Young people with HIV are dying in increasing numbers in Zimbabwe at a time when HIV-related deaths are declining for all other age groups.
A recent study reveals that young people are also less likely to get tested for the virus, as concerns about guardianship and privacy can discourage clinics from testing children.
Flaws in HIV health care
Research conducted in Zimbabwe by the London School of Hygiene and Tropical Medicine found that older children—aged between six and 15—who might have acquired HIV at birth, received inadequate access to provider-initiated HIV testing and counselling by primary health care givers.
The main reasons that health-care workers gave for not offering tests were that the child was accompanied by a guardian not appropriate for providing consent, and a lack of staff or HIV testing kits. Children who were older, or that visited the clinic with a male or a younger guardian, were less likely to be offered HIV testing.
In addition to this, health-care workers were also reluctant to offer testing as they feared that a child might experience abuse if he or she tested positive. According to the study, lengthy waiting periods endured by guardians and older children also hindered routine testing and counselling.
Around 200,000 Zimbabwean children aged between 0 and 14 years live with HIV, according to the United Nations Programme (UNDP). More than 90 percent of the children who were tested during the study and found positive had failed to get tested before, a trend that, according to the authors, reflected “suboptimal” counselling and testing in Zimbabwe. The study was carried out between January and May 2013 by interviewing primary health caregivers at six clinics in Harare, the capital, and sampled over 2,000 children. (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.100165).
Healthcare workers did not help matters, said the report, as they sometimes refused to attend to willing guardians and children, and failed to understand regulations guiding counselling and testing procedures. “They expressed confusion about the age at which a child could choose to test him/herself, what type of caregivers qualified as legal guardians, and whether guardians had to undergo testing themselves first."
Eight-year old Theresa Mpofu*, from Chitungwiza, 30km south of Harare, could be living with HIV but it might be a while before she gets to know her status. Her mother died of AIDS-related pneumonia two years ago but, even though she was aware of the possibility that Theresa could have been born with HIV, she did not get her daughter tested, according to relatives. Theresa has in the past year suffered numerous health complications that include a persistent skin rash and sores, and when her grandmother with whom she lives took her to a public hospital, the minor could not be tested because the nurses insisted that her father be present to give consent.
“Her (Theresa’s) father is still alive even though he had divorced my daughter when she died. However, he does not want to come and authorise Theresa’s testing, yet the nurses say I cannot do that as long as the father is still alive,” the grandmother, who cannot be named, told IRIN.
The girl abandoned school when her health problems became more frequent. She has only received treatment for her symptoms. Even then, she can only get medical care when the grandmother, who depends on relatives and well-wishers for their upkeep, gets money for hospital expenses. “Since her mother died of AIDS, it is possible that she might have passed the disease to Theresa”, the grandmother points out. “Something should be done to determine what exactly is causing her illnesses, otherwise she will also die.”
Zimbabwean national guidelines for testing and counselling require that a child below 16 be accompanied by a consenting legal guardian, but also provides that proxies like doctors or government social services staff can do so when it is considered to be in the best interests of the child.
As a result, “children were often sent away to seek additional permissions, and frequently did not return”. According to one female head nurse who the researchers interviewed, “very few (children) come with their parents or legal guardians ... you will always need consent.” The same nurse pointed out: “even if you see a sick child, you have to encourage the person who came with the child to get consent." The study noted that caregivers would also refuse to test children whose parents lived outside the country as there was no eligible person to give consent; caregivers could only provide treatment to evident symptoms.
The researchers urge Zimbabwe's government to develop clear testing policies and guidance on consent and guardianship, provide legal authority to caregivers to give consent on behalf of children needing testing and increase awareness of the high prevalence of HIV among older children. In addition, there is a need to train healthcare workers on counselling and fight stigmatisation and discrimination through laws, and improve testing resources.
Martha Tholanah of the International Committee of Women Living with HIV (ICW-Zimbabwe) told IRIN that the low levels of provider-initiated HIV testing and counselling to older children showed that stigma was still high in the country. “Our communities are closely knit and it is difficult to keep the status of an individual a secret once he or she is tested. This is one fear that guardians have. Testing a child will not only expose his or her status, but that of the guardians too,” she said. "Many children are probably dying because testing is left for too late or does not take place at all yet this could be avoided if there were proper guidelines on how to attend to these girls and boys."
*Not her real name.