Scaling-up Access to Paediatric ART in India Dr. B B Rewari National AIDS Control Organisation India XVII International AIDS Conference Mexico City, 7 th August 2008

Paediatric HIV in India Estimated 2.5 million persons living with HIV infection in India (0.36% prevalence) Estimated 2.5 million persons living with HIV infection in India (0.36% prevalence) Of these, the number of children estimated to be HIV infected in India is 100,000 (4%) Of these, the number of children estimated to be HIV infected in India is 100,000 (4%) Number of children estimated requiring ART services is 40,000 Number of children estimated requiring ART services is 40,000

National ART programme in India Started April 2004 at 8 centers– now 176 centres Started April 2004 at 8 centers– now 176 centres Adult first line ART fixed dose combination (FDC) Adult first line ART fixed dose combination (FDC) Children were treated in limited numbers Children were treated in limited numbers By Oct 2006, 43,744 persons on ART in India By Oct 2006, 43,744 persons on ART in India Only 1,800 children on ART Only 1,800 children on ART

National Paediatric HIV/AIDS Initiative: public health approach, 2006 Scale-up with simplified standardized tools and training Scale-up with simplified standardized tools and training National paediatric ART guidelines established National paediatric ART guidelines established Simplified weight-based dosing schedules Simplified weight-based dosing schedules Procurement of paediatric FDCs for first line ART Procurement of paediatric FDCs for first line ART Training for paediatricians and ART centre staff Training for paediatricians and ART centre staff

National Paediatric HIV/AIDS Initiative: forging partnerships Partnerships with international and national agencies Partnerships with international and national agencies Indian Academy of Paediatrics Indian Academy of Paediatrics UNICEF UNICEF WHO WHO Clinton Foundation Clinton Foundation Engagement with national and regional NGO, CBO, FBOs and positive networks Engagement with national and regional NGO, CBO, FBOs and positive networks

Constraints identified and solutions that worked CONSTRAINTSSOLUTIONS Pediatric specific dosing not available  Pediatric FDCs (DT) were procured as per weight band  Logistics and forecasting plan worked out. Medical Officers not confident of handling pediatric HIV  The dosing were simplified using weight bands.  A dosing disk was used to calculate dosing (tools)  Pediatric HIV Guidelines published and widely circulated  Sensitization of pediatricians in the private sector through IAP 6

3. Reaching Children in need of ART  Mass campaign approach adopted as a short term measure  Civil Societies involved to generate community awareness  Screening, Testing and referral- all services under one roof  CD4 referral mechanism used  Human resource deployed specially for the purpose 4. Adherence to ART  Counseling to mothers / care givers  PLHA networks to trace lost to follow up child  NGO civil societies roped in 5. Travel & accommodation constraints  Travel subsidy given by some states – railway subsidies  Community Care Centers to provide temporary stay while initiating on ART 7

Reaching out to children in need Over 380 camps done ~17,000 children screened medically 7,000 found HIV positive ~ 3,000 required ART Mass awareness campaigns approach used to screen diagnose and link HIV-infected children to ART services

Launch of National Pediatric HIV/AIDS Initiative November 2006; 9

Scaling up Access to Pediatric ART: Bringing treatment to children, 2004 – 2008 Paediatric AIDS Initiative Source: Monthly ART Centre reports, NACO 2008 BeforeAfter ART

Distribution of paediatric ART patients in India by gender, Percent Year Source: Computerized HIV patient database, NACO (25,394 records)

Paediatric ART patients in India by age group, Percent Year Source: Computerized HIV patient database, NACO (25,394 records)

Paediatric ART services, May 2008 Source: Monthly ART Centre reports, NACO 2008

Lessons learned Mass campaigns played a key role in the initial expansion of paediatric HIV treatment services Mass campaigns played a key role in the initial expansion of paediatric HIV treatment services Generated public and provider awareness of treatment Generated public and provider awareness of treatment Focused on most at risk children – diagnose and link them to care and treatment Focused on most at risk children – diagnose and link them to care and treatment Availability of paediatric FDC was key to simplifying delivery of ARV to children Availability of paediatric FDC was key to simplifying delivery of ARV to children Training of paediatricians and ART centre staff in core competencies of services for HIV infected children is essential Training of paediatricians and ART centre staff in core competencies of services for HIV infected children is essential

Next steps Continued expansion of paediatric HIV treatment services including establishing regional Pediatric HIV Centers of Excellence and addressing issues in HIV early infant diagnosis Continued expansion of paediatric HIV treatment services including establishing regional Pediatric HIV Centers of Excellence and addressing issues in HIV early infant diagnosis Comprehensive care & support both for infected and affected children: Comprehensive care & support both for infected and affected children: Nutritional Counseling & supplementation Nutritional Counseling & supplementation Care, support & psychosocial issue Care, support & psychosocial issue AZT based regimen for children AZT based regimen for children Second line ART for children Second line ART for children Care of affected children Care of affected children Develop longer term strategies to improve access to care and integrate HIV into general child health services Develop longer term strategies to improve access to care and integrate HIV into general child health services Integrated Management of Neonatal and Childhood Illness including HIV (IMNCI-HIV) Integrated Management of Neonatal and Childhood Illness including HIV (IMNCI-HIV) Improve access for orphans and children not linked to CBOs or NGOs Improve access for orphans and children not linked to CBOs or NGOs

Tools Board Games Treatment Guidelines Dosing Tools Paediatric ART Adherence Tools Paediatric ART Counselling Training

A childhood free of HIV 17

Acknowledgments We thank the children and their caregivers, development partners, partner NGO,CBO,FBO, positive networks.