Maximizing Linkages to OVC Programs PEPFAR 3.0 and OVC Programming: Implications and Promising Practices for Impact OVC Task Force Meeting. Oct 7, 2015 Brenda Yamba Acting Senior Orphans and Vulnerable Children Advisor Office of the Global AIDS Coordinator & Health Diplomacy I would like to thank the organizers for asking me to participate in this session. My presentation is aimed to provide a practical way to ‘organize’ our efforts in the coming year to improve access to quality care and treatment services for HIV infected children. Ensuring that PEPFAR programs scale up services to rapidly close the gap in critical services for HIV infected, exposed and affected children is part of our mandate towards reaching an AIDS free generation.

OVC Programs link to HIV cascade CASE FINDING Keep kids in TREATMENT cascade Foster comprehensive HEALTH 1. 3. 2. 3 reasons to link with OVC programs – in order to: Find the HIV + children and adolescents Getting the kids into treatment, adherence support, and staying on treatment (retention). Support the leaky treatment cascade for HIV+ kids and their families. Foster comprehensive health and resilience for the infected and exposed children – because their ultimate health is why we want them on treatment – but for complete health of a child infected by HIV – it takes more than treatment. So now, let’s take each of these three reasons to link with OVC programs and discuss the whys and hows of making these linkages effective. First, let’s look at case finding.

1. OVC programs can help find the kids in need of HIV/AIDS treatment HIV infected HIV Diagnosed Enrolled in Care ART Eligible ART Initiated Retention on ART Bottom line: link up with your OVC programs. Aim for 100% testing of kids in OVC programs.

Partnership between clinic/hospital and OVC program in the community 1. Case Finding Partnership between clinic/hospital and OVC program in the community Identify barriers to accessing services Formalize collaborating strategy for testing kids/families and bi-directional referrals for other services. Include knowledge of HIV status in the community/household assessment tools. Identify OVC platforms to link with clinical services Skilled OVC staff in pretest counseling & follow-up. So how do I capitalize on OVC programs for case identification? One of the biggest challenges is communicating, understanding each other and working together. By having a formal local OVC partner

OVC Programs link to HIV Cascade CASE FINDING Keep kids in TREATMENT cascade Foster comprehensive HEALTH 1. 3. 2. OVC programs can do more than help you find the kids who are HIV +, these programs can help you get the kids into treatment and stay there!

2. Keep kids in the Treatment Cascade: OVC programs can help “plug” the leaky HIV/AIDS treatment cascade for children HIV infected HIV Diagnosed Enrolled in Care ART Eligible ART Initiated Retention on ART As you know, there is a substantial loss at every step of the cascade with often around half the people at one stage in the cascade not making it to the next step. We have seen the effectiveness of OVC programs in reducing drop out already Rosen, PLoS Med 2011; Fox, TMIH 2010

2. HOW OVC programs keep children in the Treatment Cascade Methods proven to increase adherence and retention in children: Psychosocial Support (child & caregiver) Caregiver & women’s support groups Peer mentoring Individual support Economic Strengthening of family OVC program examples of results: In Zim, 100% of HIV+ <5 retained in C&T – very comprehensive In Kenya, 95% of HIV+ children linked to care & support. Some caregivers are undergoing further counseling to enhance acceptance of the results In Mozambique, OVC community workers linked family members to social support and clinical services and returned 68% of treatment defaulters to ART/clinic. How do OVC programs have such high rates for retention. It’s the comprehensive services: Randomized trails have shown that PSS support, provided through support groups, peer mentoring and individual support, along with ES increase adherence and retention. Zim: very comprehensive - health, nutrition, & psychosocial support for OVC 5 years and younger along with family support groups for their families or caregivers. nurse-led monitoring of the children and their caregivers. Centers monitored attendance, child ‘s development, health status, vaccinations and HIV status and reviewed by the nurse supervisor.

What you can do to keep children in the Treatment Cascade Formalize a partnership between clinical and OVC programs Establish referral system for HIV + children and their caregivers to OVC programs that provide: Psychosocial support for caregiver & children Economic strengthening activities like Savings groups Train OVC staff/home visitors in referring for testing, treatment, and guidance on tx adherence, monitoring and addressing LTFU What can you do to benefit from the additional support of OVC programs? Make sure very hospital and clinic is linked to an OVC programs that provides PSS and ES. And train the OVC program staff on how to support effective referrals and adherence and retention. Let them know when they don’t come back to the clinic so they can help with follow-up.

