Models of Care for Paediatric HIV Miriam Chipimo MD MPH Reproductive Health & HIV&AIDS Manager, UNICEF, Malawi

Global Context  In 2005 UNICEF raised a call to action to all working to protect children from the AIDS epidemic  Based on the UN General Assembly Special session on HIV & AIDS in 2001 to attain the MDGs  Call to Action set targets for 2010 in four key areas: P1 –Prevent infections among adolescents & young people P2 – Prevent Mother To Child Transmission of HIV P3 – Provide paediatric treatment P4 – Protect and support children affected by HIV & AIDS

Global Estimates Following the call to action in 2005:  documentation on pART improved  number of children on ART increased  75,000 by end 2005  127,300 by end 2006 (60% in East & Southern Africa region)  198,000 by 2007 By end 2007:  2.1 million (6%) of 33.2 million people with HIV were children under 15 years  420,000 children were newly infected mostly through MTCT  290,000 children had died  Number of deaths had started to fall due to scale up of PMTCT

Global Programming Framework for scale up of HIV related prevention, diagnosis, care & treatment for infants & children Published in 2008 by WHO & UNICEF & reviewed by IATT: Outlines the following strategies: 1.Government leadership, ownership and accountability 2.Integrated & decentralised delivery of HIV services for children 3.Enhanced early identification of infants exposed to HIV 4.Reliable procurement & supply management 5.Laboratory capacity to support HIV services 6.Community based capacity to support those infected and affected by HIV 7.Strengthening M&E systems to enhance quality of care

Children and AIDS in Malawi

HIV Prevalence by Age Among Pregnant Women 2007 Sentinel Surveillance Source: Malawi Sentinel Surveillance

POLICY, PROGRAMMING & FUNDING ENVIRONMENT  Strong political will to fight HIV/AIDS  National AIDS Policy, 2004 & HIV/AIDS Action Framework are in place  Global Funds & Development Partners provide financial & technical contributions coordinated by NAC  Strengthening of drug & supply management, laboratory and diagnostic services ongoing  Strong ART and HTC programmes  PMTCT & Paediatric Guidelines updated  Accelerated scale up of PMTCT services  Roll out of Early Infant Diagnosis programme has started  Strengthening the continuum of care from various entry points into ART

Tools to improve adherence in children on ART  Children are provided with a take home booklet to support adherence to ART that provides: – clear explanation, –reinforcement and documentation of dosing using pill count, –asking for missed doses –appointment schedule for follow up visit  Parent/guardian is counselled on paediatric ART and use of the booklet using the National Paediatric HIV Flipchart

PITC Early Infant Diagnosis Rapid HIV Test CPT NUTRITION COUNSELLING Initiation of ART PMTCT Testing for family UNDER FIVE CLINICS PAEDIATIC WARDS NUTRITION WARDS Negative 75% 10% 15%

FEW DEDICATED PAEDIATRIC ART CLINICS MAJORITY ARE INTEGRATED ADULT & PAEDIATRIC ART CLINICS FEW FAMILY CENTRED ART CLINICS  FIXED DRUG COMBINATION – SPLIT ADULT TABLETS AT ALL ART SITES- 2 month supplies given  CHILD FORMULATIONS AT 10 HIGH BURDEN SITES FOR CHILDREN BELOW 1 YEAR  CD4 COUNTS CAN BE MONITORED AT ALL SITES AND VIRAL LOAD AT A FEW CLINICS  VERY FEW DEDICATED SOCIAL WORKERS AT ART SITES STAND ALONE AND INTEGRATED PAEDIATRIC ART CLINICS Teen Club Community mobilisation

Achievements  Increased number of children accessing HIV testing including DBS PCR from 6 weeks after birth – in total over 5,000 children tested in 2007  No. of children receiving ART increased dramatically from 2000 in 2005 to 11,865 in 2007  Strong political will and leadership by the government of Malawi in the fight against HIV and AIDS  Strong partnership between UNICEF, Baylor, Lighthouse, WHO, CDC and Clinton Foundation to support MOH  A steady supply of quality AIDS drugs, strengthening of lab services for CD4 counts and EID  Revised registers for M&E and job aides for PMTCT & pART

Challenges  Weak continuum of care of PMTCT services from ANC, & maternity to under five clinics  Low coverage of more efficacious regimens for PMTCT and Cotrimoxazole Preventive Therapy  Late diagnosis of HIV+ children  Long turnaround time from HIV+ diagnosis to starting ART  M&E system does not monitor outcomes pART  Relatively poor access to ART services (30% of facilities)  Human resource constraints  Community not well sensitised on PMTCT & Paediatric HIV care  Psychosocial support for teenagers living with HIV  Disclosure to the child  Disclosure to family, friends and school

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