National and Global Monitoring of HIV Exposed, Uninfected Children Mary Mahy, ScD UNAIDS, Geneva

Monitoring vs surveillance vs studies Studies: to answer evaluation questions Surveillance: for early warning for potential outbreaks Monitoring systems: once the intervention is understood. And targets can be set

Questions for a monitoring system? What is the size of the population? What are the inputs to the interventions? What are the outcomes of children that are HIV exposed uninfected? Are the interventions effective? Set targets Potential sources of data

Population size estimates of HEU Fundamental for any monitoring or surveillance are “size estimates” How many children are HEU Provides baseline information and denominators Ideally disaggregated by ART exposure status, age, and sex Rough calculations – more refined calculation potentially in future Spectrum model

Estimated number of children (<15) who were HIV exposed and ART exposed AEU – HIV- and ART-exposed uninfected HEU – HIV-exposed uninfected CLHIV – children living with HIV UNAIDS 2017 estimates

Annual number of infants (<1) who are HIV exposed and ART exposed AEU – HIV- and ART-exposed uninfected HEU – HIV-exposed uninfected CLHIV – children living with HIV UNAIDS 2017 estimates

What indicators? Inputs Outcomes What interventions can change the outcomes? Outcomes Categorized by mom’s HIV status and ART status at delivery ART regimen ? Mortality Stunting and wasting Prevalence of acute respiratory infections Prevalence of other morbidity Neurological outcomes ? Birth weight Preterm birth

Existing indicators Use well tested, existing indicators What indicators maximize the ability for countries to understand potential changes in child survival or development Include in existing reporting systems Add additional variable Use for surveillance aspects

Evaluation Are we doing the right intervention in the right place at the right level of effort? Are interventions having an impact? for example, mortality among HEU is equivalent to similar counterparts Are the interventions efficient? Not at this point yet in programme development

Targets Not yet clear what these would be Implementation plans need to be set first All women living with HIV should have the right to be well informed of risks

Data Sources Health information systems Population based surveys Routine data from health systems Includes data compiled from child health visits or immunization clinics Requires that the child is in contact with the health system Requires a link to the mom’s HIV test results and ART regimen Population based surveys Cross sectional, Not clear if mom was HIV+ at delivery (or conception)?

Challenges Capturing mom’s HIV status on patient monitoring cards or systems Confidentiality of mom’s HIV status Controlling for socio-economic status, caretaking behaviour, infant feeding patterns, regimen exposure, or other confounding variables for outcomes Need a control group as mortality and other child well-being measures change over time

Way forward First, identify the “mechanism” for the poor outcomes, identify interventions, decide on action plan Then, Improve size estimates (models) Decide on a few critical (existing) indicators that measure outcomes Approach managers of data systems to test integration of HIV exposure into system Add measures of inputs once interventions are clear Integrate into child survival measures Focus on countries heavily affected by HIV