Activities by IATT on PMTCT and Paediatric HIV

Activities by IATT on PMTCT and Paediatric HIV Care and Treatment Siobhan Crowley On Behalf of PMTCT/Pediatric HIV IATT

Global Impact of HIV on Children • Children constitute: – 12 percent (530, 000 of 4. 3 million) of new global HIV/AIDS infections – 13 percent (380, 000 of 2. 9 million) of HIV/AIDS deaths annually – 6 percent (2. 3 million of 39. 5 million) of the persons living with HIV – 15 million AIDS orphans by the end of 2006 Source: UNAIDS 2006

Recommendation GPF London, 2006 • Integrate and provide routine HIV and AIDS prevention and treatment services for children. • Integrate guidance on paediatric treatment and care into child and maternal health – Develop simple generic guidelines and training on paediatric ART, cotrimoxazole and nutrition and integrate into modules within IMCI, PMTCT, TB and HIV and AIDS care training. • Integrate the distribution of free cotrimoxazole to eligible children into health services – Develop decentralized plans to scale up provision through broader pediatric care, including through clinics, home-based care and youth friendly centers.

Integrate and provide routine HIV and AIDS prevention and treatment services for children • Scale up PMTCT Plus – Endorse the 2005 Abuja Call for Action in order to ensure universal access to PMTCT Plus interventions by 2010 • Scale up prevention for young people – IATT on HIV/AIDS and Young People to strengthen comprehensive prevention, including through sexual and reproductive health services for young people • Pediatric ART formulations and diagnostic availability – Develop secure funding agreements to support local and generic production of pediatric formulations, and to provide secure funds for bulk purchasing of ART. All partners to encourage and support pharmaceutical companies to develop appropriate formulation for pediatric ART

IATT on PMTCT and Pediatric HIV • Initially focused on PMTCT; mission recently expanded to explicitly include Pediatric HIV • Broad membership including: – UN (UNICEF, WHO, UNFPA, World Bank) – USG (CDC, PEPFAR, USAID-funded orgs. , inlc. EGPAF, Columbia, AED, etc. ) – Foundations (Clinton Foundation) – Other Academic orgs, including Baylor College

IATT on PMTCT and Pediatric HIV • Key areas of focus: – Strategic approaches – Advocacy and mobilisation of national and international partners – Translating norms and standards into Programming – Monitoring and evaluation including harmonization of indicators and annual report card • Joint Technical Missions – – – To assist with accelerating scale up Countries with high MTCT burden High paediatric infections Significant contribution to under 5 mortality Government interest in scaling up PMTCT and Peds.

Joint Technical Missions for Scaling up PMTCT and Pediatric HIV • 2005 • 2007 – – – – Rwanda Cote d’Ivoire Cameroon Malawi Botswana Lesotho Myanmar • Planned 2007 -2008 • 2006 – – India Burkina Faso Zambia Tanzania – – – Swaziland Nigeria Uganda (? ) Ethiopia (? ) Kenya (? )

Opportunities provided by Joint IATT missions • Broad representation of partners • One voice regarding technical and programmatic recommendations • Partners jointly plan and commit to provision of TA, resources and implementation support for follow up • Partners respond based on comparative advantages (in country & regionally)

Government-owned Process • • • Invitation from Government TORs set by Government Rapid situation or program assessment undertaken Planning Team organized by Government Thematic discussions chaired by Govt. Scale up plan monitored and implemented by Government

JM: Thematic Areas usually examined • Program Management • Comprehensive PMTCT (primary prevention, prevention of unintended pregnancies, prevention of MTCT, care and support of children, mothers, and families) • Infant Feeding • Paediatric Care and Treatment (optimizing identification, e. g. diagnosis, and scaling up treatment) • Monitoring and Evaluation • Procurement and Supplies Management

Major areas for recommendations (1) • Program Management – Mechanism for National coordination of activities, including those of partners – Focal Points for PMTCT and Pediatrics – Decentralized implementation strategy – Task Shifting or “Task Sharing” – Training of existing health care workers

Major areas for recommendations (2) • PMTCT – How to decentralize service provision, & expand geographical service coverage – increase uptake of HIV testing and counseling in ANC settings – Prioritisation of CD 4 testing for pregnant women – Introduce more efficacious regimens outlined in revised clinical guidelines (2006) – Develop program linkages for PMTCT & CH services, e. g. include HIV exposure status on child health card prior to mother’s discharge after delivery – Increase coverage of maternal ARV, e. g. distribution of mother-baby pack prior to delivery in case delivery takes place at home

Major areas for recommendations (3) • Pediatric HIV Care and Treatment • Review treatment and care guidelines • Reinforce family based HIV care – HIV-Exposed infants • Strengthen infant follow up • Introduce or pilot early virological HIV testing at 6 weeks wherever possible (including using DBS) • Introduce earlier antibody testing (9 -12 months) • Institutionalize Co-trimoxazole prophylaxis – HIV-infected infants • Increase entry points for children , e. g. through PITC of sick children and others of unknown exposure status in certain settings • expand PCR capacity through DBS • Increase access to treatment through training of ART providers in pediatric HIV clinical management.

