When Dr Virginia José Albino leaves her post at a rural health centre in Mozambique's central province of Zambezia, HIV/AIDS services at the clinic nearly grind to a halt.

Last month, Albino went to the provincial capital, Quelimane, for a week of work-related meetings, and returned to a pile of new case files and the news that one of a handful of HIV-positive children on antiretroviral (ARV) treatment had died. "It was a child I had hopes for", she said. "I don’t know what happened".

Albino is the only doctor permanently assigned to the district of Nicoadala, which has nearly 300,000 residents and has to juggle a host of tasks, from hospital administration, evaluating new patients in the single-room HIV/AIDS clinic, to making her regular patient round. Attending to children is only part of her job, but she is usually the only one around authorised to put them in treatment.

Although last year Mozambique launched a massive national rollout of ARV drugs, the acute shortage of medical personnel is a major reason that HIV/AIDS treatment is only reaching five percent of the estimated 78,800 children in need.

A report issued last month by the international medical charity, Medecins sans Frontieres (MSF), concluded the chronic shortage of medical personnel had seriously compromised the expansion of HIV/AIDS treatment throughout southern Africa and especially when it came to treating HIV-positive children, because of the specialized care required. [See report Health staff haemorrhage limits AIDS treatment access]

Although medical assistants and nurses are gradually receiving the special training to diagnose children with HIV and to treat them for opportunistic diseases, there remains a dearth of trained staff. And while a medical assistant can put adults on ARV treatment, only doctors are able to prescribe the medication to mothers and children.

The result is crowded waiting rooms, where few staff are on hand to identify the children in need of treatment, and even if they are, there is another obstacle of convincing the mothers that treatment for their children is worth the effort.
"The mother brings her child at 7:30 in the morning and maybe [the child] is only treated at noon", Florindo Mudender, national coordinator for antiretroviral programmes, told IRIN/Plusnews. "She waits, she leaves, and she never comes back."

Few specialists

Most of the country’s medical skills are located in the capital, Maputo, while 55 doctors are registered in Zambezia, a province of almost 4 million people and an adult HIV prevalence of 18 percent. Three of its 17 districts don’t have any doctors at all, as these remote districts don’t have the proper conditions to "house the doctors with dignity," the province’s medical chief Joana Nachaque said.
In the absence of doctors, hospitals are sometimes run by some of the province's 387 medical assistants, which includes includes lab technicians and other personnel, who do not have the necessary medical skills to treat children.

Only four of the doctors in Zambezia are paediatricians, a fact which paediatricians, at least, believe further compromises the quality of childcare. Health staff without much experience in childcare worry about a child's fragility and may not be sufficiently "bold" in their treatment, Dr Maria João Soromenho, a paediatrician working in Zambezia, said. "Even a very good internist may have a fear of dealing with children."

A difficult diagnosis

Diagnosing and treating children with HIV/AIDS requires specialized knowledge that makes treating adults relatively easy in comparison. Babies younger than 18 months cannot be tested using the methods currently available in most of Mozambique, so medical staff have to make clinical judgments, which requires a trained eye. An infant with persistent diarrhoea, for instance, or who doesn’t grow properly, should be referred for possible ARV medication.

Many children are lost at this stage, say doctors, since staff do not always recognise the danger signs and although it helps to know if the mother is HIV-positive, that information is not always available or forthcoming.

A diagnosis is only possible, however, if the mother brings her child to the clinic. In Zambezia, about 95 percent of pregnant mothers who test positive and go through initial consultations, never return after giving birth.

Once a child is in treatment, medical staff must master a new set of complex tasks, perhaps chief among them is the administering of ARVs. For children, unlike for adults, the dosage changes as the child grows.

Training slow

The medical assistants who graduate from training programmes this August will not have learned how to treat children with HIV/AIDS, although a curriculum is being formulated to integrate paediatric HIV care into the regular coursework.

As it is, medical assistants and nurses must learn HIV-related childcare while in the field, through periodic training seminars that take them away from their patients. At one training session in Zambezia last month, a good portion was given over to the seemingly simple task of measuring an infant’s height.

There is also talk of eventually allowing medical assistants to prescribe antiretrovirals to children, something which currently only doctors are authorised to do. "Eventually even a senior nurse will be able to prescribe the drugs, that’s what we expect," Christiane Rudert, a health and nutrition specialist for the United Nations Children’s Fund (UNICEF) in Mozambique, said.

Ever more infected children

Though the numbers are currently low, the paediatric HIV caseload at health centres are expected to increase as more mothers are convinced of the benefits of ARV treatment for their HIV-positive children. A further reason for the rising rates of children born with HIV/AIDS is that so few mothers are enrolled in programmes to prevent vertical transmission. In 2006, the number of new infections of children, some 37,000, was 60 percent higher than in 2000, according to UNICEF.