OVC Programs link to HIV Cascade CASE FINDING Keep kids in TREATMENT cascade Foster comprehensive HEALTH 1. 3. 2. Finally, the third way OVC programs can support children in ACT is by fostering comprehensive health.

3. Foster Comprehensive Health for HIV + children HIV infected HIV Diagnosed Enrolled in Care ART Eligible ART Initiated Retention on ART Getting and keeping HIV +kids on treatment is essential for good health. But that alone won’t be enough for them to be truly, completely healthy. Once again, that is where the OVC program can help fill that need.

Why children affected by AIDS need attention to comprehensive health Elevated risk of Mental health issues – depression & anxiety School drop-out Stunting Developmental delays Abuse Death e.g. when a mother dies, the chance of her child dying within 24 months increases 10 fold. HIV impacts children and families in so many ways. Depression increases often compromising adherence, but also impacting their ability to learn and progress in school. HIV infected children and even exposed children generally have compromised brain development. HIV also necessitates adequate nutrition but causes poor absorption which can, especially in the early years, result in stunting and developmental delays. But these are all things with which OVC programs deal. This is our bread and butter.

HOW to Foster Comprehensive Health Early stimulation – training for mothers via mother support groups, in-home or peer mentoring Economic strengthening (e.g. savings groups) to support improved nutrition and access to treatment Nutrition interventions Psychosocial support, triage Help kids stay in school and succeed – gives hope (mentoring, Building hope and resilience

Contributions to PEPFAR Central Initiatives DREAMS will maximize the PEPFAR OVC program to mitigate the social effects of AIDS and therefore reduce HIV risk behaviors and risk exposure among adolescent girls through evidence-based interventions including: Education subsidies Social asset building Parenting/caregiver programs Cash transfers Combination socio-economic approaches Parenting/Caregiver: Having a positive relationship with a parent, caregiver, or other caring adult is a consistent protective factor for young women and girls against a variety of negative health and social outcomes. Skills building programs involving parents and caregivers have shown promise to change HIV related sexual behaviors among youth. Cash transfers have demonstrated consistent effects on biological and behavioral outcomes. Education: Girl students are especially vulnerable to school dropout. Educational subsidy is an effective intervention for keeping girls in school [38, 39] and is correlated with reduced sexual risk behaviors and higher HIV testing acceptance. Education also has a myriad of other positive effects in the lives of girls and young women. Combination socio-economic approaches: Approaches that combine economic and social empowerment interventions have more consistent effects on both behavioral and violence outcomes. ACT will maximize the PEPFAR OVC program’s capacity to “strengthen children’s resilience” by: Addressing socio-economic barriers in vulnerable families and therefore support increased treatment entry and retention in children and adults Scaling up evidence-based interventions Linking community and clinical services Enhancing family-centered care Strengthening the measurement of quality improvement, cost analysis, and outcomes.

The Core Package Parenting/Caregiver Programs Cash transfers, either unconditional or with schooling conditions Combination socio-economic approaches Educational subsidy The Core Package Strengthening the Family Parenting/Caregiver: Having a positive relationship with a parent, caregiver, or other caring adult is a consistent protective factor for young women and girls against a variety of negative health and social outcomes. Skills building programs involving parents and caregivers have shown promise to change HIV related sexual behaviors among youth. Cash transfers have demonstrated consistent effects on biological and behavioral outcomes. Education: Girl students are especially vulnerable to school dropout. Educational subsidy is an effective intervention for keeping girls in school [38, 39] and is correlated with reduced sexual risk behaviors and higher HIV testing acceptance. Education also has a myriad of other positive effects in the lives of girls and young women. Combination socio-economic approaches: Approaches that combine economic and social empowerment interventions have more consistent effects on both behavioral and violence outcomes.

Example: Cameroon Framing OVC Strategy within HIV Care Continuum Health Systems Strengthening Core services for OVC OVC found positive Linkage to clinical care Support for retention and adherence Core OVC services Facilitate access to HIV/AIDS –related clinical services, e.g. HTC, care, and support Household economic strengthening Promote supportive family environment Comprehensive SRH education and condom programming for adolescents. Family counseling to facilitate disclosure and client education. Food supplements for clinically malnourished OVC Core OVC services Adherence counseling and psychosocial support Food supplements for clinically malnourished OVC Core OVC services Adherence counseling and psychosocial support Case management to track and refer those LTFU Food supplements for clinically malnourished OVC Support transition from pediatric to adult treatment services Core OVC services