Major areas for recommendations (4) • Infant feeding – – – Promotion of EBF & reaffirm BFI Clarification of AFASS Review tools and Training curricula of counselors • M&E – Harmonization of programme indicators across partners – Streamlining of data reporting systems • PSM – Integration of Pediatric HIV supply into existing adult supply mechanism – Review all HIV commodities

Mission Follow Up Actions Rwanda Malawi • Development of integrated workplan for PMTCT and Peds. • Development of steering committee for children & HIV • Integration of services significantly improved by end of 2006: i) 94% of VCT sites are also PMTCT; ii) 83% of ARV sites are also PMTCT; iii) 89% of ARV sites also provide ART for children. • Ministerial instruction for testing of hospitalised children • PMTCT training modules updated Nutritional support for HIV+ mothers in last trimester and first 6 months after delivery • PMTCT coordinator moved from RH to HIV unit (locus for ART and VCT) • IMCI revised to include paediatric HIV care

Mission Follow Up Actions India Zambia • Early diagnosis for children incorporated into national HIV plan • Paediatric HIV package of care defined by Indian Institute of Paediatrics after request by Government • Nutritional support package for HIV-infected children being revamped. • Paeditric ARV dosing and formulary established • National PMTCT and paediatric guidelines revised and disseminated • U 5 card revised to include exposure status and prompt for early diagnosis and initiation of cotrimoxazole prophylaxis

Mission Follow Up Actions Burkina Faso Tanzania Lesotho All Countries • Focal points for PMTCT and Paediatrics placed in MOH • Collaboration developed with Clinton Foundation to expand access to paediatric HIV care and treatment • National PMTCT and paediatric M&E indicators finalized • New National strategic plan on HIV will include children • Policy developed to expand PITC for all children in the country being seen at U 5 clinics • Received UNITAID funding for PMTCT scale up and introduction of more efficacious regimens

Other IATT achievements & products • • Global strategy Report card Draft indicator registry and programming tool Draft programming guide on scaling up paediatric care and treatment • Scale planning guide • Regional workshops on scale up planning

GPF Follow up

Integrate Guidance on Paediatric Treatment and Care into Child and Maternal Health • Revised WHO guidelines available (2006) – ARV Treatment, including staging – Infant diagnosis guidelines (PMTCT f/u and PITC) – Co-trimoxazole guidelines – Complementary IMCI – Ped care integrated into adult tools (IMAI) • Promtion of keeping information regarding HIV exposure on child health cards • Expansion of co-trimoxazole use for exposed infants by incorporation into national guidelines • HIV expanded course on IMCI (field tested in Zambia, Uganda, Nigeria and subsequently revised) • Paeditrid HIV and PMTCT integarted inot adult HIV care approaches (IMAI)

Integrate the Distribution of Free Cotrimoxazole to Eligible Children into Health Services • Advocacy for provision of free co-trimoxazole in national plans and guidelines • Inclusion of co-trimoxazole in UNITAID funding for both UNICEF/WHO and Clinton Foundation • Recommend addition of prompt on child health cards for HIV-exposed infants

Scale up PMTCT Plus • Advocacy for training for decentralized approach and increased geographical coverage • Introduction of routine HIV screening in ANC settings • Focus on all four prongs during JMs • Look for increased linkages/integration to care and treatment, for mothers, children, families to ANC services.

Scale up Prevention for Young People • Increased focus on prongs 1 and 2 during joint missions • Technical lead by UNFPA • Activities coordinated through IATT on YP

Pediatric ART Formulations and Diagnostic Availability • Guidance on appropriate pediatric formulations being developed through WHO leadership • Development of pediatric formulations by generic manufacturers (e. g. CIPLA, Ranbaxy) • Support for bulk purchase of ARTs and diagnostics trough UNITAID • Public Private Partnership – addressing bottlenecks in formulations, supply management, in-country registration, education & training • Expanded training in Pediatric HIV clinical management (e. g. through Baylor) • Expanded training and capacity building in DBS (Clinton Foundation, EGPAF, Columbia, etc. ) • Results: Significant increase in numbers on treatment.

PMTCT Access Increasing but Lowest in Regions with Greatest Need Source: UNICEF PMTCT and Pediatric Care Report Card 2006

PMTCT Access • Scores expected to be higher for next report card as a result of increasing commitment and involvement, but still below needed levels to reach UNGASS targets in 2010.

Conclusions • IATT has been an effective forum in strengthening and consolidating the global response to PMTCT and Pediatric HIV Care and Treatment • Joint Technical Missions have been instrumental in changing landscape in countries so far with introduction of new policies, capacity building, and new resources