Directly Witness Ingestion Therapy is a Game Changer

Nearly seven out of every 10 HIV- positive children globally live in East and Southern Africa. Despite progress made to reduce new HIV infections in children, the region remains far behind the 95-95-95 fast-track global targets for ending pediatrics AIDS by 2030.

Viral load suppression is critical to treatment success and to reduce child illnesses and, death. Studies show that in every three children who had a viral load test, one was virally unsuppressed.

This was the case for two young siblings at Kitare Health Center in Homabay County. Their viral load suppression trends raising great concern.

Jacob Ocholla, a clinical officer at the facility says that “one of the children aged 7, had a viral load of 3,240 in 2016 that fell to 124 through intervention in 2018 and then shot to 6,700 in 2019. The other sibling aged 10, had a viral load of 16,000 in 2018 that fell to 93 through intervention in the same year but then shot to 2,400 in 2019.”

The mother, also their primary caregiver was not faring any better with a viral load of 35,200 in 2019, confirming suspicions that when a caregiver is not virally suppressed, children under their care are similarly likely to be unsuppressed.

“I was the third adherence counsellor to handle these children. Health providers had all but given up because we had intervened without sustainable success for many years. We needed an urgent solution,” says Collins Otieno Were, an adherence counsellor at the facility.

Ocholla says that in such difficult cases, health care providers undertake enhanced adherence counseling sessions with respective caregivers for a period of three months and repeat the process if targeted results are not achieved.

The sessions are accompanied by multi-disciplinary team (MDT) meetings attended by all involved in the team of care to pre-empt the problem.

“Ideally, when we sit for an MDT, we discuss the patient of concern in absentia and make critical decisions on the best cause of action. But this was a difficult case. The mother was already on second line treatment and the children on a first line regimen that is a second line component. We were getting to the end of the line,” says EGPAF’s Gideon Mikoye Libulele.

The patient was therefore called in during one of the MDTs to understand the magnitude of the situation. In her presence, the case was laid bare and options provided.

Health care providers agreed that the situation called for Directly Witness Ingestion Therapy (DWIT), whereby a witness ensures that medicine was in fact swallowed and not hidden inside the mouth to be spit later.

The mother would therefore present the children to the facility every morning and evening for their health provider to witness ingestion of medicine.

“This would be a tough experience for the school going children but the mother promised to take on the responsibility. We were apprehensive but she insisted,” Were explains.

Three months after the promise was made, DWIT proved to be the game changer. Both children had achieved an undetectable viral load and remain suppressed. Similarly, the mother’s viral load dropped to 470 in 2020 and is now undetectable.

These are two of 32 children in pediatrics care at the facility. In all, 29 have a viral load of below 400 copies, one has a viral load of between 400 and 999 and two have a viral load of beyond 1,000.

“This case proved that capacity building in DWIT, clinic sessions and staff’s positive attitude towards HIV clients are critical in enhancing adherence. Visiting caregivers in their home environment is equally important. In this particular case, 2019 was rocked by domestic wrangles that led to interruption of treatment,” Were expounds.

Libulele adds that an absence or change of caregivers affect adherence to treatment, “also, when children are left to take medication on their own, sometimes they forget or take some of the medication especially the flavored tablet.”

Through DWIT, pediatrics suppression rate at the facility moved from 67 percent in 2019 to 88 percent in 2020, to the current 94 percent.