1. HIV Testing of Infants and Children - Just the Beginning Elaine Abrams Track 1.0 Meeting August 12, 2008

2. HIV Testing of Infants & Children Introduction Two illustrative programs –HIV antibody testing program for children admitted to hospital wards at University Teaching Hospital, Lusaka, Zambia –Early Infant Diagnosis using Dried Blood Spots for DNA PCR Testing, Tanzania Successes & Challenges Issues for consideration

3. Why aren’t more children receiving antiretroviral treatment? Despite noteworthy successes with the scale-up of HIV services worldwide, the number of children in care and receiving ART remains low –Only 200,000 children worldwide were initiated on antiretroviral treatment (ART) as of December 2007 –Estimated 420,000 new pediatric infections and 290,000 pediatric HIV-related deaths in 2007 The identification and the diagnosis of the HIV- infected child, whether as infant or older, continue to pose formidable barriers to successful pediatric roll-out. –Furthermore, once diagnosed, multiple impediments prevent families from engaging in HIV services

4. Background: Pediatric HIV Care in Lusaka, Zambia in 2006 Estimated 28,000 children with HIV in need of ART but only 2,500 children on ART, December 2006 10,000 -15,000 pediatric admissions annually to University Teaching Hospital (UTH) –Hospitalized children suspected of HIV infection were sent to the Family Support Unit (FSU), a free standing VCT program for children and families Many children died prior to testing Most children were not tested for HIV CDC in collaboration with the MOH, UTH and ICAP supported the development of a Pediatric Center of Excellence (PCOE) for Pediatric HIV Care and Treatment at UTH PCOE with ICAP support initiated the pediatric inpatient testing program

5. Pediatric Inpatient Testing Initiative at UTH Counselors at FSU were re-oriented and re- deployed to the admissions ward where all but the sickest children needing intensive care were kept for 10-12 hours prior to admission Individualized and group counseling of parents present with their child on the admission ward –Rapid HIV testing of children by counselors; results within 30-60 minutes Follow-up counseling and testing on the hospital wards –Mothers needing to consult with father –Parents of critically ill children who couldn’t be counseled

6. 29% of children with unknown HIV status admitted to UTH tested HIV antibody positive (June 2006-Jan 2007) Jan 2006-June 2007 15,670 13,239 11,5713,3732,348 70% 29% 87% 85%

7. 20062007 Percent Of 1276 HIV antibody positive children <18 months of age, 63.2% tested DNA PCR positive, April 2006-June 2007

8. Success of the Pediatrics Inpatient Testing Program More than 15,000 children were newly tested for HIV and >3000 tested HIV antibody positive –Many with symptomatic disease –Offered HIV services at the PCOE or within the district –Testing and referral of family members initiated Young age of children hastened the availability of DNA PCR testing –DNA PCR laboratory established at the PCOE Modest investment of resources –Dedicated counseling staff, secure supply chain for HIV antibody tests –Children were assured access to ART at the PCOE

9. Challenges Stemming from the Inpatient Testing Program Large number of HIV-infected children overwhelmed capacity of HIV care services –Particularly providers and space The majority of children were enrolled in HIV care at the PCOE –Poor follow-up after hospital discharge –Delayed initiation of ART –Complexities of assuring PCR results were provided to each child/family tested

11. Early Infant Diagnosis (EID) Tanzania The CDC and ICAP, in collaboration with other partners, have supported the MOH to initiate and roll-out EID using dried blood spots for DNA PCR testing –Pilot program in Lake Region prior to National Expansion ICAP support has focused on three primary areas: –laboratory capacity –clinical training and support –guidelines and tool development

12. HIV-exposed infants (HEI) identified and tested ICAP Tanzania (Oct 06-Mar 08) Oct-Dec06 Jan-Mar07 Apr-Jun07 Jul-Sep07 Oct-Dec07 Jan-Mar08

13. Follow-Up After 1 st PCR test ICAP Tanzania 51% did not come back for results 54% did not come back for results

14. Successes of the EID program in Tanzania Established clinical capacity to identify and care for HIV exposed infants Established laboratory capability for EID Increasing number of infants being tested for DNA PCR to establish infection status during the first year of life –Should lead to increased number of young babies on ART Plan in place to increase laboratory and clinical capacity to perform EID throughout the country

15. Challenges confronted in the EID program Significant systems barriers –Slow turn around of results Limited laboratory capacity Delays getting results to sites –Poor follow-up of infants tested for EID For further exploration Hypothesized reasons: cost, travel, competing priorities, unaccustomed to appointment system, death, relocation –Linkages between PMTCT and infant follow-up care as well as between EID and HIV care and treatment services not fully developed

16. Conclusions & Questions Testing programs for children, including early infant diagnosis, are successfully identifying HIV exposed and infected children Engaging HIV exposed and infected children in successful long term follow-up and HIV treatment requires further attention and innovative programming –Importance of building programs that are family-focused and provide services to adults and children in a cohesive and coherent manner –Pressing need to transform health systems from an acute care model to one prepared to meet the health needs of children and adults with chronic diseases like HIV