Increasing Uptake of HIV Early Infant Diagnosis (EID) Services in Four Countries (Cambodia, Namibia, Senegal & Uganda)

20 July 2010, Vienna

S Tripathi, Matt Barnhart, C Kiyaga, M Nghatanga, M Chhi Vun, A S Wade, R Gass, A Chatterjee, R Ekpini, C Luo

Agenda

Infants and young children are dramatically underrepresented in PMTCT and pediatric HIV services. However, a momentum of policy, technology, and programming hope to close the gap

Without access to treatment, >33% of HIV positive infants die before the end of their first year of life, and 50% in the first two years of life

Early Infant Diagnosis for HIV (via virologic testing) linked with infant treatment are essential for the survival of HIV exposed infants

Context for EID

Strong Policy Guidance

Dramatic Gaps Remain

Tools to close the gap are available

Clear Data

Though 90% of children living with HIV acquired HIV by vertical transmission, few infants and young children access testing and care early in their lives; many die without accessing HIV care1

Guidance recently released regarding: (1) stronger post natal follow up, (2) importance of EID testing and (3) immediate initiation on ART for HIV positive infants <12m

(1) Only 15% of HIV exposed infants in low and middle income countries accessed EID testing in their first two months of life in 2008.

Opportunities for Improvement in EID

• Senegal Cambodia• Namibia Uganda

Objective:

Review program scale up of EID within the context of exposed infant services across a diverse group of low and middle income countries to understand bottlenecks and lessons learned from service delivery, as well as the impact of EID service

Countries Reviewed: Four Ministries of Health led EID service reviews with technical support from UNICEF

Methods/Approach:

Review a selection of 18-25 EID collection sites per country spanning geographic, health center level, HIV service availability and time since starting EID metrics

Reviewed transport and central laboratory components in each country

Implemented standardized questionnaire at EID sites to understand sample volume and programmatic practices, and key informant interviews with national program partners to learn about program scale up and program management

Background on the national EID service scale up (sample volumes)EID sample volumes have increased steadily in all four countries

0

50

100

150

200

2006Q1 2006Q3 2007Q1 2007Q3 2008Q1 2008Q3 2009Q1 2009Q3

Background on National EID Programs

0

2000

4000

6000

8000

10000

2006Q1 2006Q3 2007Q1 2007Q3 2008Q1 2008Q3 2009Q1 2009Q3

Quarterly EID Sample Volume since Start of Program (HV)

Sam

ples

per

qua

rter

Namibia

Uganda

Quarterly EID Sample Volume since Start of Program (LV)

Sam

ples

per

qua

rter

Senegal*

Cambodia

(*) Quarterly data not available, yearly volumes averaged

Quarterly volumes are steadily rising in

Uganda, Senegal and Cambodia, all three

still <50% EID Coverage (in 2008)

Less than one half of infants ever tested via EID across these four countries were tested in their first two months of life. Coverage of the optimal service (early testing) is consequently even lower

Portion of HIV Exposed Infants in Need Receiving EID Service in First Two Months of Life

Missed early testing

opportunities: PMTCT follow

up appointments,

vaccination schedule

0

10

20

30

40

50

PositivePCR

Results Enrolled I nitiated Alive

Of those infants testing HIV positive via EID, attrition post testing is significant

Patients lost

Patients EID tested

Follow up of Infants Testing Positive via EID at Review Sites

0

500

1000

1500

2000

2500

3000

3500

PositivePCR

Results Enrolled I nitiated Alive

3182

2330

EnrolledPositive via EID

Initiated on ART

Rec. Results

Active on ART

1170878

Uganda-72% not alive & on ART

No data

0

25

50

75

100

PositivePCR

Results Enrolled I nitiated Alive

87

EnrolledPositive via EID

InitiatedReceived Results

Alive on ART

2330

4

90

Received Results/ Enrolled

Positive via EID

Initiated on ART

Results at Site

Active on ART

38 33

93

Senegal 67% not alive & on ART

Cambodia- 67% not alive & on ART

No data 6

14

27

100

Infa

nts

Infa

nts

Infa

nts

• There are clearly numerous challenges related to the implementation of EID which merit particular attention as they are dramatically curtailing the impact of the service such as late age at testing, centralized service uptake, and still slowly rising service coverage

With these findings, Ministries of Health have already begun to strategize, pilot and address critical bottlenecks in order to optimize the impact of the EID service

• The landscape for HIV exposed infants and young children is better today than it has ever been before:

PMTCT coverage is increasing.

Infant testing services are becoming widely available.

Children respond exceedingly well to ART if tested early and treated early.

There is significant Ministry and partner momentum and investment

Lessons learned provide strategic opportunities to bolster EIDUnderstanding the operational challenges hindering the implementation and impact of EID can help to target future investments

Deepest thanks to all four Ministries of Health who led these EID service reviews:

Dr. Mean Chhi Vun and Dr. Sok Panha, Ministry of Health, Kingdom

of Cambodia

Ministry of Health and Social Services, Republic of Namibia

Dr. Charles Kiyaga, Ministry of Health Republic of Uganda

Dr. Abdoulaye S. Wade, Ministère de la Santé, Republique du Sénégal

UNICEF HQ and UNICEF country offices, particularly R. Gass