Health care for children affected by HIV IATT on Children and HIV and AIDS Washington DC, April 2007 Siobhan Crowley

Context 10 million HIV infected young people new HIV infections in 2006 in children < 15 years 90% of children infected through mother-to-child transmission. Vast majority of pregnant women in need of PMTCT services are not receiving them In 2005, of the > 2 mill pregnant women living with HIV received ARV prophylaxis for MTCT prevention (coverage 11% [8%16%]) Significant increase in resources for HIV

HIV and child health Child health outcomes affected by health of mother and family; maternal illness & death worsening child outcomes Increasing orphanhood attributable to HIV Slow steady progress in access to ART

International commitments: Millennium Development goals Reduce by two thirds the mortality rate among children under five (MDG 4) Reduce by three quarters the maternal mortality ratio (MDG 5) Halt and begin to reverse the spread of HIV/AIDS, & halt and begin to reverse the incidence of malaria and other major diseases (MDG 6) UNGASS declaration of commitment (2001) –strengthen health-care systems –develop national strategies to provide psychosocial care for individuals, families and communities affected by HIV/AIDS –implement care strategies to strengthen families and communities to provide treatment for all people living with HIV/AIDS; Universal access ………(2005 G8 Summit at Gleneagles) and (June 2006 UNGASS) –work towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010.

Number of people receiving ARV therapy in low- and middle- income countries,

Ten low- and middle-income countries with the highest number of HIV infected pregnant women with number of ARVs received for PMTCT, (2005 data)

Estimated number of children under 15 years receiving antiretroviral therapy, children needing antiretroviral therapy, and percentage coverage in low- and middle income countries according to region, December 2006

Children and ART were estimated to be in need of antiretroviral therapy, 680,000 in Africa children had access to treatment by the end of 2006, coverage rate of about 15% (12%19%) Proxy for care - only 4% eligible for Co- trimoxazole receiving it (2005 data) Follow up of HIV exposed children very poor

Only countries with over 1000 ART need among children are included in this graph

Progress on UA Approximately 57% of adults receiving treatment in countries are women, while women represent 48% (41%–57%) of adults living with HIV/AIDS. Ratio of men to women receiving treatment is in line with regional HIV prevalence sex ratios Little data on other 'care' provided 50% increase in the number of children receiving ART during the last year South Africa, children in need ART estimated to be has coverage of 21%, the no of children receiving treatment having increased by 50% between Dec 2005 and Sept 2006 For: Nigeria children in need of ART treatment but only 3% were estimated to be receiving it by Sept India coverage is only between 3 -19%. Zimbabwe coverage is estimated to be about 6%.

HIV treatment outcomes in children KIDS ART linc data confirm good treatment outcomes in children Kenya (Nyandiko et al 2006) Adherence and CD4 response to ART no different for orphan children At 1 year follow up Mortality 7.1 % vs. 6.6 for orphans vs non orphans Short term outcomes same for orphan vs. non orphan (70 wks)

Survival on ART children Preliminary data from KIDS-ART-LINC Collaboration

Mortality in children affected & infected Mwanza study (Ng'weshemi et al, Measure 2002) Infant mortality in children with HIV +ve mother 158/1000 compared to 79/1000 for HIV negative mothers By age 5 mortality risk was 270 for HIV exposed child, 138 for non exposed child (HR 2.2), and 386 for those whose mother ill or died during infancy Effect of maternal death independent of HIV status (HR 4.6) Fraction of infant mortality attributable to maternal HIV was 8.1%, where ANC prevalence 4.3% Other studies report mortality 3-10 X higher for children exposed to HIV

Joint survival of mother baby pairs - Tanzania Longitudinal community based study in Mwanza TZ. Ng'weshemi et al.2002 HIV negative mother n = 4130 HIV positive mother n = 214

Risk and protective factors for child health Nutrient intake Community Improved child health outcomes Adult time inputMedical care Individual Household Adapted from Ainsworth 2000

Factors worsening child health outcomes ContextualHealth system Poor householdEpidemic child health diseases Recent adult deathHigh HIV prevalence Higher market pricesHigh rates malnutrition > Distance to marketORS not available at HF Little parental education> Distance to HF Young maternal agePoor measles vacc coverage Safe waterMother HIV +ve Increased morbidity & mortality stunting wasting Poor PSS outcomes Age, Sex, Disability, HIV

