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

Activities by IATT on Activities by IATT on PMTCT and Paediatric PMTCT and Paediatric

HIV Care and TreatmentHIV Care and Treatment

Siobhan CrowleySiobhan Crowley

On Behalf ofOn Behalf of

PMTCT/Pediatric HIV IATTPMTCT/Pediatric HIV IATT

Global Impact of HIV on Global Impact of HIV on ChildrenChildren

• Children constitute: Children constitute:

– 12 percent12 percent (530,000 of 4.3 million) of new global (530,000 of 4.3 million) of new global HIV/AIDS infections HIV/AIDS infections

– 13 percent13 percent (380,000 of 2.9 million) of HIV/AIDS (380,000 of 2.9 million) of HIV/AIDS deaths annually deaths annually

– 6 percent6 percent (2.3 million of 39.5 million) of the (2.3 million of 39.5 million) of the persons living with HIVpersons living with HIV

– 15 million15 million AIDS orphans by the end of 2006 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 IATT on PMTCT and Pediatric HIVPediatric HIV

• Initially focused on PMTCT; mission recently expanded Initially focused on PMTCT; mission recently expanded to explicitly include Pediatric HIVto explicitly include Pediatric HIV

• Broad membership including:Broad membership including:– UN (UNICEF, WHO, UNFPA, World Bank) UN (UNICEF, WHO, UNFPA, World Bank) – USG (CDC, PEPFAR, USAID-funded orgs., inlc. EGPAF, USG (CDC, PEPFAR, USAID-funded orgs., inlc. EGPAF,

Columbia, AED, etc.)Columbia, AED, etc.)– Foundations (Clinton Foundation)Foundations (Clinton Foundation)– Other Academic orgs, including Baylor CollegeOther Academic orgs, including Baylor College

IATT on PMTCT and IATT on PMTCT and Pediatric HIVPediatric HIV

• Key areas of focus:Key areas of focus:– Strategic approaches Strategic approaches – Advocacy and mobilisation of national and international partnersAdvocacy and mobilisation of national and international partners– Translating norms and standards into Programming Translating norms and standards into Programming – Monitoring and evaluation including harmonization of indicators and Monitoring and evaluation including harmonization of indicators and

annual report cardannual report card

• Joint Technical MissionsJoint Technical Missions– To assist with accelerating scale upTo assist with accelerating scale up– Countries with high MTCT burdenCountries with high MTCT burden– High paediatric infectionsHigh paediatric infections– Significant contribution to under 5 mortalitySignificant contribution to under 5 mortality– Government interest in scaling up PMTCT and Peds. Government interest in scaling up PMTCT and Peds.

Joint Technical Missions for Joint Technical Missions for Scaling up PMTCT and Scaling up PMTCT and

Pediatric HIVPediatric HIV• 20052005

– RwandaRwanda– Cote d’IvoireCote d’Ivoire– CameroonCameroon– MalawiMalawi

• 20062006– IndiaIndia– Burkina FasoBurkina Faso– ZambiaZambia– TanzaniaTanzania

• 20072007– BotswanaBotswana– LesothoLesotho– MyanmarMyanmar

• Planned 2007-2008Planned 2007-2008– SwazilandSwaziland– NigeriaNigeria– Uganda (?)Uganda (?)– Ethiopia (?)Ethiopia (?)– Kenya (?)Kenya (?)

Opportunities provided by Opportunities provided by Joint IATT missionsJoint IATT missions

• Broad representation of partnersBroad representation of partners• One voice regarding technical and programmatic One voice regarding technical and programmatic

recommendationsrecommendations• Partners jointly plan and commit to provision of TA, Partners jointly plan and commit to provision of TA,

resources and implementation support for follow upresources and implementation support for follow up• Partners respond based on comparative advantages (in Partners respond based on comparative advantages (in

country & regionally)country & regionally)

Government-owned Government-owned ProcessProcess

• Invitation from GovernmentInvitation from Government• TORs set by GovernmentTORs set by Government• Rapid situation or program assessment undertaken Rapid situation or program assessment undertaken • Planning Team organized by GovernmentPlanning Team organized by Government• Thematic discussions chaired by Govt.Thematic discussions chaired by Govt.• Scale up plan monitored and implemented by GovernmentScale up plan monitored and implemented by Government

