1. Impact of Early Infant Diagnostic (EID) Testing for HIV Exposed Infants in Namibia Dr. Ndapewa Hamunime (MOHSS) Dr. Andreas Shiningavamwe (NIP) Republic of Namibia [A-240-0316-12275] 20 July 2010

2. 2 Background Population ~2million Surface area of 802,4116km 2 Sparsely populated: population density 2.2/km 2 35 public hospitals, 34 health districts 11.5% of GRN budget spent on health Newly established Medical School 2010 95% of drugs, supplies imported

3. Context and Response Global Context Early Infant Diagnosis for HIV linked with HIV care is critical for the survival of HIV exposed infants Response National Early Infant Diagnosis (EID) service launched in late 2005 by the Ministry of Health and Social Services (MOHSS) in collaboration with the National Institute of Pathology Ltd (NIP) Windhoek Significant investment in EID has taken place since 2006 As the service has scaled up, program evaluations continue to be used to guide programming to maximize infant care Namibia has rapidly responded to HIV positive infant vulnerability with EID and infant treatment

4. Methods (1) A selection of 25 EID collection sites across all 13 regions were reviewed SITES

5. Methods (2) The full EID service was reviewed at each site At each site, the full EID service continuum was examined: SCOPE EID Sample Collection Point(s) (& cotrimoxazole) Result Return to Infant HIV Care for HIV + Infants Testing at NIP Windhoek PMTCT Family testing of PLHAs Infants on Wards Identification of Exposed Infant Result Return to Site PCR 1 Negative Infants: Follow up Vaccination Sample Transport to Processing laboratory

6. Scale up of EID Sample Collection (via DBS) EID collection sites, EID samples, and EID coverage have increased dramatically over time Site ever collecting a DBS sample for the national program 2006 EID Collection Sites over Time (sites) Since 2006, sites offering EID have grown dramatically: EID was available in all regions by the end of 2006 EID is available at all 79 ART sites and over 200 PMTCT sites Over 31,900 EID samples have been tested since the start of the service In 2008, 86% of HIV exposed infants accessed EID EID Samples tested in public sector Monthly EID Samples Volume over Time 200720082009 2006200720082009

7. Early Identification (1) Over time, more of the HIV exposed infants receiving an EID test are getting tested early Tested ≥ 6 m Tested 2 ≤ x <6 m Tested in first two months of life Namibian Algorithm encourages EID testing at 6 weeks Because of Infant health deterioration, early testing is key In early years of the service, only 50% of infants tested were tested in their first two months of life Every year, a larger portion of infants tested had their first EID sample collected in the first two months of life Portion of Infants EID Tested by Age Band at PCR 1

8. Early Identification (2) However, more must be done to take advantage of high PMTCT coverage for earlier EID In 2008, Namibia had a 92% PMTCT coverage Of infants receiving their first EID tests, over 90% of them were coded as coming from PMTCT However, only 49.6% of all infants tested were tested in their first two months of life We are working hard to further reinforce the linkage between PMTCT and early EID testing and exposed infant care Est. HIV Pos Pregnant Women 1 Accessed PMTCT 1 Known Pos 1 EID 49.6% <2m Coverage of PMTCT Service (2008) (1) UNICEF, UNAIDS, WHO. Towards Universal Access 2009,Vienna: 2009. Tested ≥ 6 m Tested 2 ≤ x <6 m Tested in first two months of life

9. EID Sample Transportation and Processing A centralized transportation system, and one Central PCR laboratory has allowed for smooth processing Efficient sample transport system linked with local NIP laboratories (who manage intake) allows for rapid transport (mean <1 day from sample collection to arrival at local NIP) Centralization of EID along with strong lab organization and management ensures high throughput and fast turn around time Technicians rotate and process samples daily – processing volumes of ~1,000 -1,300 EID samples/monthly Turn around times from sample collection to result completion are consistently <10 days Monthly EID Sample Volume (samples) 20062007200820092006200820092007 Mean Turn around Time (days) Collection to local NIP Local NIP to analysis

10. Referral to HIV Care and Treatment Examining HIV positive infant follow up at individual sites gives indications of attrition challenges 200620082009 (n=203) 2007 (n=293)(n=439)(n=50) Infants <12m enrolled never initiated Infants 6m after enrolling Infants <12m initiated ≤6m after enrolling weeks HIV Pos Infants Enrolled at ≤12m of Age at 25 Reviewed Sites since 2006 Mean Time between enrollment and ART Initiation of Infants enrolled in HIV care (weeks) EID is critical because it allows for the earlier identification of and care for HIV positive infants Portion of HIV positive infants put on ART within 6 months of enrolling is increasing Mean time between enrollment and initiation of HIV positive infants is steadily decreasing

11. Conclusions and Programmatic Implications Program reviews and analyses can inform future program interventions High PMTCT and EID coverage Dramatic increases in EID volumes Decreasing age at testing Centrally managed program Consistent and fast sample turn around time Strong technical capacity Partner collaboration EID Strengths Ever Present Challenges Higher than optimal average age at testing More support for follow-up of HIV exposed infants, referral of HIV positive infants to HIV care, and clinical care for infants testing positive particularly with regards to ART initiation Strengthen private sector involvement Efforts to Strengthen the EID in Namibia  Linkages between PMTCT, DPT1 vaccination and early EID testing at sites reinforce through mentoring and supervision  EID test sites increased from 242 to 292 since review  A new automated EID equipment procured and installed at NIP  Community engagement and defaulter tracing system strengthened

12. Acknowledgements UNICEF (HQ, ESAR, NAMIBIA CO) USAID US Center for Disease Control Clinton Foundation I-TECH WHO GRN