Article Text

HIV IN THE PAEDIATRIC INTENSIVE CARE UNIT IN A RESOURCE-CONSTRAINED ENVIRONMENT
  1. S Kling1,
  2. R P Gie1,
  3. P Goussard1
  1. 1Paediatrics and Child Health, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

Abstract

HIV/AIDS creates ethical problems for the paediatric intensivist in a resource-constrained environment. The high prevalence and the burden of severe disease impact on scarce intensive care unit beds. The diagnosis is frequently established only after admission and the prognosis of the child may be uncertain. Antiretroviral therapy (ART) may not be available. Ethically acceptable policies must be established for the admission and management of HIV-positive children requiring intensive care.

Aim To assess the ethical aspects surrounding admission and management of HIV-positive children in public sector paediatric intensive care units (PICU) in South Africa.

Methodology A questionnaire regarding admission policies and management of HIV-positive children was sent to eight tertiary hospital PICU. Clinical scenarios were also posed.

Results Responses were received from six PICU. At the time of the study, only one PICU refused admission to HIV-positive children (justification: poor long-term prognosis −20% survival at 6–8 months’ follow-up). PICU would not admit children with clinical stage 4 disease, severe wasting, nervous system involvement and delayed diagnosis or readmission for ventilation of Pneumocystis carinii pneumonia. ART played an important role. Two PICU would not utilise their last intensive care unit bed for an HIV-positive child. Practices between PICU varied for a 6-month-old HIV-infected underweight baby not on ART, with diarrhoea and septicaemia. Withdrawal of life support would be considered in cases of prolonged ventilation.

Conclusion HIV-positive children are often discriminated against regarding PICU admission in South Africa. Life-limiting decisions in resource-constrained environments are often rationing decisions. The individual child’s best interests must be weighed up against the best interests of other children.

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