JM: Thematic Areas usually JM: Thematic Areas usually examined examined

• Program ManagementProgram Management

• Comprehensive PMTCT (primary prevention, prevention of Comprehensive PMTCT (primary prevention, prevention of unintended pregnancies, prevention of MTCT, care and support of unintended pregnancies, prevention of MTCT, care and support of children, mothers, and families)children, mothers, and families)

• Infant FeedingInfant Feeding

• Paediatric Care and Treatment (optimizing identification, e.g. Paediatric Care and Treatment (optimizing identification, e.g. diagnosis, and scaling up treatment) diagnosis, and scaling up treatment)

• Monitoring and EvaluationMonitoring and Evaluation

• Procurement and Supplies ManagementProcurement and Supplies Management

Major areas for Major areas for recommendations (1)recommendations (1)

• Program ManagementProgram Management– Mechanism for National coordination of activities, Mechanism for National coordination of activities,

including those of partnersincluding those of partners– Focal Points for PMTCT and PediatricsFocal Points for PMTCT and Pediatrics– Decentralized implementation strategyDecentralized implementation strategy– Task Shifting or “Task Sharing” Task Shifting or “Task Sharing” – Training of existing health care workersTraining of existing health care workers

Major areas for Major areas for recommendations (2)recommendations (2)

• PMTCTPMTCT– How to decentralize service provision, & expand geographical How to decentralize service provision, & expand geographical

service coverageservice coverage– increase uptake of HIV testing and counseling in ANC settingsincrease uptake of HIV testing and counseling in ANC settings– Prioritisation of CD4 testing for pregnant women Prioritisation of CD4 testing for pregnant women – Introduce more efficacious regimens outlined in revised clinical Introduce more efficacious regimens outlined in revised clinical

guidelines (2006)guidelines (2006)– Develop program linkages for PMTCT & CH services, e.g. include Develop program linkages for PMTCT & CH services, e.g. include

HIV exposure status on child health card prior to mother’s HIV exposure status on child health card prior to mother’s discharge after deliverydischarge after delivery

– Increase coverage of maternal ARV, e.g. distribution of mother-Increase coverage of maternal ARV, e.g. distribution of mother-baby pack prior to delivery in case delivery takes place at homebaby pack prior to delivery in case delivery takes place at home

– Enhance primary prevention activities Enhance primary prevention activities

Major areas for Major areas for recommendations (3)recommendations (3)

• Pediatric HIV Care and TreatmentPediatric HIV Care and Treatment• Review treatment and care guidelines Review treatment and care guidelines • Reinforce family based HIV careReinforce family based HIV care

– HIV-Exposed infantsHIV-Exposed infants• Strengthen infant follow upStrengthen infant follow up• Introduce or pilot early virological HIV testing at 6 weeks wherever possible (including Introduce or pilot early virological HIV testing at 6 weeks wherever possible (including

using DBS)using DBS)• Introduce earlier antibody testing (9-12 months)Introduce earlier antibody testing (9-12 months)• Institutionalize Co-trimoxazole prophylaxisInstitutionalize Co-trimoxazole prophylaxis

– HIV-infected infantsHIV-infected infants

• Increase entry points for children ,e.g. through PITC of sick children and others of Increase entry points for children ,e.g. through PITC of sick children and others of unknown exposure status in certain settingsunknown exposure status in certain settings

• expand PCR capacity through DBS expand PCR capacity through DBS • Increase access to treatment through training of ART providers in pediatric HIV clinical Increase access to treatment through training of ART providers in pediatric HIV clinical

management. management.

Major areas for Major areas for recommendations (4)recommendations (4)

• Infant feedingInfant feeding– Promotion of EBF & reaffirm BFIPromotion of EBF & reaffirm BFI– Clarification of AFASSClarification of AFASS– Review tools and Training curricula of counselors Review tools and Training curricula of counselors

• M&EM&E– Harmonization of programme indicators across partners Harmonization of programme indicators across partners – Streamlining of data reporting systemsStreamlining of data reporting systems

