Healthcare Workers' Perspectives on the Barriers to Providing HIV Services to Children in Sub-Saharan Africa. AIDS Res Treat


Background. In order to accelerate the HIV response to meet the UNAIDS 90-90-90 indicators for children, healthcare workers need to lead a scale-up of HIV services in primary healthcare settings. Such a scale-up will require investigation into existing barriers that prevent healthcare workers from effectively providing those services to children. Furthermore, if the identified barriers are not well understood, designing context-specific and effective public health response programmes may prove difficult. Objective. This study reviews the current literature pertaining to healthcare workers' perspectives on the barriers to providing HIV services to children in the primary care setting in Sub-Saharan Africa. Methods. English articles published between 2010 and April 2018 were searched in electronic databases including Sabinet, MEDLINE, PubMed, and Google Scholar. Key search words used during the search were “healthcare workers’ perspectives” and “barriers to providing HIV testing to children” OR “barriers to ART adherence AND children” and “barriers to HIV disclosure AND children.” Results. There are various barriers to provider-initiated counselling and testing (PICT) of children and disclosure of HIV status to children, including the following: lack of child-friendly infrastructure at clinics; lack of consensus on legal age of consent for both HIV testing and disclosure; healthcare worker unfamiliarity with HIV testing and disclosure guidelines; lack of training in child psychology; and confusion around the healthcare worker’s role, which most believed was only to provide health education and clinical services and to correct false information, but not to participate in disclosure. Additionally, primary caregivers were reported to be a barrier to care and treatment of children as they continue to refuse HIV testing for their children and delay disclosure. Conclusion. Training, mentoring, and providing healthcare workers with guidelines on how to provide child-focused HIV care have the potential to address the majority of the barriers to the provision of child-friendly HIV services to children. However, the need to educate primary caregivers on the importance of testing children and disclosing to them is equally important.

1. Introduction

Sub-Saharan Africa (SSA) is home to 12% of the global population, yet it bears 71% (6.8 million) of the global burden of HIV [1, 2]. Sub-Saharan Africa is also home to 90% of the global burden of HIV-infected children aged <15 years [3]. While SSA’s 33% decline in new infections among children aged 0-14 years achieved in 2016 is commendable, the HIV incidence rates remain unacceptably high in this age group [4]. Reduction in new infections has been attributed to improved antiretroviral treatment (ART) and access thereto and scale-up of effective prevention of mother-to-child transmission (PMTCT) programmes dubbed a significant public health success [2, 5]. However, despite the substantial impact of PMTCT in reducing child morbidity and mortality, immense challenges remain in the delivery of HIV services for children in low resource settings. One of the biggest challenges is that many HIV-infected pregnant women still do not access antenatal care and therefore miss out on the health facility-based PMTCT interventions [6]. After pregnancy, the opportunities for early infant diagnosis (EID) of HIV-exposed children are limited, and many children remain undiagnosed in their infancy. They often only present after they have developed advanced AIDS-defining illnesses, resulting in poor prognosis even after being given ART [6].

The failure of EID interventions, which should be done during infancy, undercut the value of implementing PMTCT if exposed children continue to be missed by the healthcare system. The South African Prevention of Mother-to-Child Transmission Evaluation (SAPMTCTE) study found that, of the 2856 HIV-exposed infants attending facilities that reported providing EID, 62% had had a known HIV status documented on the child-health card or they were waiting for the 6-week immunisation. The remaining 38% of HIV-exposed children had no HIV status documented on their road to health cards, nor were their mothers intending to request EID services at the 6-week immunisation visit, which potentially puts them at risk of being missed opportunities for EID [18]. Additionally, studies conducted in Zimbabwe alluded to the existence of undiagnosed “slow progressors” presenting with advanced HIV disease at health facilities in late childhood and bringing to light an unanticipated emergent epidemic of older survivors of MTCT [19, 20]. These studies also linked the existence of an emergent epidemic in older children to the failure of public health to measure and directly observe the survival patterns of slow progressors [19].

