventions have been shown to decrease opportunistic infection-related mortality, implementation of many of these interventions remains inconsistent.

CONCLUSIONS

In order to reduce opportunistic infection-related mortality, early ART must be expanded, training for front-line clinicians must be improved, and additional research is needed to improve screening and diagnostic algorithms.

Beyond early infant diagnosis: case finding strategies for identification of HIV-infected infants and children

There are 3.4 million children infected with HIV worldwide, with up to 2.6 million eligible for treatment under current guidelines. However, roughly 70% of infected children are not receiving live-saving HIV care and treatment. Strengthening case finding through improved diagnosis strategies, and actively linking identified HIV-infected children to care and treatment is essential to ensuring that these children benefit from the care and treatment available to them. Without attention or advocacy, the majority of these children will remain undiagnosed and die from complications of HIV. In this article, we summarize the challenges of identifying HIV-infected infants and children, review currently available evidence and guidance, describe promising new strategies for case finding, and make recommendations for future research and interventions to improve identification of HIV-infected infants and children.

Computer-generated reminders and quality of pediatric HIV care in a resource-limited setting

OBJECTIVES

To evaluate the impact of clinician-targeted computer-generated reminders on compliance with HIV care guidelines in a resource-limited setting.

METHODS

We conducted this randomized, controlled trial in an HIV referral clinic in Kenya caring for HIV-infected and HIV-exposed children (<14 years of age). For children randomly assigned to the intervention group, printed patient summaries containing computer-generated patient-specific reminders for overdue care recommendations were provided to the clinician at the time of the child's clinic visit. For children in the control group, clinicians received the summaries, but no computer-generated reminders. We compared differences between the intervention and control groups in completion of overdue tasks, including HIV testing, laboratory monitoring, initiating antiretroviral therapy, and making referrals.

RESULTS

During the 5-month study period, 1611 patients (49% female, 70% HIV-infected) were eligible to receive at least 1 computer-generated reminder (ie, had an overdue clinical task). We observed a fourfold increase in the completion of overdue clinical tasks when reminders were availed to providers over the course of the study (68% intervention vs 18% control, P < .001). Orders also occurred earlier for the intervention group (77 days, SD 2.4 days) compared with the control group (104 days, SD 1.2 days) (P < .001). Response rates to reminders varied significantly by type of reminder and between clinicians.

CONCLUSIONS

Clinician-targeted, computer-generated clinical reminders are associated with a significant increase in completion of overdue clinical tasks for HIV-infected and exposed children in a resource-limited setting.

Performance of the integrated management of childhood illness algorithm for diagnosis of HIV-1 infection among African infants

OBJECTIVES

Early infant HIV-1 diagnosis and treatment substantially improve survival. Where virologic HIV-1 testing is unavailable, integrated management of childhood illness (IMCI) clinical algorithms may be used for infant HIV-1 screening. We evaluated the performance of the 2008 WHO IMCI HIV algorithm in a cohort of HIV-exposed Kenyan infants.

METHODS

From 1999 to 2003, 444 infants had monthly clinical assessments and quarterly virologic HIV-1 testing. Using archived clinical data, IMCI sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated using virologic testing as a gold standard. Linear regression and survival analyses were used to determine the effect of age on IMCI performance and timing of diagnosis.

RESULTS

Overall IMCI sensitivity, specificity, PPV, and NPV value were 58, 87, 52, and 90%, respectively. Sensitivity (1.4%) and PPV (14%) were lowest at 1 month of age, when 81% of HIV infections already had occurred. Sensitivity increased with age (P < 0.0001), but remained low throughout infancy (range 1.4-35%). Specificity (range 97-100%) was high at each time point and was not associated with age. Fifty-eight percent of HIV-1-infected infants (50 of 86) were eventually diagnosed by IMCI, and use of IMCI was estimated to delay diagnosis in HIV-infected infants by a median of 5.9 months (P < 0.0001).

