Mamta Manglani, Yashwant Gabhale, Mamatha Murad Lala, Sudha Balakrishnan, Khanindra Bhuyan, Bharat Bhushan Rewari and Maninder Singh Setia*
Aims: To evaluate the effectiveness of telemedicine in clinical management of children living with HIV/AIDS in resource limited settings.
Background: Telemedicine is an important mechanism for service delivery in health care settings, both in resource rich and resource poor settings. Such service delivery mechanisms have shown to be associated with virologic suppression and higher CD4 counts. These services are also associated with improved access, shorter visiting times, and higher patient satisfaction.
Objective: We designed the present two-group comparison study to compare the clinical evaluation and management of children in the antiretroviral therapy (ART) centres linked to telemedicine facility with those who are not linked to this facility in Maharashtra, India.
Methods: We analysed clinical records from six ART centres in Maharashtra; of these 250 children were in the linked ART centres and 301 were in the non-linked ART centres. The outcomes were classified according to investigations, management, and monitoring. For management, we evaluated: 1) initiation of cotrimoxazole prophylaxis; 2) Children not initiated on ART when required; 3) ART regime after appropriate investigations; and 4) Change of regime (if immunologically indicated). For monitoring, we assessed the haematological monitoring of children on ART.
Results: The mean (SD) ages of children in linked and non-linked ART centres were 10.8 (4.6) and 10.9 (4.6) years respectively (p=0.80). After adjusting for individual and structural level variables, physical examination (OR: 2.0, 95% CI; 1.2, 3.2), screening for tuberculosis (OR: 12.9, 95% CI: 2.0, 82.9) and cotrimoxazole prophylaxis was significantly more likely in the linked centres compared with non-linked centres (OR: 1.8, 95% CI: 1.4, 2.2). A higher proportion of children eligible for ART were not initiated on treatment in the non-linked centres compared with linked centres (26% vs. 8%, p=0.06). Children were less likely to be initiated on zidovudine-based regimens without baseline haemoglobin or with baseline haemoglobin of less than 9 gm% in linked centres (OR: 0.7, 95% CI: 0.6, 0.8). Similarly, children in the linked centres were less likely to have been started on nevirapine based regimens without baseline liver enzymes (OR: 0.8, 95% CI: 0.7, 0.9).
Conclusions: Thus, the overall clinical management of Children Living with HIV/ AIDS (CLHA) was better in ART centres linked with the telemedicine initiative compared with those which were not linked. Children in the linked ART centres were more likely to have a complete baseline assessment (physical, hematological, radiological, and screening for TB), Presence of pediatrician in the centres was helpful.
Telemedicine, investigations, prophylaxis, management, Children Living with HIV/ AIDS, resource limited settings
Pediatric Centre of Excellence for HIV, Department of Pediatrics, LTM Medical College and General Hospital, Mumbai, Pediatric Centre of Excellence for HIV, Department of Pediatrics, LTM Medical College and General Hospital, Mumbai, Pediatric Centre of Excellence for HIV, Department of Pediatrics, LTM Medical College and General Hospital, Mumbai, UNICEF, Near 73, Lodhi Gardens, Lodhi Estate, New Delhi, Delhi 110003, UNICEF, Near 73, Lodhi Gardens, Lodhi Estate, New Delhi, Delhi 110003, WHO Regional Office of South East Asea, World Health House, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, Epidemiologist, MGM Institute of Health Sciences, Navi Mumbai