increasing uptake of hiv early infant diagnosis (eid) services in four countries (cambodia, namibia,...
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Increasing Uptake of HIV Early Infant Diagnosis (EID) Services in Four Countries (Cambodia, Namibia, Senegal & Uganda)
20 July 2010, Vienna
S Tripathi, Matt Barnhart, C Kiyaga, M Nghatanga, M Chhi Vun, A S Wade, R Gass, A Chatterjee, R Ekpini, C Luo
Agenda
Infants and young children are dramatically underrepresented in PMTCT and pediatric HIV services. However, a momentum of policy, technology, and programming hope to close the gap
Without access to treatment, >33% of HIV positive infants die before the end of their first year of life, and 50% in the first two years of life
Early Infant Diagnosis for HIV (via virologic testing) linked with infant treatment are essential for the survival of HIV exposed infants
Context for EID
Strong Policy Guidance
Dramatic Gaps Remain
Tools to close the gap are available
Clear Data
Though 90% of children living with HIV acquired HIV by vertical transmission, few infants and young children access testing and care early in their lives; many die without accessing HIV care1
Guidance recently released regarding: (1) stronger post natal follow up, (2) importance of EID testing and (3) immediate initiation on ART for HIV positive infants <12m
(1) Only 15% of HIV exposed infants in low and middle income countries accessed EID testing in their first two months of life in 2008.
Opportunities for Improvement in EID
• Senegal Cambodia• Namibia Uganda
Objective:
Review program scale up of EID within the context of exposed infant services across a diverse group of low and middle income countries to understand bottlenecks and lessons learned from service delivery, as well as the impact of EID service
Countries Reviewed: Four Ministries of Health led EID service reviews with technical support from UNICEF
Methods/Approach:
Review a selection of 18-25 EID collection sites per country spanning geographic, health center level, HIV service availability and time since starting EID metrics
Reviewed transport and central laboratory components in each country
Implemented standardized questionnaire at EID sites to understand sample volume and programmatic practices, and key informant interviews with national program partners to learn about program scale up and program management
Background on the national EID service scale up (sample volumes)EID sample volumes have increased steadily in all four countries
0
50
100
150
200
2006Q1 2006Q3 2007Q1 2007Q3 2008Q1 2008Q3 2009Q1 2009Q3
Background on National EID Programs
0
2000
4000
6000
8000
10000
2006Q1 2006Q3 2007Q1 2007Q3 2008Q1 2008Q3 2009Q1 2009Q3
Quarterly EID Sample Volume since Start of Program (HV)
Sam
ples
per
qua
rter
Namibia
Uganda
Quarterly EID Sample Volume since Start of Program (LV)
Sam
ples
per
qua
rter
Senegal*
Cambodia
(*) Quarterly data not available, yearly volumes averaged
Quarterly volumes are steadily rising in
Uganda, Senegal and Cambodia, all three
still <50% EID Coverage (in 2008)
Less than one half of infants ever tested via EID across these four countries were tested in their first two months of life. Coverage of the optimal service (early testing) is consequently even lower
Portion of HIV Exposed Infants in Need Receiving EID Service in First Two Months of Life
Missed early testing
opportunities: PMTCT follow
up appointments,
vaccination schedule
0
10
20
30
40
50
PositivePCR
Results Enrolled I nitiated Alive
Of those infants testing HIV positive via EID, attrition post testing is significant
Patients lost
Patients EID tested
Follow up of Infants Testing Positive via EID at Review Sites
0
500
1000
1500
2000
2500
3000
3500
PositivePCR
Results Enrolled I nitiated Alive
3182
2330
EnrolledPositive via EID
Initiated on ART
Rec. Results
Active on ART
1170878
Uganda-72% not alive & on ART
No data
0
25
50
75
100
PositivePCR
Results Enrolled I nitiated Alive
87
EnrolledPositive via EID
InitiatedReceived Results
Alive on ART
2330
4
90
Received Results/ Enrolled
Positive via EID
Initiated on ART
Results at Site
Active on ART
38 33
93
Senegal 67% not alive & on ART
Cambodia- 67% not alive & on ART
No data 6
14
27
100
Infa
nts
Infa
nts
Infa
nts
• There are clearly numerous challenges related to the implementation of EID which merit particular attention as they are dramatically curtailing the impact of the service such as late age at testing, centralized service uptake, and still slowly rising service coverage
With these findings, Ministries of Health have already begun to strategize, pilot and address critical bottlenecks in order to optimize the impact of the EID service
• The landscape for HIV exposed infants and young children is better today than it has ever been before:
PMTCT coverage is increasing.
Infant testing services are becoming widely available.
Children respond exceedingly well to ART if tested early and treated early.
There is significant Ministry and partner momentum and investment
Lessons learned provide strategic opportunities to bolster EIDUnderstanding the operational challenges hindering the implementation and impact of EID can help to target future investments
Deepest thanks to all four Ministries of Health who led these EID service reviews:
Dr. Mean Chhi Vun and Dr. Sok Panha, Ministry of Health, Kingdom
of Cambodia
Ministry of Health and Social Services, Republic of Namibia
Dr. Charles Kiyaga, Ministry of Health Republic of Uganda
Dr. Abdoulaye S. Wade, Ministère de la Santé, Republique du Sénégal
UNICEF HQ and UNICEF country offices, particularly R. Gass