Impact of Early Infant Diagnostic (EID) Testing for HIV Exposed Infants in Namibia

1. Impact of Early Infant Diagnostic (EID) Testing for HIV Exposed Infants in Namibia [A-240-0316-12275] 20 July 2010 Dr. Ndapewa Hamunime (MOHSS) Dr. Andreas Shiningavamwe (NIP) Republic of Namibia

2. Background • Population ~2million • Surface area of 802,4116km2 • Sparsely populated: population density 2.2/km2 • 35 public hospitals, 34 health districts • 11.5% of GRN budget spent on health • Newly established Medical School 2010 • 95% of drugs, supplies imported

3. Namibia has rapidly responded to HIV positive infant vulnerability with EID and infant treatment Global Context Early Infant Diagnosis for HIV linked with HIV care is critical for the survival of HIV exposed infants Context and Response • Response • National Early Infant Diagnosis (EID) service launched in late 2005 bythe Ministry of Health and Social Services (MOHSS) in collaboration with the National Institute of Pathology Ltd (NIP) Windhoek • Significant investment in EID has taken place since 2006 • As the service has scaled up, program evaluations continue to be used to guide programming to maximize infant care

4. Methods (1) A selection of 25 EID collection sites across all 13 regions were reviewed SITES

5. Methods (2) The full EID service was reviewed at each site • At each site, the full EID service continuum was examined: HIV Care for HIV + Infants PMTCT EID Sample Collection Point(s)(& cotrimoxazole) Testing at NIP Windhoek Result Return to Infant SCOPE Vaccination Family testing of PLHAs PCR 1 Negative Infants: Follow up Infants on Wards Identification of Exposed Infant Sample Transport to Processing laboratory Result Return to Site

6. Scale up of EID Sample Collection (via DBS) EID collection sites, EID samples, and EID coverage have increased dramatically over time EID Collection Sites over Time (sites) • Since 2006, sites offering EID have grown dramatically: • EID was available in all regions by the end of 2006 • EID is available at all 79 ART sites and over 200 PMTCT sites • Over 31,900 EID samples have been tested since the start of the service • In 2008, 86% of HIV exposed infants accessed EID Site ever collecting a DBS sample for the national program 2006 2007 2008 2009 Monthly EID Samples Volume over Time EID Samples tested in public sector 2006 2007 2008 2009

7. Early Identification (1) Over time, more of the HIV exposed infants receiving an EID test are getting tested early • Namibian Algorithm encourages EID testing at 6 weeks • Because of Infant health deterioration, early testing is key • In early years of the service, only 50% of infants tested were tested in their first two months of life • Every year, a larger portion of infants tested had their first EID sample collected in the first two months of life Portion of Infants EID Tested by Age Band at PCR 1 Tested ≥ 6 m Tested 2 ≤ x <6 m Tested in first two months of life

8. Early Identification (2) However, more must be done to take advantage of high PMTCT coverage for earlier EID • In 2008, Namibia had a 92% PMTCT coverage • Of infants receiving their first EID tests, over 90% of them were coded as coming from PMTCT • However, only 49.6% of all infants tested were tested in their first two months of life • We are working hard to further reinforce the linkage between PMTCT and early EID testing and exposed infant care Coverage of PMTCT Service (2008) 49.6% <2m Est. HIV Pos Pregnant Women1 Known Pos1 Accessed PMTCT1 EID Tested ≥ 6 m Tested 2 ≤ x <6 m Tested in first two months of life (1) UNICEF, UNAIDS, WHO. Towards Universal Access 2009,Vienna: 2009.

9. EID Sample Transportation and Processing A centralized transportation system, and one Central PCR laboratory has allowed for smooth processing • Efficient sample transport system linked with local NIP laboratories (who manage intake) allows for rapid transport (mean <1 day from sample collection to arrival at local NIP) • Centralization of EID along with strong lab organization and management ensures high throughput and fast turn around time Monthly EID Sample Volume (samples) Mean Turn around Time (days) 2006 2007 2008 2009 2006 2007 2008 2009 Technicians rotate and process samples daily – processing volumes of ~1,000 -1,300 EID samples/monthly Turn around times from sample collection to result completion are consistently <10 days Collection to local NIP Local NIP to analysis

10. Referral to HIV Care and Treatment Examining HIV positive infant follow up at individual sites gives indications of attrition challenges HIV Pos Infants Enrolled at ≤12m of Age at 25 Reviewed Sites since 2006 • EID is critical because it allows for the earlier identification of and care for HIV positive infants • Portion of HIV positive infants put on ART within 6 months of enrolling is increasing 2006 2007 2008 2009 (n=203) (n=293) (n=439) (n=50) Infants <12m enrolled never initiated Infants <12m initiated >6m after enrolling Infants <12m initiated ≤6m after enrolling Mean Time between enrollment and ART Initiation of Infants enrolled in HIV care (weeks) • Mean time between enrollment and initiation of HIV positive infants is steadily decreasing weeks

11. Conclusions and Programmatic Implications Program reviews and analyses can inform future program interventions EID Strengths Efforts to Strengthen the EID in Namibia • High PMTCT and EID coverage • Dramatic increases in EID volumes • Decreasing age at testing • Centrally managed program • Consistent and fast sample turn around time • Strong technical capacity • Partner collaboration • Linkages between PMTCT, DPT1 vaccination and early EID testing at sites reinforce through mentoring and supervision • EID test sites increased from 242 to 292 since review • A new automated EID equipment procured and installed at NIP • Community engagement and defaulter tracing system strengthened Ever Present Challenges • Higher than optimal average age at testing • More support for follow-up of HIV exposed infants, referral of HIV positive infants to HIV care, and clinical care for infants testing positive particularly with regards to ART initiation • Strengthen private sector involvement

12. Acknowledgements UNICEF (HQ, ESAR, NAMIBIA CO) USAID US Center for Disease Control Clinton Foundation I-TECH WHO GRN