1. Are We Reaching the Children? Issues in Pediatric HIV Programming Anouk Amzel, MD, MPH Jacqueline Firth, MD, MPH Office of HIV/AIDS USAID March 7, 2014 9:45am

2. Outline  Epidemiology of Pediatric HIV  Perinatal Infection and Implications  Prevention of Infant Infections  How are infant infections different from adult infections?  Where Can HIV-positive children be found?  Adolescents Living with HIV  Starting and Keeping Children and Adolescents LHIV on Treatment  Treatment of Children and Youth with HIV  Retention in Care and Treatment Programs

3. Epidemiology

4. Children and HIV  How many new HIV infections occurred among children (0-14 years) in low- and middle-income countries in 2012?  What percentage of HIV-infected children received ART in 2012?  What percentage of infants living with HIV will die before their first birthday without treatment?  Before their second birthday? “Towards an AIDS-Free Generation: Children and AIDS 6 th Stocktaking Report 2013”, UNICEF, Nov. 2013 260,000 34% One-third Half

5. Where are Children Living with HIV?

6. The Good News

7. Prevention of infant infections

8. BREASTFEEDING POPULATION Overall cumulative risk MTCT (without antiretroviral drugs): 40-45% Timing of MTCT >28 wks Labor- Delivery 35-40% 1-6 mos6-24 mos0-1 mo Pregnancy 10-25% <28 wks Breastfeeding 35-40% EarlyLate AntenatalPostpartum EarlyLate Slide courtesy of Lynne Mofenson-- modified

9. PMTCT Strategies and Timeline 1984 1994 1999 2004 2010 2013 AZT shown to decrease MTCT in the US 1 st case of pediatric HIV infection reported Short-course AZT found to decrease MTCT SdNVP found to decrease MTCT AZT + sdNVP endorsed by WHO PMTCT guidelines WHO guidelines recommend PMTCT Options A and B Programmatic considerations lead WHO to endorse options B/B+

10. Translation of Trial Results into Practice Slide courtesy of Lynne Mofenson

11. Elimination of MTCT Requires More than Just ARVs No ARVs for PMTCT 2009 ARV coverage (53% women reached) 90% ARV coverage --90% ARV coverage + --HIV incidence women↓ by 50% + --no unmet family planning --90% ARV coverage + --HIV incidence ↓by 50% + --no unmet family planning + --limit BF to 12 mos Mahy M et al. Sex Trans Infect 2010;86 Suppl 2:ii48-55 Slide courtesy of Lynne Mofenson --New Perinatal HIV Infections, 25 Countries in the Year 2015 --Virtual Elimination Goal <40,000 Perinatal Infections/Year and <5% MTCT

12. How are infant infections different from adult infections?

13. Timing of Infections-Adults Clinical LatencyInfection AIDS = HIV virus = CD4 count

14. Timing of Infection-Pediatrics Symptomatic within 1 st year of life Typically infected in utero Symptomatic within first 5 years of life Typically infected intra-partum Symptomatic in childhood and adolescence Typically infected through breastfeeding Rapid Progressors (10-30%) Median Progressors (70-85%) Late Progressors (<5%)

15. Slide modified from K4Health “Module I Intro to Ped HIV Care and Treatment” HIV + Infant and Child Survival without ART Without ART, 50% of HIV positive infants will die by age 2

16. Why does HIV infection progress faster in Children? A Theory: Immune system immaturity  Allows HIV replication in blood lymphocytes without strong response  Intestinal infection not blocked as effectively in children because of low defenses there as well

17. What about that Mississippi Baby who was “Cured?”  An unusual case whose treatment is being explored further  The mother --newly infected close to delivery (diagnosed at delivery—received no ARVs during pregnancy)  Infant-- started on an atypical protocol (triple ARVs at 30 hours of life after confirmation of HIV infection)  Viral suppression--day of life #21 on HAART  The child was LTFU after 18mo, returned at 23 months of age, off of ARVs since 18 months of age  No HIV was detected when returned to care, despite the child being off of ARVs  Experts postulate that the “functional cure” is due to a lack of development of HIV viral DNA reservoir D Persaud, et al “Functional HIV Cure after Very Early ART of an Infected Infant” Session 10-Oral Abstracts (Paper #48LB); NH Tobin and GM Aldrovandi “Are Infants Unique in Their Ability to be “Functionally Cured” of HIV-1?” Current HIV/AIDS Report Jan 2014

18. Issues for HIV-exposed but uninfected infants  Higher risk of morbidity and mortality in first few months of life  Neonatal sepsis, pneumonia, diarrhea  Especially with lower maternal CD4 count/more severe HIV disease  Higher rates of preterm delivery, low birth weight  Worsened with maternal treatment with HAART prenatally  Question of developmental delay vs. normal neurodevelopment (L Kuhn, P Kasonde, M Sinkala, et al.“Does Severity of HIV Disease in HIV-Infected Mothers Affect Mortality and Morbidity among Their Uninfected Infants?,” Clin Infect Dis. 2005 December 1; 41(11): 1654–1661.) (Chen JY et al. 19th CROI, Seattle, WA, March 2012 (Abs 1028) )

