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 care 1 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 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 Background on National EID Programs Quarterly EID Sample Volume since Start of Program (HV) Samples per quarter Namibia Uganda Quarterly EID Sample Volume since Start of Program (LV) Samples per quarter 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

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 EnrolledPositive via EID Initiated on ART Rec. Results Active on ART Uganda-72% not alive & on ART No data 87 EnrolledPositive via EID InitiatedReceived Results Alive on ART Received Results/ Enrolled Positive via EID Initiated on ART Results at Site Active on ART Senegal 67% not alive & on ART Cambodia- 67% not alive & on ART No data Infants

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 EID Understanding 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