CONCLUSION

IMCI had low sensitivity during the first month of life, when the majority of HIV-1 infections had already occurred and initiation of treatment is most critical. Although sensitivity increased with age, the substantial delay in HIV-1 diagnosis using IMCI limits its utility in early infant HIV-1 diagnosis.

Is increasing complexity of algorithms the price for higher accuracy? virtual comparison of three algorithms for tertiary level management of chronic cough in people living with HIV in a low-income country

Background

The algorithmic approach to guidelines has been introduced and promoted on a large scale since the 1970s. This study aims at comparing the performance of three algorithms for the management of chronic cough in patients with HIV infection, and at reassessing the current position of algorithmic guidelines in clinical decision making through an analysis of accuracy, harm and complexity.

Methods

Data were collected at the University Hospital of Kigali (CHUK) in a total of 201 HIV-positive hospitalised patients with chronic cough. We simulated management of each patient following the three algorithms. The first was locally tailored by clinicians from CHUK, the second and third were drawn from publications by Médecins sans Frontières (MSF) and the World Health Organisation (WHO). Semantic analysis techniques known as Clinical Algorithm Nosology were used to compare them in terms of complexity and similarity. For each of them, we assessed the sensitivity, delay to diagnosis and hypothetical harm of false positives and false negatives.

Results

The principal diagnoses were tuberculosis (21%) and pneumocystosis (19%). Sensitivity, representing the proportion of correct diagnoses made by each algorithm, was 95.7%, 88% and 70% for CHUK, MSF and WHO, respectively. Mean time to appropriate management was 1.86 days for CHUK and 3.46 for the MSF algorithm. The CHUK algorithm was the most complex, followed by MSF and WHO. Total harm was by far the highest for the WHO algorithm, followed by MSF and CHUK.

Conclusions

This study confirms our hypothesis that sensitivity and patient safety (i.e. less expected harm) are proportional to the complexity of algorithms, though increased complexity may make them difficult to use in practice.

Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions

Early infant diagnosis (EID) of HIV-1 infection confers substantial benefits to HIV-infected and HIV-uninfected infants, to their families, and to programs providing prevention of mother-to-child transmission (PMTCT) services, but has been challenging to implement in resource-limited settings. In order to correctly inform parents/caregivers of infant infection status and link HIV-infected infants to care and treatment, a 'cascade' of events must successfully occur. A frequently cited barrier to expansion of EID programs is the cost of the required laboratory assays. However, substantial implementation barriers, as well as personnel and infrastructure requirements, exist at each step in the cascade. In this update, we review challenges to uptake at each step in the EID cascade, highlighting that even with the highest reported levels of uptake, nearly half of HIV-infected infants may not complete the cascade successfully. We next synthesize the available literature about the costs and cost effectiveness of EID programs; identify areas for future research; and place these findings within the context of the benefits and challenges to EID implementation in resource-limited settings.

The motor development of orphaned children with and without HIV: Pilot exploration of foster care and residential placement

Background

The AIDS epidemic has lead to an increase in orphaned children who need residential care. It is known that HIV leads to delayed motor development. However, the impact of place of residence on motor function has not been investigated in the South African context. The aim of the study was therefore to establish if children in institutionalised settings performed better or worse in terms of gross motor function than their counterparts in foster care. A secondary objective was to compare the performance of children with HIV in these two settings with those of children who were HIV negative.

Methods

Forty-four children both with and without HIV, were recruited from institutions and foster care families in Cape Town. The Peabody Development Motor Scale (PDMS II) was used to calculate the total motor quotient (TMQ) at baseline and six months later. Comparisons of TMQ were made between residential settings and between children with and without HIV.

Results

Twenty-one children were infected with HIV and were significantly delayed compared to their healthy counterparts. Antiretroviral therapy was well managed among the group but did not appear to result in restoration of TMQ to normal over the study period. HIV status and place of residence emerged as a predictor of TMQ with children in residential care performing better than their counterparts in foster care. All children showed improvement over the six months of study.