19. Where can HIV-positive children be found?

20. How to find Children with HIV  Screen for HIV exposure at all points of routine contact with infants and children (i.e. EPI clinics)  Rationale —lots of exposure to young infants (use as a safety net to capture exposed infants LTFU from PMTCT cascade)  Perform Routine Provider Initiated Testing & Counseling (PITC) in all areas where sick children are seen (OPD, malnutrition clinics/wards, TB clinics/wards, in-patient wards)  Rationale —infants and children with HIV who have not been tested get sick when their immune system wanes  Test high risk populations (children of HIV+ adults in care and treatment, OVCs, key population youth)  Rationale —these children/youth are high risk based on in-utero exposure to HIV, possible parental loss due to HIV, or personal high risk behaviors

21. Adolescents

22. What about Adolescents?  How many new HIV infections occurred among adolescents (15–19 years) in 2012?  How many adolescents (10–19 years) were living with HIV in 2012?  How did AIDS-related deaths among adolescents (10-19 years) change between 2005 and 2012? 300,000 2.1 million Increased by 50%

23. Where are Adolescents Living With HIV?

24. Half of adolescents living with HIV are in six countries

25. Adolescents  Adolescents are the only age group in which AIDS- related deaths have increased  Discrimination, poverty, inequalities, and harsh laws often prevent adolescents from seeking and receiving testing, health care and support  Too many children and adolescents die because they miss out on HIV treatment and care “Towards an AIDS-Free Generation: Children and AIDS 6 th Stocktaking Report 2013”, UNICEF, Nov. 2013

26. Infections among adolescents are not slowing fast enough

27. Adolescent AIDS-related deaths: the only group where deaths are increasing

28. Most adolescents don’t know their HIV status

29. “Feminization” of HIV starts in the young

30. Treatment of children and youth with HIV

31. Pediatric ART Coverage Trend Note: ART coverage from previous years has been recalculated based on new estimates Source: UNAIDS, Together We Will End AIDS, 2012

32. Children half as likely as adults to get the treatment they need

33. 10-19% 20-29% 30-39% 40% and above Pediatric ART Coverage by Country Slide courtesy of Eric Dzuiban, CDC

35. 2013 WHO Guidelines- Pediatric Treatment Recommendations The new 2013 WHO Guidelines now recommend: 1) When to start HAART in the different ages:

36. For all children less than 3 years of age: For children and adolescents: 2) And with what triple drug regimen to start: 2013 WHO Guidelines- Pediatric Treatment Recommendations

37. Retention in care and treatment programs

38. Factors that Negatively Affect Retention  Populations at high risk for Loss to Follow Up (LTFU)  Caregiver factors  Health care provider factors  Institutional factors

39. Interventions that Can Improve Retention of Children and Youth  Individual support  Treatment buddies/peer support  Disclosure  Medication/appointment reminders (SMS, phone calls, etc)  Facility-level interventions  Coordination between staff and services  Integration of services (e.g. family-centered care)  Task-shifting  Community-based support  Home-based nursing care  Community support groups (including teen clubs)

40. The Good News

41. A Few Resources  Adolescent Transition toolkit: http://www.aidstar- one.com/sites/default/files/AIDSTAR-One_ALHIV_Toolkit.pdf http://www.aidstar- one.com/sites/default/files/AIDSTAR-One_ALHIV_Toolkit.pdf  Pediatric and Adolescent Disclosure Handbooks: http://www.aidstar- one.com/focus_areas/treatment/resources/pediatric_disclos ure_materials http://www.aidstar- one.com/focus_areas/treatment/resources/pediatric_disclos ure_materials  WHO Adolescent-Friendly Services: http://apps.who.int/iris/bitstream/10665/75217/1/97892415035 94_eng.pdf?ua=1; http://whqlibdoc.who.int/hq/2003/WHO_FCH_CAH_02.14.pdf ?ua=1 http://apps.who.int/iris/bitstream/10665/75217/1/97892415035 94_eng.pdf?ua=1 http://whqlibdoc.who.int/hq/2003/WHO_FCH_CAH_02.14.pdf ?ua=1  2013 WHO Consolidated ARV Guidelines: http://www.who.int/hiv/pub/guidelines/arv2013/en/ http://www.who.int/hiv/pub/guidelines/arv2013/en/  UNICEF Children and AIDS 6 th Stocktaking Report: http://www.childrenandaids.org/files/str6_full_report_29-11- 2013.pdf http://www.childrenandaids.org/files/str6_full_report_29-11- 2013.pdf

42. Thank you!

43. Next Session Room Numbers: Please fill out an evaluation by going to this session’s page on your mobile app OR by filling out a paper evaluation in the back of the room. Thank you! Listen Up: What African MSM Want in the Response to HIV301 A Practical Way to Maintain Skills Wherever Providers Deliver Babies302 Establishing an Interactive Education System for Frontline Health Workers307 Health Finance Food Court: What's Cooking?308 Shaken, Not Stirred: The Intersection of Alcohol, Gender, and Health310 A Vaccine's Journey: The Many Steps to Saving Lives311 Postpartum Family Planning: Bridging Barriers and Motivating Change405 Combating Counterfeit and Substandard Medicines407 How Much Will It Cost to Reach Key Populations?413 Antenatal Corticosteroid Jeopardy!: Exploring Maternal Interventions for Preterm Birth414 Innovations to an M&E System Improves Data Quality and Speed of Malaria Prevention Program ResultsBetts Theatre Business Planning for the Rest of Us Continental Ballroom Bringing Together Public and Private Sectors for Health Impact Grand Ballroom