1. 1 Towards getting more HIV- positive infants on lifesaving treatment: assessing turn- around times for early infant diagnosis in Lesotho M Gill, HJ Hoffman, A Isavwa, M Mokone, M Foso, JT Safrit, A Tiam MOAD0202

2. Kingdom of Lesotho Population1.9 million HIV prevalence among pregnant women 27.7% ANC attendance (first visit)91.8% Deliveries in health facilities69.8% HIV testing in ANC95% Maternal PMTCT coverage (facility based) 96% Infant prophylaxis uptake (facility based) 97% DHS-MOH, 2009; Annual joint review MOH, 2013.

3. Background  Globally, only 34% of ART eligible children aged <15 years are receiving ART  Without treatment, 1/3 of HIV-infected children will not see their first birthday and almost 1/2 will die before 2 years of age  In Lesotho  37,000 children are living with HIV  38% of eligible children are receiving ART  Average ART initiation is 5 years of age  Long turn-around-time (TAT) for early infant diagnosis (EID) has been identified as a significant challenge DK. Ekouevi et all 2011 ; WHO/UAIDS/UNICEF Universal Access 2011; S. Essajee, 2010; UNAIDS, 2013

4. Objectives 1)To identify delays in the EID process, from sample collection to receipt of results by caregiver and infant ART initiation in HIV infected infants 2)To determine the 6-8 week HIV infection rate among HIV exposed infants who had an EID test done

5. Methods  Retrospective review of all 6-8 week-old, HIV-exposed infants who received an HIV test in selected sites in 2011; central lab records linked to facility records  25 purposefully selected study sites:  Included sites from both hospitals and health centers and each of the three geographic zones  Included 11 hard-to-reach sites with higher-than- average EID turnaround time  TAT for EID was calculated using abstracted dates from laboratory EID database and registers  Geometric means (with 95% CI) for TAT were calculated and compared by region using linear mixed models

6. Step-by-step DNA-PCR testing in Lesotho

7. Infant/mother characteristics HIV-exposed infants with 6-8 week EID (n=1187) Mean age at blood draw (days)47 HIV-positive children (n)47 HIV transmission rate at 6-8 weeks4% HIV infected mothers of study infants (n=1045) Mean maternal age (years)28 Mean gravida/parity2.4/1.4 Mean number of ANC visits3.1 Mean gestational age at first ANC (weeks) 26

8. EID Total TAT time: 61.7 days (CI = 55.3, 68.7) 14.0 days 2.7 days 23.3 days 3.3 days 10.4 days

9. Mean TAT per stage by Geography Highlands Lowlands Foothills

10. Mean TAT per stage by HIV status HIV uninfected HIV infected

11. Mean TAT from HIV positive results to initiation on ART distributed by region Number of days

12. Results return for HIV infected infants HIV positive EID results are distributed by EGPAF through mobile 3-G internet to health facilities ahead of paper based results. Once Health care workers are informed, community workers track the infant before the appointment date.

13. Conclusions Average TAT from specimen collection to caregiver receipt of test results in the study facilities was approximately 2 months. The longest delay occurred between specimen receipt in the central laboratory and result receipt at the district laboratory HIV infected infants had rapid ART initiation due to a system of expedited notification of positive results to caregivers and same-day treatment initiation Interventions to expedite result transfer back to facilities and in-country testing would allow for faster initiation of infants on life-saving treatment

14. ACKNOWLEDGEMENTS Funding for this research was provided by the University of California Los Angeles (UCLA) student dance marathon program. We would like to acknowledge: – The MOH of Lesotho – Health care workers in the sites – The research team and all EGPAF staff – Our patients

15. Thank you!