Stunting among U5 by household assets Ainsworth + Semali 2000

Health & well being of orphans +/- HIV Tanzania: (Makame et al, 2002) HIV orphans compared with non orphans (n =41 matched controls) Unmet needs higher than non orphans and high reported PSS Kenya (Lindblake et al, Trop med & Int Health Population based study 1190) 7.9% lost one or both parents (6.4 lost father, 0.8 lost mother and 0.7% both) No differences seen on most key health indicators between orphans and non orphans, except in W/HZ 0.3 SD, lower in paternal orphans and orphans > 1 year Malawi (Crampin etal 2003) young orphanage children are more likely to be undernourished and more stunted than village children Guinea Bissau (Masmas et al 2004) Excess mortality associated with loss of mother in first 2 years of life Zambia (Setse et al 2006) HIV infection status significantly associated with incomplete immunization < 7 years maternal education or < 3 children at home 2 x as likely to have incomplete vaccination,

Health system - protective factors for child health < 5 km to health facility High measles coverage > Parental education ORS available at the health facility Mother kept alive and well

Programming approaches to CCA 'Back to basics' - same basics, or new basics ? Key interventions to improve child health outcomes are known Models for service delivery not premised on chronic and continual care, or 'family' as unit of operation

IMCI Broad strategy designed to reduce childhood mortality, morbidity and disability in developing countries. It encompasses improving: HCWs Case management skills health system delivery of essential interventions family and community practices

Quality, efficiency and cost of facility- based child health care through IMCI in Tanzania & Uganda Tanzania IMCI training is associated with significantly better child health care in facilities at no additional cost to districts. The cost per child visit managed correctly was lower in IMCI than in routine care settings Facility-based IMCI is good value for money Uganda investing in IMCI training at a primary facility level can yield a significant 44.3% improvement in service quality for a modest 13.5% increase in annual facility costs. Bryce et al, Health Policy Plan Dec;20 Suppl 1:i69-i76. Armstrong Schellenberg JR et al Lancet. 2004;364(9445): Bishai et al, Health Econ Mar 26

IMCI & equity in Tanzania Equity differentials for six child health indicators (underweight, stunting, measles immunization, access to treated and untreated nets, treatment of fever with antimalarial) improved significantly in IMCI districts compared with comparison districts (p<0.05) four indicators (wasting, DPT coverage, caretakers' knowledge of danger signs and appropriate care seeking) improved significantly in comparison districts compared with IMCI districts (p<0.05) (Masanja et al,Health Policy Plan Dec;20 Suppl 1:i77-i84)

IMCI Health worker performance Brazil: IMCI case management training significantly improves health worker performance Nurses trained in IMCI performed as well as, and sometimes better than, medical officers trained in IMCI Brazil, Uganda & Tanzania children receiving care from health workers trained in IMCI significantly more likely to receive correct prescriptions for antimicrobial drugs than those receiving care from workers not trained in IMCI South Africa IMCI trained workers showed marked improvement in assessment of danger signs in sick children, assessment of co-morbidity, rational prescribing, and starting treatment in the clinic. No change in the treatment of anaemia, prescribing of vit A,or counselling of caregivers, & no change in the knowledge of caregivers regarding medication or when to return to the health facility. Facilities were well stocked and supervision regular both before and after IMCI Amaral et al, Cad Saude Publica. 2004;20 Suppl 2:S Epub 2004 Dec 15 Chopra et al Arch Dis Child Apr;90(4):

Implications for health sector Access to ART- enhances capacity of family to care & protect, to plan for future, enables prevention, addresses stigma Need decentralisation & improved coverage of immunization and essential child survival interventions Simplified, standardised and integrated approaches, e.g. IMCI/IMAI enable scale up Supportive policy and legislative environment necessary Focusing on improving access and engagement with poorest families most likely to improve child health outcomes Community & home based structures and systems exist and are needed to support effective health service delivery e.g. community IMCI Need to address health needs of caregivers Integration of service delivery

Health sector – key responsibilities Make sure HIV NSP/NAP include children & families Have specific targets or benchmarks for children Know & understand the OVC framework Have defined and agreed definitions of vulnerability Ensure HIV policies, norms & standards stipulate; – right to access services for children – free HIV services for children/families – prioritisation of service delivery for children & families – continuum of care – essential package of care for children – roles, tasks and duties of private sector & not for profit partners, – address stigma & CCA Ensure coordination mechanisms for engagement of other sectors Ensure National scale up plans built on coordinated plans for decentralised delivery of the essential package of services

For IATT CCA Strategic How to strengthen national capacity to deliver on protective factors and minimise risks to CH What additional tools or support do national govmts /MOH need to do this ? Messages – back to same basics – doing same things differently, vs. doing different things IATT Relationship to PMTCT IATT? Greater acceptance that MoH are part of solution not just the problem