• PSMPSM– Integration of Pediatric HIV supply into existing adult supply Integration of Pediatric HIV supply into existing adult supply

mechanismmechanism– Review all HIV commodities Review all HIV commodities

Mission Follow Up Mission Follow Up ActionsActions

RwandaRwanda •Development of integrated workplan for PMTCT and Peds.Development of integrated workplan for PMTCT and Peds.•Development of steering committee for children & HIVDevelopment of steering committee for children & HIV•Integration of services significantly improved by end of 2006: i) Integration of services significantly improved by end of 2006: i) 94% of VCT sites are also PMTCT; ii) 83% of ARV sites are also 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.PMTCT; iii) 89% of ARV sites also provide ART for children.•Ministerial instruction for testing of hospitalised childrenMinisterial instruction for testing of hospitalised children•PMTCT training modules updatedPMTCT training modules updatedNutritional support for HIV+ mothers in last trimester and first 6 Nutritional support for HIV+ mothers in last trimester and first 6 months after deliverymonths after delivery

MalawiMalawi •PMTCT coordinator moved from RH to HIV unit (locus for ART PMTCT coordinator moved from RH to HIV unit (locus for ART and VCT)and VCT)•IMCI revised to include paediatric HIV careIMCI revised to include paediatric HIV care•Generic PMTCT training package adapted for local useGeneric PMTCT training package adapted for local use•Community IMCI programme adapted to optimize ID of childrenCommunity IMCI programme adapted to optimize ID of children

Mission Follow Up Mission Follow Up ActionsActions

IndiaIndia • Early diagnosis for children incorporated into national HIV Early diagnosis for children incorporated into national HIV planplan• Paediatric HIV package of care defined by Indian Institute of Paediatric HIV package of care defined by Indian Institute of Paediatrics after request by GovernmentPaediatrics after request by Government• Nutritional support package for HIV-infected children being Nutritional support package for HIV-infected children being revamped.revamped.•Paeditric ARV dosing and formulary establishedPaeditric ARV dosing and formulary established

ZambiaZambia • National PMTCT and paediatric guidelines revised and National PMTCT and paediatric guidelines revised and disseminateddisseminated• U5 card revised to include exposure status and prompt for U5 card revised to include exposure status and prompt for early diagnosis and initiation of co-trimoxazole prophylaxisearly diagnosis and initiation of co-trimoxazole prophylaxis• PMTCT and paediatric M&E indicators revised and rolled PMTCT and paediatric M&E indicators revised and rolled outout

Mission Follow Up Mission Follow Up ActionsActions

Burkina FasoBurkina Faso • Focal points for PMTCT and Paediatrics placed in MOHFocal points for PMTCT and Paediatrics placed in MOH• Collaboration developed with Clinton Foundation to Collaboration developed with Clinton Foundation to expand access to paediatric HIV care and treatmentexpand access to paediatric HIV care and treatment

TanzaniaTanzania • National PMTCT and paediatric M&E indicators finalized National PMTCT and paediatric M&E indicators finalized • New National strategic plan on HIV will include children New National strategic plan on HIV will include children

LesothoLesotho • Policy developed to expand PITC for all children in the Policy developed to expand PITC for all children in the country being seen at U5 clinicscountry being seen at U5 clinics

All CountriesAll Countries • Received UNITAID funding for PMTCT scale up and Received UNITAID funding for PMTCT scale up and introduction of more efficacious regimensintroduction of more efficacious regimens• Received funding for other PMTCT/Peds activities from Received funding for other PMTCT/Peds activities from HQ.HQ.•Ongoing TA and review of policy and related documentsOngoing TA and review of policy and related documents

Other IATT achievements & Other IATT achievements & products products

• Global strategy Global strategy • Report cardReport card• Draft indicator registry and Draft indicator registry and

programming toolprogramming tool• Draft programming guide on scaling up Draft programming guide on scaling up

paediatric care and treatment paediatric care and treatment • Scale planning guide Scale planning guide • Regional workshops on scale up Regional workshops on scale up

planning planning

GPF Follow up

Integrate Guidance on Paediatric Treatment and Care into

Child and Maternal Health• Revised WHO guidelines available (2006)Revised WHO guidelines available (2006)

– ARV Treatment, including stagingARV Treatment, including staging– Infant diagnosis guidelines (PMTCT f/u and PITC)Infant diagnosis guidelines (PMTCT f/u and PITC)– Co-trimoxazole guidelinesCo-trimoxazole guidelines– Complementary IMCI Complementary IMCI – Ped care integrated into adult tools (IMAI)Ped care integrated into adult tools (IMAI)

• Promtion of keeping information regarding HIV exposure on child health cardsPromtion of keeping information regarding HIV exposure on child health cards

• Expansion of co-trimoxazole use for exposed infants by incorporation into national Expansion of co-trimoxazole use for exposed infants by incorporation into national guidelinesguidelines