In Sub-Saharan Africa, finding children of the survivors of MTCT remains a challenge as the opportunities for reentry into mainstream HIV care and treatment programmes are limited [6]. In addition, existing HIV testing and counselling programmes seldom focus on children older than 18 months of PMTCT, despite the existence of provider-initiated counselling and testing (PICT) guidelines. These guidelines encourage healthcare workers to proactively offer HIV testing and counselling to all primary caregivers, regardless of their reason for visiting the facility. Some of the barriers to implementing PICT include healthcare worker shortages, healthcare worker belief that children who do not have any symptoms need not be tested [16], and the unwillingness of the primary caregivers of exposed children to consent to HIV testing for their children [12]. In addition, studies have attributed primary caregivers’ unwillingness to consent to self-stigma, fear of being blamed by the child, and fear of traumatising the child [12, 21].

After HIV diagnosis and HIV treatment initiation of a child, new challenges arise. Studies have shown that adherence to the HIV treatment regimen is problematic for children below the age of 14 years [22, 23]. This is because children are dependent on parents and other family members for access and support to correctly take their medication [24]. Studies have found that a primary caregiver’s willingness to collect medication for the child and administer the medication is a determinant of the child’s adherence to treatment [24, 25]. Moreover, studies have also reported that children of school-going age default because their lifestyles prevent them from going to the health facility for their monthly clinical assessment and drug pickup [26–28]. These behaviours put them at high risk of defaulting, as paediatric formulations require constant review and adjustments in accordance with fluctuations in weight. Some research blames children’s nonadherence to ART on the lack of child-friendly palatable paediatric ART formulations resulting in children’s refusal to take the medicine [29]. Research has also linked nonadherence to ART among children to the child’s lack of knowledge of their HIV-positive status (child not disclosed to), lack of understanding of the consequences of defaulting, and inadequate knowledge about HIV and how the ARVs work [7]. Literature suggests that adherence to HIV treatment is more effective if the child has been disclosed to, is aware of his/her HIV-positive status, and understands the importance of adhering to the treatment regimen [11]. However, the challenge in most Sub-Saharan countries is that, by law, the decision to test the child and to disclose HIV status to a child under the age of 18 years remains the responsibility of the primary caregiver, and the healthcare worker can only support the process [23].

There is evidence suggesting that healthcare workers fail to provide children with HIV services because they lack adequate knowledge and skills to approach children and their caregivers [12, 21]. This is exacerbated by healthcare workers’ lack of training on existing guidelines for providing child-friendly HIV testing services and disclosure counselling [8, 12, 15]. A study conducted in Ghana found that healthcare workers were unsure of the language or approach to use, particularly when providing counselling and health education during HIV testing and counselling services (HTS), and whether or not to provide these to the child or only discuss with the primary caregiver [21]. This is a huge concern as the WHO HIV testing and counselling guidelines [30] recommend that the child is provided with appropriate pre- and posttest counselling, adherence counselling, and basic HIV education as standard HIV services.

Providing children with HIV testing, adherence, and disclosure services after PMTCT remains a huge challenge in Sub-Saharan Africa. Therefore, it is imperative to ensure that the barriers preventing healthcare workers from providing these services to children in Sub-Saharan Africa are examined. This will be the first step towards developing and implementing viable solutions. The study focuses on “healthcare worker perspectives” because healthcare workers are the face of healthcare in the delivery of HIV services to children and their primary caregivers.


This study reviewed healthcare workers’ perspectives on the barriers preventing them from providing quality HIV testing, adherence, and disclosure services to children in Sub-Saharan Africa. Child-centred approaches should be adopted by healthcare providers to ensure that children receive holistic and age-appropriate care. Developing formal guidelines, training and mentoring healthcare workers on these child-focused approaches, developing child-friendly job aides, and creating child-friendly areas have a potential to marginally improve the quality of HIV services provided to children in low resource settings. This will, in turn, push Sub-Saharan Africa closer to achieving its 90-90-90 goals.

Mutambo C
Hlongwana K
AIDS Res Treat
Publication Date: 
March, 2019
IBN number: