Presented by: Katie Sindelar, Clinton Health Access Initiative Government of Lesotho An Assessment of the Effectiveness of Reaching Undiagnosed HIV+ Children through Community-Based Testing in Lesotho Presented by: Katie Sindelar, Clinton Health Access Initiative Authors: Katie Sindelar, Clinton Health Access Initiative - Lesotho Jessica Joseph, Clinton Health Access Initiative - Applied Analytics It is a pleasure to be here on behalf of my co-author and my entire time in Lesotho to share our findings on the effectiveness of reaching undiagnosed HIV+ children through community based testing in Lesotho.

Disclosure I have no conflicts of interest with the research I am presenting.

Background: Context of HIV in Lesotho The Country Lesotho is a small, landlocked country in Southern Africa Population: 2.5 million Highly transient population (~20% reside in South Africa) Mountainous and difficult terrain On ART: 105,635 ART Coverage: 35% Male Life Expectancy: 52 Female Life Expectancy: 55 Adults: 15+ years (2014) HIV in Lesotho 2nd highest prevalence globally: 23% Incidence rate: 1.76 Provider-Initiated Testing and Counseling began in 2014 Free ART services at all public facilities Test and Treat introduced in 2016 Children: 0 – 14 years (2014) Lesotho is…. Prior to project commencement in 2014, data showed significant gaps in the prevention of mother to child transmission and early infant diagnosis programs Results in only 20% ART coverage of children 0 – 14 years old. Prevalence: 2.8% On ART: 5,687 ART Coverage: 30%

Project Overview: Mobilizing HIV Identification & Treatment (M-HIT) The Problem Significant gaps were found in the continuum of care for children with no consistent alternatives to facility HIV testing and counseling (HTC) Community-based HTC was identified as a solution in filling these gaps Project Overview The M-HIT project commenced in October 2015 and will end in March 2018 Operating in 2 of the 10 districts with the highest HIV prevalence and unmet HTC needs Project Objectives Utilize community-based testing strategies to rapidly identify undiagnosed or lost: HIV-Exposed Infants HIV+ Children, 0 – 14 years HIV+ Pregnant Women HIV+ Breastfeeding Women Support linkage to care from community HTC to initiation on ART in the facility or an outreach clinic 1 Due to the absence of significant hiv-testing and counseling, or HTC, outside of the facility, community based HTC was identified as a solution in reaching more people with these services. 2

Project Overview: Community Testing Strategies The project identified the following 6 testing strategies specifically to target children: Targeted Testing Community Testing Mobile Outreach Clinic (MOC) Full range of health services brought to rural communities on a monthly basis with a focus on HTC and mother and child care services Provision of HTC services at venues with children who have been identified as high-risk of HIV infection (e.g. orphanage) A tent is erected in a high-traffic pedestrian location to provide HTC to anyone interested (e.g. bus station) Counselors request consent from ART patients during routine facility refill visits to provide home-based HTC for all household members During door-to-door testing, if someone identifies as HIV+ their household members are indexed and tested Door-to-Door Index (D2D) Index Testing During facility-index testing, surrounding households are approached for HTC services to conceal the targeted approach Door-to-Door (D2D) Testing Facility Index Testing

Project Overview: Data Collection The following data was collected for all newly identified or lost HIV+ children: Patient Demographics Age Gender Residence Testing Event Date Strategy Location Mother’s ART Status *If accompanied by Mother Facility Attendance History Date of last visit Reason for visit Testing History Previous test date Testing Method (DBS/Rapid Test) A mobile application was designed for project staff to capture real-time patient data at point-of-care just after a positive test has been received. Data was collected from December 2015 to April 2017.

Outcome: 47,823 children were tested, with a 0.43% positivity yield Facility Index Testing Overall Results 47,823 children tested 206 tested positive 0.43% positivity yield 152 were enrolled in the app Facility Yield Facility yields were only slightly higher at 0.85% in the same districts between January 2016 and March 2017 MOCs account for 48% of all identifications Yields were highest in both index testing strategies Targeted strategies did not result in higher yields Although yields were considerable lower than anticipated, we see that facility yields were also under 1% around the same time, at 0.85%.

HIV+ Identifications by Age Category & Strategy Outcome: The majority of children identified were between 5 and 14 years - 60.2% HIV+ Identifications by Age Category & Strategy 55 37 35 25 MOCs were effective at identifying children of all ages Unexpected given MOCs only operate during school hours D2D testing strategies were successful at finding older children, 5 – 14 years Overall identifications were 48.7% female to 51.3% male Near even ratios among all age groups

Outcome: Community-based HTC is effective at finding HIV+ children who had never been tested before Overall Previous Testing History -Immediately we can see that community-based testing was effective at finding children who had never been tested before, at 70% of the overall children identified. -We also see Dried blood spot…. -When we break this down by age, it is apparent that testing history decreases as age increases. -Only 24% of children 0 – 1 had no testing history, showing that older children are much more overlook for HTC services than younger children. Testing coverage decreases as age increased More children <5 had been tested with a dried blood spot (DBS), than children >5 with a rapid test Suggests older children are more frequently overlooked for HTC than younger children Lack of DBS testing history among older children shows that positive children were not successfully reached with HTC when young

Outcome: Many children are not routinely accessing services at facilities, demonstrating the need to expand HTC to the community level Facility Attendance History by Age Category* 9 4 4 *These findings only include the 49% of children identified with known facility visit history Only 49% of children identified positive had known facility attendance history… Only 49% of children had known facility attendance history 36% of children had not been to a facility in over a year All children <1 had been to a facility Children 2 – 5 years have low facility visit history considering the growth monitoring they should be receiving

Outcome: Linkage and retention can still be effective from community testing (87.2%) retention in care at 3 months amongst all children who initiated on ART. *Results only include children who were enrolled in the program 3 months prior to April 20, 2017 Linkage to care support included optional counselor accompaniment to the facility for all strategies except MOCs Retention in care was highest for children 2 – 5 years old, followed closely by 10 – 14 year olds Retention was lowest among children 0 – 1 years

Lessons Learned Community-based HTC is effective at reaching hard to find HIV+ children and will be an essential strategy in achieving UNAIDS target of 90% of people knowing their status. Community-based testing was effective at finding: Children with no testing history (70%) Children over 5 years old (60%) Children >5 are much more frequently overlooked for HTC than children <5 years. Community-based HTC does not pose a significant barrier in linkage to care and has proven to have high retention rates at 3 months (87.2%).

Please email with any questions or comments: Thank you! Thank you to my coauthor Jessica Joseph and the Clinton Health Access Initiative team in Lesotho, especially the Pediatric HIV team for their dedication in this project. I would also like to thank the implementing partners: Lesotho’s Ministry of Health Vodafone Foundation Baylor College of Medicine Children’s Foundation Lesotho Population Services International Lesotho Riders for Health Lesotho This project was made possible through a consortium of funders: U.S. Agency for International Development (USAID), Vodafone Foundation, the ELMA Foundation, Elton John AIDS Foundation, Viiv Healthcare and the Government of Lesotho. Please email with any questions or comments: ksindelar@clintonhealthaccess.org