Sixth Annual Presidents Emergency Plan for AIDS Relief Track 1.0 ART Program Meeting

1. Provider Initiated Testing and Counseling and Decentralization of Pediatric HIV Care and Treatment in Africa Sixth Annual Presidents Emergency Plan for AIDS Relief Track 1.0 ART Program Meeting August 11-12, 2008 Washington, D.C.

2. Goals of Presentation • To present a preliminary data for a provider initiated counseling and testing program of inpatient pediatric patients at Kamuzu Central Hospital in Lilongwe, Malawi • To describe the process for the scale up and decentralization of pediatric care and treatment services in the Mokhotlong Health Services Area in Lesotho

3. Malawi • Hospitals in Malawi continue to be important healthcare access points for undiagnosed HIV infected children • In 2006, < 10% of pediatric admissions at Kamuzu Central Hospital in Lilongwe, Malawi received HIV and testing and counseling • In late 2007 the Malawi Ministry of Health approved systems of routine HIV testing and counseling for certain settings, including hospitals • No prior routine pediatric inpatient or outpatient testing was being done. No detailed national government policy on pediatric HIV testing for hospitalized patients

4. VCT vs. PITC

5. Program Indicators

6. PITC 8 Step System

7. Clinical Review of HIV Exposed Infants • Document DNA PCR has been done • Prescribe CPT if > 6 weeks of age • Infant feeding counseling • Nutritional evaluation (weight/height) • Review for danger signs of HIV-infection • Refer for follow up of DNA PCR testing

8. Clinical Review of HIV Infected Patients • Determine if ART eligible, check WHO stage, CD4 count • Prescribe CPT • Screen TB • Nutritional evaluation (weight/height) • Infant feeding counseling • Refer to outpatient HIV clinic upon discharge

9. ** 4 patient escorts were added in April ‘08

10. KCH PITC Results October 2007-June 2008 10% 5% 85%

11. Follow-up of New Positives

12. Lessons Learned • Addition of patient escorts allowed the program to reach the goal of 70% of new admissions being tested • Once testing is offered, > 92% of parents accept testing for the child • Linkage back to the HIV physician on the ward has not been consistent • Linkage from ward to outpatient ART is not optimal

13. Way Forward • Working on methods to increase communication with the inpatient HIV specialist so that children that have been screened can be reviewed • Investigating the reasons for poor outpatient follow up to ART clinic and methods to remedy this • Starting to expand this pediatric testing program to other regional hospitals in Malawi

14. Decentralization of Care and Treatment in Lesotho • Goal of universal access to HIV/AIDS care and treatment • Reaching rural populations and children have been identified as major challenges to this goal • Both of these challenges are quite pertinent to Lesotho

15. Lesotho • Mokhotlong Health Service Area (MHSA) • Population of MHSA: 96,000 with 29,000 (30%) <12 years of age; adult prevalence of HIV is 18% • Rural and mountainous • 1 MOHSW and 0 private hospitals • 8 MOHSW health centers, 3 other clinics – most staffed by a nurse and nurse assistant only and will receive 1 physician visit per month if there are physicians • Current physician staff – 2 Congolese, 2 Zimbabwean, 2 Cuban but has been 0

17. BIPAI-Lesotho • BIPAI-Lesotho began work in Mokhotlong in partnership with the MOHSW and UNICEF to provide pediatric-focused family HIV care and treatment scale-up in October 2006 • Prior to the initiative, 20 children on ART in the entire Mokhotlong region

18. Scale Up of Services • Focus on strengthening existing ART clinic – at the district hospital • Site selection outside district hospital prioritized based on public health need • Sustained intermittent training through biweekly 5-day physician clinical mentor placements • Encouraging local providers to implement their increasing skills and identify skill gaps while mentors are absent • Direct patient care when the need exists • Determine resource needs in partnership with local staff and seeking solutions locally and through the MOHSW

19. Results • To date, over 25 local staff intensively trained on HIV care and treatment • Introduced DBS DNA PCR at the district hospital and 3 village health centers • Improved inpatient pediatric care • Nearly 100% HIV testing on the Children’s Medical Ward • Much improved linkages to the ART clinic

20. Pediatric Data • 5 fold increase in children on ART from 20 in Oct 06 to 100 in April 08 • Large relative increase, especially in comparison to similar centers in Lesotho • 4 village health centers with nurse based ART now provide care and treatment to children • Increase in % of ART patients at district ART clinic who are children from 12% to 18%

21. Lessons Learned • In rural districts ART needs to be able to be delivered to children at the village health center level • Task shifting to nurses at this level is required • These services need to be integrated into the daily services at this level • Requires intensive hands on mentoring, not workshop mentality • This is not a rapid process if it is done correctly

22. Next steps • LERATO Project: Lesotho Expansion of Rural AIDS Treatment and Outreach • Accelerate and further decentralize HIV care in Mokhotlong and other HSA’s through health system strengthening • Infrastructure improvements • Infusion of human resource capacity • Continue mentoring efforts to village health center level • Continue strengthening of district hospitals into regional referral centers

23. Goals of Presentation • To present a preliminary data for a provider initiated counseling and testing program of inpatient pediatric patients at Kamuzu Central Hospital in Lilongwe, Malawi • To describe the process for the scale up and decentralization of pediatric care and treatment services in the Mokhotlong Health Services Area in Lesotho