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Where Are We Headed with Paediatric Prevention and Treatment

Where Are We Headed with Paediatric Prevention and Treatment. Shaffiq Essajee Melbourne, July 25 2014. Global progress on PMTCT continues despite shrinking resources for HIV scale up. As maternal ARV access has increased, so the estimated number of new child infections has fallen to 240,000.

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Where Are We Headed with Paediatric Prevention and Treatment

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  1. Where Are We Headed with Paediatric Prevention and Treatment Shaffiq Essajee Melbourne, July 25 2014

  2. Global progress on PMTCT continues despite shrinking resources for HIV scale up As maternal ARV access has increased, so the estimated number of new child infections has fallen to 240,000 Source: UNAIDS 2013 HIV and AIDS estimates, 2014, and UNAIDS/WHO/UNICEF Global AIDS Response Progress Report Universal Access data, 2006-14

  3. Option B or B+ has now been adopted in all the 22 priority Global Plan countries, but the pace of implementation needs to increase Globally close to 80% of countries have adopted Option B or B+ in their national program Source: lATT/WHO Global Update on the Health Sector Response to HIV, 2014.

  4. There are 60% fewer new infections in children but there has not been a commensurate decline in child deaths 60% reduction in new infections from peak of 580,000 per year 40% reduction in mortality from peak of 330,000 per year Source: UNAIDS 2013 HIV and AIDS estimates, 2014, and UNAIDS/WHO/UNICEF Global AIDS Response Progress Report /Universal Access data, 2006-14

  5. Unlike paediatric prevention, paediatrictreatment efforts are stagnating especially when compared with adult coverage • The denominator has increased – now “All people living with HIV” not “People in need of ART” • Coverage for The gap between adult and child coverage has widened. 38% 24% Source: UNAIDS/WHO/UNICEF 2008-2014 GARPR/Universal Access reporting and UNAIDS 2013 HIV and AIDS estimates

  6. We have been failing to achieve equity for children for a long time, but the situation today is different to the past We don’t have the right drugs and formulations to treat children… Yes we do! We still need a child friendly heat stable form of lopinavir/ritonavir but this is coming soon… Source: CHAI Ceiling Price 2013

  7. We have been failing to achieve equity for children for a long time, but the situation today is different to the past WHO guidelines offer simplified harmonized weight band doses for all ages and all forms It’s too complicated to treat children, you need specialists just to do the dosing…. No it isn’t Source: Adapted from WHO Consolidated guidelines 2013

  8. We have been failing to achieve equity for children for a long time, but the situation today is different to the past 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 - 2007 2008 2009 2010 2011 Number of PCR tests each year 1,200,000 15x increase We cant make an HIV diagnosis in infants because virological testing is too difficult Yes we can! 80,000 Year Global AIDS Report notes that 44% of infants areaccessing an EID test within 2 months of life and in many countries this is above 90% Source: CHAI UNITAID Program data 2012

  9. Five issues stand out as key bottlenecks across the continuum of care from diagnosis to treatment 1 • We are not looking in the right places to identify HIV infected children. • When we do find infected children many are lost before enrollment into care • We are stalling in efforts to expand pediatric access though decentralization and task shifting Diagnosis 4 • We are not integrating paediatric HIV and MCH • We have failed to harness the community as a partner for pediatric scale up 2 Linkage 5 3 Treatment

  10. Diagnosis 1 • We are not looking in the right places to identify HIV infected children. • When we do find infected children many are lost before enrollment into care • We are stalling in efforts to expand pediatric access though decentralization and task shifting Diagnosis 4 • We are not integrating paediatric HIV and MCH • We have failed to harness the community as a partner for pediatric scale up 2 Linkage 5 3 Treatment

  11. Globally paediatric testing is focused on infant diagnosis within PMTCT, but in the era of B+ are we looking in the right places? 1 OPD testing of sick infants and outreach to infants whose mothers were lost to follow up of from PMTCT Inpatient wards 8% of tests 16% of pos Source: Uganda national EID testing program statistics 2012

  12. In Malawi, where B+ has been in place longest, National Program data confirm the shifting trend of paediatric HIV prevalence 1 Source: Malawi Ministry of Health 2014

  13. Testing in inpatient or outpatient settings can identify older children and infants who “slip through the cracks” of PMTCT 1

  14. Recommendations & policy guidance exist for PITC in children in generalized epidemics, but they are rarely implemented 1 • PITC Eligibility: All children 6-15 with unknown status • Sites: 6 primary clinics in Harare over a 4-month period • 2,831 children eligible but only 70% were offered a test • Reasons for not testing • Unsuitable guardian – especially male guardians • Lack of staff time or reagents • Child “did not seem sick” or was “too old to have HIV” • 90% of children tested could have received PITC earlier Kranzer et al. PLOS one 2014 Source: Rollins et al. AIDS 2009

  15. Loss to follow up and Linkage 1 • We are not looking in the right places to identify HIV infected children. • When we do find infected children many are lost before enrollment into care • We are stalling in efforts to expand pediatric access though decentralization and task shifting Diagnosis 4 • We are not integrating paediatric HIV and MCH • We have failed to harness the community as a partner for pediatric scale up 2 Linkage 5 3 Treatment

  16. In this 4-country retrospective review, between 62 and 74% of positive infants could not be accounted for after 1 year 2 Retention of infected infants in Uganda Each positive infant identified costs an estimated $240 to $440 depending on vertical transmission rates Source: Chatterjee et al. BMC Public Health, 2011. Collins et al. CROI 2014.

