In Patient Testing Program at University Teaching Hospital, Lusaka, Zambia

1. In Patient Testing Program atUniversity Teaching Hospital,Lusaka, Zambia Mary Katepa-Bwalya 8th March 2006

2. Zambia Country Profile Population 10,3 million One of the poorest countries in the world Per capita GDP $280 80% of the population afflicted by poverty One of the countries most affected by HIV HIV prevalence about 16% 30% of pregnant women are HIV positive 28,000 infants born with HIV each year

3. University Teaching Hospital Tertiary hospital in Lusaka, Zambia Medical and nursing schools Adult and pediatric ART clinics

4. Pediatric COE at UTH Provide high quality comprehensive HIV care and antiretroviral treatment to HIV exposed and infected children. National and Regional learning and training center for pediatric care in Zambia. Center for operational research and clinical trials.

5. Center of Excellence Out-Patient Facility: One stop Center Within the Department of Pediatrics and Child Health at UTH Funded by the Centers for Disease Control and Prevention In collaboration with ICAP, Columbia University Technical assistance also provided by Boston University Family Centered Approach Multidisciplinary Team Clinicians (physicians, nurses, clinical officers) Counselors Social Workers Nutritionists Pharmacists Laboratory technicians

6. The Inpatient Testing Initiative Traditional HIV testing models overlook the special needs of infants and children Rapid disease progression in HIV-infected children (50% mortality by age 2) creates an urgent need to identify HIV-infected infants Parents may not identify risk and/or symptoms of HIV; few children attend stand-alone VCT centers Provider-initiated testing is particularly important in pediatrics Hospitalized children at high risk for HIV infection

7. Goal of the Inpatient Testing Program Goal: To incorporate HIV testing as a routine part of medical care for all infants and children admitted to inpatient services at UTH.

8. Objectives of the Inpatient Testing Program Objectives: To increase the number of inpatient children being counseled and tested for HIV. To increase early identification of HIV-exposed and HIV-infected children. To increase the number of children assessed and enrolled into HIV care and treatment at UTH. To increase the number of children on ART.

10. Program Implementation All first point of contact wards are targeted (e.g. Admission ward (AO1), Isolation ward (AO5) and Nutrition Ward (AO7). 4 counselors from the Family Support Unit offer C&T from 08:00-16:00 on these wards. All inpatient wards and multidisciplinary team staffers are sensitized. Counselors conduct group counseling and individual counseling. Counselors and nurses work together to maintain records that can be used throughout a child’s admission and for follow-up.

11. Program ImplementationFollow-up Counselors follow-up patients who have deferred testing and/or were missed at the first point of contact (e.g., night time admission). Once identified as exposed or HIV-infected physicians order baseline labs and CD4 counts. Follow-up for ART eligibility then occurs at the children’s review clinic unless they are admitted for a lengthy stay.

12. Pediatric Inpatient Testing Program Met with enormous success during 6 month implementation phase: High rate of acceptance of HIV testing by parents of hospitalized children Good follow-up into outpatient system for those identified as HIV antibody positive Availability of counseling staff has facilitated introduction of inpatient testing Given high admission numbers, counselors will not be able to meet test demand Incorporate HIV counseling and testing into routine aspect of care provided by all clinicians, particularly nurses and physicians

13. Children admitted and counseled

14. Children Counseled and TestedSeptember 2005–February 2006

15. Proportion of Children Tested Who are Positive

16. Age Breakdown of Children Tested December 2005

17. Multidisciplinary TeamPhase II Provider initiated testing: present as an “opt out” service available at UTH. Multidisciplinary team would be involved in C&T and disseminate “opt out” approach. Counselors will focus their efforts on counseling and engaging children into care. All team members have responsibility to address HIV in their routine care of the patient.. This allows the family to receive the same message and approach from multiple points of contact.

18. Barriers (reason for refusal) Majority of children and caretakers agree to counseling and testing with two major exceptions: Caretaker defers decision until she receives consent from her husband and/or other caretaker. Child is too ill (caretaker too distracted) to carry out appropriate counseling. Limited human capacity – counselors only work day shift Monday – Friday.

19. Accomplishments Introduction of routine C&T in first contact wards. Developed a follow up system for inpatients not C&T at first contact Follow up of children previously tested for assessment and enrollment into care Currently 900 children in care 600 children on treatment

20. Lessons Learned Adequate staffing is essential on all levels of the multidisciplinary team. All health workers need to offer testing for HIV as routine services to increase enrollment into care and treatment. More than half the children who are HIV positive are infants. Hospital statistics need to be reviewed prior to assigning counselors in order to target peak locations and times. M&E system should be in place from the beginning to be able to report statistics and track patients. Sensitization and group counseling is essential.

21. Pediatric Advocacy – Next Steps and Recommendations Build capacity & expertise in care & Tx of paediatric HIV/AIDS “Opt-out” testing to be offered as part of routine services offered by the department Increase infant diagnosis capacity Enhance development & distribution of a stand-alone pediatric ART guideline (HW & HBC) Dev. Training modules for care & Tx of paediatrics HIV/AIDS for the health workers as well as the community (HBC) Keep children on government’s agenda