• HIV expanded course on IMCI (field tested in Zambia, Uganda, Nigeria and HIV expanded course on IMCI (field tested in Zambia, Uganda, Nigeria and subsequently revised)subsequently revised)

• Paeditrid HIV and PMTCT integarted inot adult HIV care approaches (IMAI)Paeditrid HIV and PMTCT integarted inot adult HIV care approaches (IMAI)

Integrate the Distribution of Free Co-trimoxazole to Eligible Children into Health Services

• Advocacy for provision of free co-trimoxazole in national plans and Advocacy for provision of free co-trimoxazole in national plans and guidelinesguidelines

• Inclusion of co-trimoxazole in UNITAID funding for both Inclusion of co-trimoxazole in UNITAID funding for both UNICEF/WHO and Clinton FoundationUNICEF/WHO and Clinton Foundation

• Recommend addition of prompt on child health cards for HIV-Recommend addition of prompt on child health cards for HIV-exposed infantsexposed infants

Scale up PMTCT Plus

• Advocacy for training for decentralized approach and Advocacy for training for decentralized approach and increased geographical coverageincreased geographical coverage

• Introduction of routine HIV screening in ANC settingsIntroduction of routine HIV screening in ANC settings

• Focus on all four prongs during JMsFocus on all four prongs during JMs

• Look for increased linkages/integration to care and Look for increased linkages/integration to care and treatment, for mothers, children, families to ANC services.treatment, for mothers, children, families to ANC services.

Scale up Prevention for Young People

• Increased focus on prongs 1 and 2 Increased focus on prongs 1 and 2 during joint missionsduring joint missions

• Technical lead by UNFPA Technical lead by UNFPA • Activities coordinated through IATT Activities coordinated through IATT

on YPon YP

Pediatric ART Formulations and Diagnostic Availability

• Guidance on appropriate pediatric formulations being developed Guidance on appropriate pediatric formulations being developed through WHO leadershipthrough WHO leadership

• Development of pediatric formulations by generic manufacturers (e.g. Development of pediatric formulations by generic manufacturers (e.g. CIPLA, Ranbaxy)CIPLA, Ranbaxy)

• Support for bulk purchase of ARTs and diagnostics trough UNITAIDSupport for bulk purchase of ARTs and diagnostics trough UNITAID• Public Private Partnership – addressing bottlenecks in formulations, Public Private Partnership – addressing bottlenecks in formulations,

supply management, in-country registration, education & trainingsupply management, in-country registration, education & training• Expanded training in Pediatric HIV clinical management (e.g. through Expanded training in Pediatric HIV clinical management (e.g. through

Baylor)Baylor)• Expanded training and capacity building in DBS (Clinton Foundation, Expanded training and capacity building in DBS (Clinton Foundation,

EGPAF, Columbia, etc.)EGPAF, Columbia, etc.)

• Results:Results: Significant increase in numbers on treatment. Significant increase in numbers on treatment.

PMTCT Access Increasing but PMTCT Access Increasing but Lowest in Regions with Lowest in Regions with

Greatest NeedGreatest Need

1.6%

9.5% 7.5%

21.6%

91.5%

2.3%

10.3%13.9%

23.6%

85.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

West andCentral Africa

C. and SAmerica

East and SouthAfrica

East Asia andPacific

C & EasternEurope

% o

f all

HIV

+ p

regn

ant w

omen

rec

eivi

ng A

RV

pr

ophy

laxi

s

2004 2005

Source: UNICEF PMTCT and Pediatric Care Report Card 2006

PMTCT AccessPMTCT Access

• Scores expected to be higher for Scores expected to be higher for next report card as a result of next report card as a result of increasing commitment and increasing commitment and involvement, but still below needed involvement, but still below needed levels to reach UNGASS targets in levels to reach UNGASS targets in 2010.2010.

ConclusionsConclusions

• IATT has been an effective forum in IATT has been an effective forum in strengthening and consolidating the strengthening and consolidating the global response to PMTCT and global response to PMTCT and Pediatric HIV Care and TreatmentPediatric HIV Care and Treatment

• Joint Technical Missions have been Joint Technical Missions have been instrumental in changing landscape instrumental in changing landscape in countries so far with introduction in countries so far with introduction of new policies, capacity building, of new policies, capacity building, and new resourcesand new resources