  17. Strategies such as SMS printers to return results to clinics have already been shown to improve infant retention 2 Caregiver returns for results DBS drawn for PCR 14 days  6 wks 10 wks Results are available when caregiver returns EID sample received at laboratory Laboratory can immediately send results via SMS printers 5 -10 days Sample processed

  18. POC offers “while you wait results” so may improve both clinical outcomes and reduce wastage of resources 2 1 3 2 • 827 HIV-exposed infants tested using Poc EID and traditional DNA PCR • 60% of infants were between 1-2 months of age. • Overall 85 positive samples by DNA PCR, with excellent correlation (only 2 samples were discordant) and sensitivity = 98.5%, specificity = 99.9% • PoC gives rapid results AND is very portable allowing for use where needed – eg in labour ward or in community settings Source: Jani et al. JAIDS 2014

  19. Decentralization and Task shifting 1 • We are not looking in the right places to identify HIV infected children. • When we do find infected children many are lost before enrollment into care • We are stalling in efforts to expand pediatric access though decentralization and task shifting Diagnosis 4 • We are not integrating paediatric ART with MCH • We have failed to harness the community as a partner for pediatric scale up 2 Linkage 5 3 Treatment

  20. Among 1740 South African children on ART, 18 month outcomes were the same in all tiers of the health system 3 Mortality Viral suppression CD4 Recovery Bock et al. Trans R Soc Trop Med Hyg 2008;102:905-911

  21. While task sharing in adults is well-established, for children despite evidence, national programs have been slow to adopt 3 Non-physician managed ART compared with physician managed ART Mortality and retention outcomes from 6 to 36 months of follow up were comparable Source: Penazzato et al. JAIDS 2014

  22. Integration of paed HIV and MCH 1 • We are not looking in the right places to identify HIV infected children. • When we do find infected children many are lost before enrollment into care • We are stalling in efforts to expand pediatric access though decentralization and task shifting Diagnosis 4 • We are not integrating paediatric ART with MCH • We have failed to harness the community as a partner for pediatric scale up 2 Linkage 5 3 Treatment

  23. A pilot program in Uganda has had success in retaining mother-baby pairs by providing an integrated package of HIV services 4 • 22 MCH clinics at sites where ART is also available • MCH nurse-midwives trained in maternal and paediatric HIV care • Mothers and infants referred in from multiple entry points (including the ART clinic) HIV Service package Maternal ART (B+) InfantCotrimoxazole Infant NVP prophylaxis Infant diagnosis Fixed F/U appointment CONTINUITY COORDINATION MCH service package • Nutritional assessment • Infant feeding counseling Immunization Growth monitoring FP services USAID Applying Science to Strengthen and Improve Systems Source: Nsubuga-Nyombi et al. TUSA03 AIDS 2014

  24. Finding the balance between horizontal versus vertical service delivery systems 4

  25. Involving the Community 1 • We are not looking in the right places to identify HIV infected children. • When we do find infected children many are lost before enrollment into care • We are stalling in efforts to expand pediatric access though decentralization and task shifting Diagnosis 4 • We are not integrating paediatric ART with MCH • We have failed to harness the community as a partner for pediatric scale up 2 Linkage 5 3 Treatment

  26. The Tingathe Program was piloted at 3 sites between 2008 and 2011 and showed marked improvement in case-finding 5 Community health workers specialized in HIV testing & counseling, active case identification, PMTCT support, and linkage to care Now expanded to 6 districts in central Malawi Source: Ahmed et al. Manuscript submitted for publication

  27. Conclusions • We have the tools we need we just need to shed our complacency • Our approach to finding infected and exposed children needs to go beyond PMTCT and reinvigorate PITC for children • Solutions are local as much as global. No one size fits all for concepts like integration, community involvement and task shifting • Even as we push for elimination of new infections in children we must also push to treat all children in need. There can be no dichotomy between treatment and prevention.

  28. Acknowledgements Chewe Luo Craig McLure Subhasree Raghavan Lynne Mofensen Elaine Abrams Saeed Ahmed Martina Penazzato Nathan Ford Nigel Rollins Nandita Sugandhi Charles Kiyaga Anisa Ghadrshenas Polly Clayden Ashraf Grimwood John Miller Stuart Kean Tamara Nsubuga-Nyombi

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