Conclusions

Foster parents were well supported administratively in the community by social welfare services but their children might have lacked stimulation in comparison to those in institutional settings. This could have been due to a lack of resources and knowledge regarding child development. The assumption that foster homes provide a better alternative to institutions may not be correct in a resource poor community and needs to be examined further.

Barriers to implementation of the HIV guidelines in the IMCI algorithm among IMCI trained health workers in Zambia

BACKGROUND

Zambia adopted integrated management of Childhood illnesses (IMCI) in 1995 and a number of adaptations have been made to the generic WHO/UNICEF IMCI guidelines to better conform to Zambia's health service needs. One significant adaptation is the incorporation of HIV guidelines into the IMCI algorithm. Since 2004, health workers that have undergone IMCI case management training have also received training in HIV assessment. During initial follow-up visits in 11 districts 90 health workers were assessed in 2007 to determine their adherence to the IMCI algorithm. The assessment showed that 97% of the health workers assessed did not review or mention the HIV guidelines even though they had received HIV training as part of IMCI. This study aimed to explore reasons for non-adherence to HIV guidelines in the IMCI algorithm and make recommendations on how this can be improved.

METHODS

Both quantitative and qualitative methods were used to collect information from eligible health workers. Forty (40) health workers were randomly selected from among those who received initial follow-up visits between March 2007 and January 2008. The health workers were selected from eight districts in four provinces of Zambia. Qualitative data was collected using Focus group discussion and key informant interviews

RESULTS

83% of the respondents said they had no difficulties in following the HIV adapted IMCI guidelines. 17% said they had difficulties. Of those who admitted having difficulties (60%) had difficulties in HIV assessment. Interesting, prompting and focus group discussions revealed that most respondents actually had difficulties in HIV assessment but could not admit it readily. Some barriers that contributed to non-adherence to the guidelines included lack of time due to inadequate staffing, lack of privacy in the health facilities and HIV related stigma from both caregivers and health workers. Frequent use of guidelines and supervision appeared to re-enforce adherence to the guidelines.

CONCLUSION

The findings in this study suggest that training in HIV adapted IMCI guidelines is not sufficient to enable health workers to actually use their knowledge in their daily practice. Barriers may exist which prevent them from adhering to the guidelines. Addressing these barriers is critical in increasing the uptake of paediatric ART in Zambia.

Disease profile of children under 5 years attending primary health care clinics in a high HIV prevalence setting in South Africa

OBJECTIVE

To describe the presenting complaints and disease profile of children attending primary health care (PHC) clinics in two provinces of South Africa.

METHODS

Participants were sick children 2-59 months old presenting for care at PHC clinics in KwaZulu-Natal (KZN) and Limpopo provinces from 2006-2007. Children were assessed by an expert Integrated Management of Childhood Illnesses (IMCI) practitioner. Children for whom parental/guardian consent was obtained were tested for HIV.

RESULTS

A total of 1357 children attending one of 74 clinics were assessed. HIV seroprevalence overall was 7.1%, but was significantly higher in KZN than Limpopo (7.5 vs. 2.4%; OR = 3.3, 95%CI 1.9-5.8%). Commonest presenting complaints were cough (72%), skin conditions (22%) and diarrhoea (19%). Of 1349 children, 120 (8.9%) had a weight below the third percentile; 108/1357 (8.0%) children required urgent referral, most commonly for severe pneumonia (53.7%) and severe malnutrition (16.7%). In multivariate analyses, severe pneumonia, growth faltering and urgent referral were independently associated with younger age, residence in KZN and HIV infection (P < 0.05).

CONCLUSIONS

Many children with severe illnesses and undiagnosed HIV infection present to PHC facilities. PHC staff require skills to correctly manage these conditions and undertake HIV testing. Although IMCI provides evidence-based guidelines, implementation must be improved to achieve adequate coverage of life-saving interventions.