INVESTING IN COMMUNITY SYSTEMS TO SUPPORT LIFELONG ART INITIATED IN MATERNAL & CHILD HEALTH SETTINGS Dr. Chewe Luo MD, PhD, FRCP UNICEF PROGRAM DIVISION NEW YORK ICASA, HARARE 29th November 2015

Source: UNAIDS/UNICEF/WHO Global AIDS Response Progress Reporting and UNAIDS 2014 HIV and AIDS estimates, July Note: data unavailable for Central and Eastern Europe and the Commonwealth of Independent States. GLOBAL PLAN TARGET (90%) We have made tremendous progress

3 in 5 pregnant and breastfeeding women living with HIV received ARV medicines to prevent mother-to-child transmission of HIV. We are closer than ever to the elimination of new HIV infections among children. Source: UNAIDS/UNICEF/WHO Global AIDS Response Progress Reporting and UNAIDS 2014 HIV and AIDS estimates, July 2015.

2015 Update of HIV and AIDS Data Source: UNAIDS 2014 HIV and AIDS estimates, July Note: Tanzania is still reviewing the fertility assumption in their estimates. Therefore, values for Tanzania should be considered provisional.

Source: UNAIDS/UNICEF/WHO Global AIDS Response Progress Reporting and UNAIDS 2014 HIV and AIDS estimates, July 2015.

Slide Credit: Andreas Jahn MD PhD, Frank Chimbwandira MD. WHO 2015 ARV Guidelines Clinical Guideline Development Group. June 2015 Malawi’s Marked Increase in PMTCT Uptake with Option B+

WHERE ARE WE WITH ROLL OUT OF OPTION B+ ?

Option B+ Guideline Status by November 2015 Among Global Plan 22 Priority Countries

Source: UNICEF analysis of UNAIDS 2014 HIV and AIDS estimates, July Distribution of the number of pregnant women living with HIV receiving most effective antiretroviral medicines for PMTCT by regimen, 21 sub-Saharan African Global Plan countries,

Source: UNICEF analysis of UNAIDS 2014 HIV and AIDS estimates, July Estimated percentage of infants born to pregnant women living with HIV who are vertically infected with HIV (mother- to-child transmission rate), sub-Saharan Africa,

Source: UNICEF analysis of UNAIDS 2014 HIV and AIDS estimates, July Distribution of estimated number of new HIV infections among children (aged 0-14) by timing of infection, sub- Saharan Africa, 2000 vs Perinatal Infections (within 6 weeks of birth) Postnatal Infections (beyond 6 weeks of birth)

RETENTION THE LAST HURDLE FOR ELIMINATING NEW CHILD INFECTIONS

Long term retention in Malawi

15 What we know about drop out? Mostly to lost-to-follow-up (LTF), not death or transfer 17% of women newly initiating Option B+ were LTF at 6 mos Mothers initiated on life long ART in pregnancy were 5X more likely to be LTF and were unlikely to return after their 1st visit, compared to those initiated for their own health (OR 5.0, 95% CI 4.2–6.1) Pregnant women who started ART on the same day as the HIV diagnosis are 2-times more likely not to return, compared to those who started later (OR 2.2, 95%CI 1.8–2.8). Facilities that offered additional adherence counselling had lower LTF

Slide Credit: Lyson Tenthani and Andreas Haas et al. Retention of HIV+ pregnant and breastfeeding women on universal antiretroviral therapy (Option B+) in Malawi Malawi: Cumulative incidence of loss to follow-up Retention in care in different populations in Malawi

Slide Credit: Fatima Tsiouris. Optimizing HIV Treatment Access (OHTA) for Pregnant and Breastfeeding Women Initiative Multi-Country Workshop Meeting Nov Uganda – 3 month retention cohort 28% of loss-to-follow-up occurs after Option B+ initiation in Uganda

Pregnant women have worse retention than non-pregnant women in the same age group, and young pregnant women have the worst retention *Among patients enrolling April 2008-March Loss to follow-up is defined as patients not known to have died or transferred without a visit in the last year of data collection (pre-ART) or the last 6 months of data collection (ART). Patients LTF are censored 3 months after their last visit (pre-ART) or 15 days after their last visit (ART). Matt Lamb 2011 Young pregnant women yrs Pregnant women yrs

LINKAGES TO ENHANCE COMMUNITY- FACILITY ACCESS & RETENTION ENHANCED

Strategies should address persistent bottlenecks along the continuum of care for women and children Cultural, social & gender barriers Confidentiality, privacy, disclosure Inadequate support Poor knowledge of PMTCT Perceived or actual poor quality of clinical care Limited human resources Lack of tracking and follow up Long distances and transport constraints Food insecurity & poverty

Conceptual framework to guide programming based on identification of 11 promising practices

HOW DO WE ENHANCE COMMUNITY SYSTEMS TO SUPPORT PMTCT? Better and earlier monitoring of retention in care, including in the post natal period Better monitoring and assess costs of community actions to ascertain effectiveness Define core elements of community-facility linkage actions for HIV as part of national community health policies and guidelines Contribute to national community health / social welfare and protection systems investments for HIV results

OBJECTIVES OF THE FORUM Highlights from and conversation with early adopters