Transcript National Scale-Up of Early Infant Diagnosis (EID) Testing

Impact of Early Infant Diagnostic
(EID) Testing for HIV Exposed
Infants in Namibia
[A-240-0316-12275]
20 July 2010
Dr. Ndapewa Hamunime (MOHSS)
Dr. Andreas Shiningavamwe (NIP)
Republic of Namibia
Background
• Population ~2million
• Surface area of
802,4116km2
• Sparsely populated:
population density 2.2/km2
• 35 public hospitals, 34
health districts
• 11.5% of GRN budget
spent on health
• Newly established Medical
School 2010
• 95% of drugs, supplies
imported
2
Context and Response
Namibia has rapidly responded to HIV positive infant vulnerability with EID and infant treatment
Global Context
Early Infant Diagnosis for HIV linked with HIV care is critical for the
survival of HIV exposed infants
Response
• National Early Infant Diagnosis (EID) service launched in late 2005
by the Ministry of Health and Social Services (MOHSS) in
collaboration with the National Institute of Pathology Ltd (NIP)
Windhoek
• Significant investment in EID has taken place since 2006
• As the service has scaled up, program evaluations continue to be
used to guide programming to maximize infant care
Methods (1)
SITES
A selection of 25 EID collection sites across all 13 regions were reviewed
Methods (2)
SCOPE
The full EID service was reviewed at each site
At each site, the full EID service continuum was examined:
PMTCT
Vaccination
Family
testing of
PLHAs
Infants on
Wards
EID Sample
Collection
Point(s)
Testing at NIP
Windhoek
(& cotrimoxazole)
Identification of
Exposed Infant
Sample Transport to
Processing laboratory
Result Return
to Site
Result
Return to
Infant
HIV Care
for HIV +
Infants
PCR 1
Negative
Infants:
Follow up
Scale up of EID Sample Collection (via DBS)
EID collection sites, EID samples, and EID coverage have increased dramatically over time
250
• Since 2006, sites offering EID
have grown dramatically:
EID Collection Sites over Time (sites)
Site ever collecting a DBS
sample for the national program
200
150
• EID was available in all
regions by the end of 2006
• EID is available at all 79
ART sites and over 200
PMTCT sites
100
50
0
1500
1200
• Over 31,900 EID samples have
been tested since the start of
the service
• In 2008, 86% of HIV exposed
infants accessed EID
20063
2006
20073
2007
20083
2008
20093
2009
Monthly EID Samples Volume over Time
EID Samples tested
in public sector
900
600
300
0
2006
2007
2008
2009
Early Identification (1)
Over time, more of the HIV exposed infants receiving an EID test are getting tested early
Portion of Infants EID Tested by Age Band at PCR 1
100%
90%
• Because of Infant
health deterioration,
early testing is key
80%
70%
60%
50%
40%
30%
20%
• Namibian Algorithm
encourages EID
testing at 6 weeks
47.70%
53.80%
61.20%
32.60%
10%
0%
2006
2007
Tested ≥ 6 m
Tested 2 ≤ x <6 m
Tested in first two months of life
2008
2009
• In early years of the
service, only 50% of
infants tested were
tested in their first two
months of life
• Every year, a larger
portion of infants
tested had their first
EID sample collected
in the first two months
of life
Early Identification (2)
However, more must be done to take advantage of high PMTCT coverage for earlier EID
• In 2008, Namibia had a 92% PMTCT
coverage
9000
• Of infants receiving their first EID
tests, over 90% of them were coded
as coming from PMTCT
6000
• However, only 49.6% of all infants
tested were tested in their first two
months of life
Coverage of PMTCT Service (2008)
3000
49.6%
<2m
0
We are working hard to further
reinforce the linkage between
PMTCT and early EID testing
and exposed infant care
(1) UNICEF, UNAIDS, WHO. Towards Universal Access 2009,Vienna: 2009.
HIV est
Est.
HIV
Pos
Pregnant
Women1
Know HIV
PMTC T
Known
Accessed
Pos1
PMTCT1
EID
EID
Tested ≥ 6 m
Tested 2 ≤ x <6 m
Tested in first two months of life
EID Sample Transportation and Processing
A centralized transportation system, and one Central PCR laboratory has allowed for smooth
processing
•
Efficient sample transport system linked with local NIP laboratories
(who manage intake) allows for rapid transport (mean <1 day from
sample collection to arrival at local NIP)
•
Centralization of EID along with strong lab organization and
management ensures high throughput and fast turn around time
28
Monthly EID Sample Volume (samples)
1600
1400
1200
1000
800
600
400
200
0
21
Mean Turn around Time (days)
14
7
2006
2007
2008
2009
Technicians rotate and process
samples daily – processing volumes of
~1,000 -1,300 EID samples/monthly
0
2006
2007
2008
2009
Turn around times from sample
collection to result completion are
consistently <10 days
Collection to local NIP
Local NIP to analysis
Referral to HIV Care and Treatment
Examining HIV positive infant follow up at individual sites gives indications of attrition challenges
•
EID is critical because it allows
for the earlier identification of
and care for HIV positive
infants
HIV Pos Infants Enrolled at ≤12m of Age
at 25 Reviewed Sites since 2006
100%
90%
80%
70%
60%
50%
40%
•
Portion of HIV positive infants
put on ART within 6 months of
enrolling is increasing
30%
20%
10%
0%
2006
2007
2008
2009
(n=203)
(n=293)
(n=439)
(n=50)
Infants <12m enrolled never initiated
Infants <12m initiated >6m after enrolling
Infants <12m initiated ≤6m after enrolling
weeks
Mean Time between enrollment and ART
Initiation
of Infants enrolled in HIV care (weeks)
30
•
20
10
0
2006
2007
2008
2009
Mean time between
enrollment and initiation of
HIV positive infants is steadily
decreasing
Conclusions and Programmatic Implications
Program reviews and analyses can inform future program interventions
EID Strengths
•
•
•
•
•
•
•
High PMTCT and EID coverage
Dramatic increases in EID
volumes
Decreasing age at testing
Centrally managed program
Consistent and fast sample turn
around time
Strong technical capacity
Partner collaboration
Ever Present Challenges
•
•
•
Higher than optimal average age at
testing
More support for follow-up of HIV
exposed infants, referral of HIV
positive infants to HIV care, and
clinical care for infants testing
positive particularly with regards to
ART initiation
Strengthen private sector
involvement
Efforts to Strengthen
the EID in Namibia
Linkages between PMTCT,
DPT1 vaccination and early EID
testing at sites reinforce through
mentoring and supervision

 EID test sites increased from
242 to 292 since review
 A new automated EID
equipment procured and installed
at NIP
 Community engagement and
defaulter tracing system
strengthened
Acknowledgements
UNICEF (HQ, ESAR, NAMIBIA CO)
USAID
US Center for Disease Control
Clinton Foundation
I-TECH
WHO
GRN