Global Perspectives on Treat All for Children and Adolescents with HIV

PATA Global Summit

Shaffiq Essajee

Courtesy of Mary Mahy, UNAIDS

New HIV infections are declining among children!

47% decline

33% decline56% decline

Source: UNAIDS 2017

And as children “age out” into adulthood the total number of children with HIV is also declining

And the epidemic is shifting in terms of age…fewer young children, more adolescents living with HIV

2.1 million children living with HIV in 2016

Source: UNAIDS, 2017

If you are seeing these changes in your own clinicsand programmes – CONGRATULATIONS!This means your PMTCT efforts are working andyour clients are growing up on ART…

Source: UNAIDS, 2017

But paediatric treatment coverage is still too low…

In 2016, 920,000 children on ART (43%) vs 15 million adults on ART (54%)

Source: UNAIDS, 2017

And the problem is with the youngest and the oldest childrenART coverage by age group (Among countries that submitted age specific data)

So, what are the concrete steps that we can take?

Implement Treat All policies for children

There should be ZERO “pre-ART” kids in your clinic registers…if there are, TREAT them! If there any who have been lost to follow up, tracking, finding and bringing them back to care should be a priority

1

Improve Linkage to ART

2

Gaps

Low linkages- Incomplete referral systems

Intervention:

• Placement of focal person/peer at testing points to facilitate escort to CTC

• OVC case managers escort newly identified CLHIV from the community to CTC

• Same day initiation of HIV care APR _20 14(BASELINE) APR _2015(YR1) APR _2016(YR2)

HTC_POS 1100 1254 1885

TX_NEW 786 1239 1830

LINKAGE 71% 99% 97%

71%

99% 97%

0%

20%

40%

60%

80%

100%

120%

0

200

400

600

800

1000

1200

1400

1600

1800

2000

HTC_POS TX_NEW LINKAGE

LINKAGE INCREASED FROM 71% -> 97-99%

Source: ACT Initiative in Tanzania

Don’t delay ART start!

3

Slide: Courtesy of Elizabeth Obimbo

Consider Same-day ART for children/adolescents

4

ENABLERS

Health providers (inc peers) with good counseling skills

Uninterrupted supply of ARV commodities at sites

Simplified initiation processes

Mother or caregiver already receiving ART

Physically escorting clients from test site to ART clinic

Decentralization of pediatric HIV care and treatment to the lowest level health facilities

BARRIERS

Heavy workload for health workers

Co-infections that require staggering treatment

Poor counselling skills

ARV drug stock outs

“Unaccompanied” minors

Promote nurse-initiated ART for children

• In Tanzania in 2013, Pedscoverage was just 26.5% coverage

• Severe physician shortage (0.03 per 1,000 population)

• Nurse initiated management of ART (NIMART) proposed to address this

• Policy adoption SOP in-service training nurse service delivery model permitting testing, ART, and dispensing

Source: ACT initiative, Tanzania

4322

9314

4174

17810

1786

5363

2291

9440

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

Dispensary Health Center Hospital Total

TX_NEW TX_NEW by Nurses

5

By the end of 2016, peds coverage increased to 52.2%

Integrate TB and HIV diagnosis to identify CLHIV

6

Source: Hesseling et al. 2009

Integrate TB and HIV diagnosis to identify CLHIV

6

13

7

13

9

27

7

28

2

67

%

88

%

92

%

93

%

27

% 29

% 23

%

23

%

56

% 86

% 86

%

84

%

QUARTERLY 1 QUARTERLY 2 QUARTERLY 3 QUARTERLY 4

TB patients registered during the reporting period

TB patients who had an HIV test result recorded in the TB register

TB patients who had an HIV test result recorded in the TB register(positive results)

HIV Positive TB (co-infected) patients who start ART

Q1 Q2 Q3 Q4

• Integrating HTS into TB clinics

• Training of TB sector HCW on PICT

• Allocation of Peer educator to escort HIV+ children

• Provision of incentives for Peer educators

• Development of linkage tool to capture ART initiation

Source: ACT initiative, Mozambique

What is retention like in children?

Source: Abuogi LL PLOS One 2016

Retention of HIV-Infected Children in the First 12 months of ART

Source: CDC - ACT Initiative

VL >1000 copies/ml

VL undetectable

And what about rates of VL suppression?

What drives low retention in children?

Source: B. Phelps AIDS 2013

Stigma

Lack of Disclosure

Age (<2yo)

MalnutritionAdvanced Disease

Parent/caregiver interpretation of

health status of child

Economic Barriers

Proximity to clinic

Mental health problems

Loss of caregiver

Long clinic wait times

Understaffing at clinics

Inadequate clinical/lab

services

7

Source: ACT initiative, Mozambique

Family Based Care Approach• All family members are seen at the same

time at HIV clinic and receive all package of services needed for the health of the family including counselling and testing for HIV.

• HIV+ family members have their clinical apointment on the same day with the same doctor .

• AVRs pick-up and Lab specimen collection are also done at the same day and time for all family members.

• Counsellor provides morning lectures and identifies potential families for this service

Adult retentionPediatric retention

Family based approaches to improve retention

Community interventions to address challenges

8

Source: ACT initiative, Tanzania

Gap: Low retention

Interventions:

• Children clubs established

• Peer counsellors identified and linked to supported health facilities.

• Lay counsellors tracked clients in the community

2,975

3,898 3,837

4,473

78%

87%

76%

78%

80%

82%

84%

86%

88%

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

Crude retention 2015 crude retention 2016

RETENTION TREND 2015 VS 2016 AMONG CHILDREN <15 YEARS

Curr TX

Curr TX (prev.yr)+ New_TX(Curr.yr)

% Retention

8

Source: Kheth’Impilo - Fatti G et al. IAS 2017

• Cohort study• Community-based

support• Adolescents and youth

on ART in South Africa• 6,706 clients at 47

facilities

with CBS

without CBS

P<0.0001

0

.1

.2

.3

.4

.5C

um

ula

tive

in

cid

en

ce

of lo

ss t

o f

ollo

w-u

p

0 1 2 3 4 5

Years after starting ART

aHR: 0.60 (95% CI: 0.51-0.71); p<0.0001

P=0.027

without CBS

with CBS

0

.1

.2

.3

.4

.5

Cu

mu

lative

in

cid

en

ce

of m

ort

ality

0 1 2 3 4 5

Years after starting ART

aHR: 0.52 (95% CI: 0.37-

0.73); P<0.0001

Loss to follow-up Mortality

Community interventions to address challenges

8

Community interventions to address challenges

• Comprehensive toolkit built on pilot experience

• Step by step guide how to implement C3

(Clinic-CBO Collaborations)

• Aim to optimise local collaborations between

CBOs and local clinic partners

• Launch November 2017 AIDS Impact &

December 2017 ICASA

Resources

• UNICEF’s learning collaborative http://www.childrenandaids.org/

• The PEPFAR ACT Initiative report http://www.pedaids.org/page/-

/uploads/resources/ACT_Report_04_2017_FINAL-digital.pdf

• George Siberry

• Nandita Sugandh

• Jessica Rodrigues

• Nande Putta

• Chewe Luo

• Dominic Kemps

Acknowledgements