Transcript Models of Care for Paediatric HIV Miriam Chipimo MD MPH Reproductive Health & HIV&AIDS Manager, UNICEF, Malawi.

Models of Care for Paediatric
HIV
Miriam Chipimo MD MPH
Reproductive Health & HIV&AIDS Manager,
UNICEF, Malawi
Global Context
 In 2005 UNICEF raised a call to action to all working to
protect children from the AIDS epidemic
 Based on the UN General Assembly Special session on
HIV & AIDS in 2001 to attain the MDGs
 Call to Action set targets for 2010 in four key areas:
P1 –Prevent infections among adolescents &
young people
P2 – Prevent Mother To Child Transmission of HIV
P3 – Provide paediatric treatment
P4 – Protect and support children affected by HIV &
AIDS
Global Estimates
Following the call to action in 2005:
 documentation on pART improved
 number of children on ART increased
 75,000 by end 2005
 127,300 by end 2006 (60% in East & Southern Africa region)
 198,000 by 2007
By end 2007:
 2.1 million (6%) of 33.2 million people with HIV were children
under 15 years
 420,000 children were newly infected mostly through MTCT
 290,000 children had died
 Number of deaths had started to fall due to scale up of PMTCT
Numbers of HIV Infected Children Accessing ART Globally
90,000
84,817
80,000
2005
2006
70,000
60,000
50,000
48,981
40,000
30,000
16,949
20,000
11,248
10,000
4,174
10,674
9,749
5,954
2,982
1,300
810 1,444
South Asia
CEE/CIS
8
58
0
Eastern &
Southern
Africa
West &
Central
Africa
Latin
East Asia &
America &
Pacific
Carribeans
Middle East
& North
Africa
Global Programming Framework for scale up of HIV related
prevention, diagnosis, care & treatment for infants & children
Published in 2008 by WHO & UNICEF & reviewed by IATT:
Outlines the following strategies:
1. Government leadership, ownership and accountability
2. Integrated & decentralised delivery of HIV services for
children
3. Enhanced early identification of infants exposed to HIV
4. Reliable procurement & supply management
5. Laboratory capacity to support HIV services
6. Community based capacity to support those infected and
affected by HIV
7. Strengthening M&E systems to enhance quality of care
Children and AIDS in Malawi
Median HIV prevalence trends 1998 - 2007
25
20
%
15
10
5
0
1998
1999
2001
2003
Year
2005
2007
HIV Prevalence by Age Among Pregnant Women
2007 Sentinel Surveillance
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
19.00%
17.10%
15.30%
13.80%
12.30%
11.30%
8.00%
4
-4
9
-3
4
-3
9
-2
4
-2
4
-2
an
th
9
-1
+
45
40
35
30
25
20
15
15
ss
Le
15
Source: Malawi Sentinel Surveillance
POLICY, PROGRAMMING & FUNDING ENVIRONMENT

Strong political will to fight HIV/AIDS

National AIDS Policy, 2004 & HIV/AIDS Action Framework 20052009 are in place

Global Funds & Development Partners provide financial &
technical contributions coordinated by NAC

Strengthening of drug & supply management, laboratory and
diagnostic services ongoing

Strong ART and HTC programmes

PMTCT & Paediatric Guidelines updated

Accelerated scale up of PMTCT services

Roll out of Early Infant Diagnosis programme has started

Strengthening the continuum of care from various entry points
into ART
Tools to improve adherence in children on ART
 Children are provided with a take
home booklet to support
adherence to ART that provides:
– clear explanation,
– reinforcement and documentation
of dosing using pill count,
– asking for missed doses
– appointment schedule for follow
up visit
 Parent/guardian is counselled on
paediatric ART and use of the
booklet using the National
Paediatric HIV Flipchart
HIV health services in Malawi in 2007
120
100
100
Percentage
80
73
77
60
45
40
30
26
20
13
17
3
0
Total Health HF providing HF providing HF providing HF providing Pregnant National HIV HIV+ PW Newborns
Facilities
PMTCT
HTC
ART
EID
women prevalence received
receiving
(544)
tested for
rate
ARV
ARV
HIV
prophylaxis prophylaxis
Trends in Number of Children Accessing ART
25,000
23,441
Children on ART
Children needing ART
20,358
20,000
19,040
18,152
17,638
Number of children
16,780
15,000
11,865
10,000
5,115
5,000
1,820
0
120
659
0
2001
2003
2004
2005
Year
2006
2007
UNDER FIVE CLINICS PAEDIATIC WARDS NUTRITION WARDS
PMTCT
10%
PITC
Early Infant
Diagnosis
Rapid
HIV Test
CPT
Initiation of
ART
Testing
for 15%
family
NUTRITION COUNSELLING
75%
Negative
STAND ALONE AND INTEGRATED PAEDIATRIC ART CLINICS
Community
mobilisation
FEW FAMILY
CENTRED ART
CLINICS
FEW
DEDICATED
PAEDIATRIC
ART CLINICS
Teen Club
MAJORITY ARE
INTEGRATED ADULT &
PAEDIATRIC ART CLINICS
 FIXED DRUG COMBINATION – SPLIT ADULT TABLETS AT ALL
SITES- 2 month supplies given
ART
 CHILD FORMULATIONS AT 10 HIGH BURDEN SITES FOR CHILDREN
BELOW 1 YEAR
CD4 COUNTS CAN BE MONITORED AT ALL SITES AND VIRAL LOAD
AT A FEW CLINICS
 VERY FEW DEDICATED SOCIAL WORKERS AT ART SITES
Achievements
 Increased number of children accessing HIV testing including DBS
PCR from 6 weeks after birth – in total over 5,000 children tested in
2007
 No. of children receiving ART increased dramatically from 2000 in
2005 to 11,865 in 2007
 Strong political will and leadership by the government of Malawi in the
fight against HIV and AIDS
 Strong partnership between UNICEF, Baylor, Lighthouse, WHO, CDC
and Clinton Foundation to support MOH
 A steady supply of quality AIDS drugs, strengthening of lab
services for CD4 counts and EID
 Revised registers for M&E and job aides for PMTCT & pART
Challenges
 Weak continuum of care of PMTCT services from ANC, &
maternity to under five clinics
 Low coverage of more efficacious regimens for PMTCT and
Cotrimoxazole Preventive Therapy
 Late diagnosis of HIV+ children
 Long turnaround time from HIV+ diagnosis to starting ART
 M&E system does not monitor outcomes pART
 Relatively poor access to ART services (30% of facilities)
 Human resource constraints
 Community not well sensitised on PMTCT & Paediatric HIV care
 Psychosocial support for teenagers living with HIV
 Disclosure to the child
 Disclosure to family, friends and school
Finally a short movie &
thank you for your attention