Finding children and adolescents living with HIV: Optimising HIV testing strategies in Johannesburg and Kwa-Zulu Natal, South Africa Dr Jackie Dunlop 26 July 2018

Case-finding strategies Testing at health facility entry points Index case finding through HIV- infected parents and siblings Health facilities and in the community Use of a screening tool to identify children needing testing Strengthening of adolescent and youth friendly services (AYFS) Community testing Door to door Johannesburg Umkhanyakude Zululand uMgungundlovu eThekwini

Facility partners: Case finding modalities (Mar 16 – Dec 17) Johannesburg Partners (Mar 2016 – Dec 2017) KZN Partners (May 2017 – Mar 2018) Case finding strategy HIV tested HIV positive Positivity Rate Index Testing 2 163 111 5% 840 135 16% EPI 2 956 19 1% 2 012 9 0.5% IMCI 5 306 67 5 576 79 Screening Tool (5-14y) 325 17 - Family Planning 439 66 15% 2 078 149 7% AYFS 687 69 10%

Index Case Finding Community Health Workers Linkage officers Facility based testing Clinic nurses/ counsellors Screen HIV or TB-positive children and adults Index and contact information recorded on data collection tool Facility Social auxiliary workers Community based testing Family Tracers Home-based testing Counsellors Community KidzAlive Family Tool (Zoë-Life) Community Health Workers

Child contacts identified Contacts testing HIV positive Index Case Finding JHB Facility KZN Facility JHB Community KZN Community Index Clients Screened 4266 - 301 Child contacts identified 1555 834 1776 Contacts HIV tested 2163 840 114 1172 Contacts testing HIV positive 111 135 1 33 HIV Positivity Rate 5% 16% 1% 3% Returned for Testing 54% 14% 66%

Index Case Finding The positivity rates differed between the two implementation regions (KZN 16% vs JHB 5%) Many more contacts were tested in the KZN community strategy: KZN 66% vs JHB 14% Home testing done in KZN Family tracers in KZN allowed for better community – facility linkage Proportionately more contacts received testing in the community compared to the facility for KZN, which is reversed in JHB KidzAlive Family Tool (Zoë-Life)

Validated screening tool NDOH Guidelines IMCI Validated screening tool

Screening Tool 5 – 14 year olds (Apr to Dec 2017): Child presents to a facility Screening Tool used to identify high risk of HIV infection Identified high risk children are offered PICT Should child test HIV positive Complete index patient tracing tool Index tracing Data captured on Monitoring Tool 639 children were screened 396 had a positive screening question 325 were tested for HIV 17 tested HIV positive (14 were based on Q1) Positivity Rate = 5.4%

Adolescent and Youth Friendly Services Nurses and counsellors trained and mentored on AYFS, SRHR for adolescents and PICT Capacitation of facility staff Designated area for youth, “Happy Hours” identified (2-4pm), provision of equipment to make area more appealing to youth Capacitation of the facility Choose an individual trained on AYFS and passionate about adolescents and youth Dedicated AYFS champion at facility level Youth day events held Events for ALHIV and peers ALHIV educated on HIV testing services and invited to bring sexual partners in for testing Index testing of partners Youth ambassadors were placed at facilities to create awareness of AYFS services. Demand Creation Adolescents in school uniform are prioritised for testing and other services Prioritising adolescents for services Collaborated with DREAMS team to educate adolescents on HIV and creating awareness of AYFS at health facilities School outreach

Adolescent and Youth Friendly Services With access improved, youth started using the services A designated clinician meant they didn’t spend long hours in the clinic The ‘safe space’ provided saw an increase in the number of youth that were able to identify their risk and consent to testing

Community partners: Case finding modalities (Mar 16 – Dec 17) Johannesburg Partners (Jan 2016 – Apr 2018) Kwa-Zulu Natal Partners (May 2017 – Mar 2018) Case finding strategy HIV tested HIV positive Positivity Rate OVCY 763 11 1% 616 46 7% Mobile Points - 524 37 Community hotspot* 4530 162 4% Door to door (home-based) 114 0% 6021 126 2% School Testing 920 Early Childhood Dev Centres 72 1 77 Wellness Day Testing 1944 6 0,3% 3086 41 *May-Nov 2017

Community Strategies that worked Home-based testing was an important strategy in KZN Door to Door testing (yield 2%) Included testing of children mostly younger than 12 years old Using TB contact tracing also yielded good results in one sub- district Testing at mobile points and community hotspots were also useful strategies (yields 7% and 4%) School-based testing After school testing in the vicinity of the school Focussed on adolescents 14 years and older (provide own consent) No recruiting done in schools (not permitted)

Key message: Strategies Strategy Important Points Index Case Finding Use a standardised tool for data collection Most effective when linked to home-based testing in KZN Dedicated staff for screening index clients and testing children are needed Screening Tool Effective in finding HIV-infected children 5-14 years old attending health facilities Adolescent and Youth Friendly Service Implementation AYFS standards assist to make a facility more ”comfortable” for adolescents and youth This leads to improved accessing of care and more opportunities to test Home-based Testing An important strategy to test those not coming to the facility Focuses mainly on children under 12 years old School based testing Often difficult to access schools for HTS information provision Testing may take place near the school

Acknowledgements Dr Carol Tait – Anova Health Institute Dr Thameshree Naidu – KZN Unfinished Business Mr Mdu Mntambo – AIDS Foundation of South Africa Mr Andrew Munemeri – HIVSA Departments of Health in Kwa-Zulu Natal and Johannesburg Thanks to all our partners involved in Unfinished Business South Africa for sharing their best practices and intervention data.

Our Partners: