ACT 2014/5 -2016/7 Dr Laura Oyiengo MD. M.Med Pediatrics and Child Health Program Manager Pediatric HIV Care and Treatment NASCOP.

OUTLINE HIV snapshot of Kenya 90-90-90 KASF Challenges along the continuum of Pediatric HIV care ACT

HIV Burden in Kenya

90-90-90 To drive global & national level action on pediatric HIV treatment, UNAIDS with EGPAF, WHO, UNICEF, and other partners – launched new treatment targets specifically for children that were designed to:- Encourage increased HIV diagnosis and initiation of pediatric ART Address challenges around adherence and retention that affect long-term health outcomes as children move from infancy, through childhood and adolescence, and into adulthood. The “90-90-90” targets aim to have :- 90% of all children living with HIV diagnosed, 90% of those diagnosed HIV-positive receiving treatment, and 90% of those children receiving treatment achieve viral suppression by 2020.

Kenya AIDs Strategic Framework 2014/15-2018/19 The Vision A Kenya free of HIV new HIV infection, stigma and AIDS related deaths Reduce new infections by 75% Reduce AIDS related mortality by 25% Reduce HIV related stigma and discrimination by 50% Increase domestic financing of the HIV response to 50% Contribute to achieving Vision 2030 through universal access to comprehensive HIV Prevention, Care and Treatment Priority Interventions and Recommended Actions; SD 1 - 8 . The Goal Objectives

KASF Strategic Direction 2: Targeting the 90-90-90 Linkages to care and treatment Access to ART Retention , adherence Treatment outcomes : Viral suppression Identification and diagnosis 90% of HIV infected persons are identified HIV testing and linkage 90% on Antiretroviral therapy Care and ART 90% of those on ART achieve viral suppression retention , adherence , viral measurement

The new Kenya AIDS Strategic Framework sets a clear targets to accelerate treatment and care for children exposed to and living with HIV in a system where health has been devolved. Accessing antiretroviral therapy (ART) is a matter of life and death for HIV-infected children.

UNAIDS AND KASF 90–90–90 90% 90% Tested 90% ART Viral suppression BY THE YEAR 2020

WHAT DOES 90-90-90 MEAN FOR A CHILD 90% of all children living with HIV are diagnosed HIV risk identified Taken for HIV test by caretaker Gets blood drawn Caretaker learns test results 90% of all children diagnosed HIV-positive are receiving treatment Gets referred for care Is taken to clinic for care Caretaker learns how to manage HIV in child Receives and starts ART 90% of all children receiving treatment are achieving viral load suppression Is given ART as prescribed (lifelong) Is brought to clinic regularly for: - Adherence support, Clinic/lab evaluation, Medication refills & other health care services When appropriate, learns about HIV-positive status; begins managing own care Transitions to adult care

CHALLENGES ATTAINING EACH 90 IN CHILDREN IDENTIFICATION CHALLENGES Unknown HIV status in parents means unknown risk of HIV transmission to children Low uptake of antenatal and postnatal care services means that children of HIV-positive adults may remain unidentified Stigma prevents caretakers from having children tested for HIV. (CATCH - 87% CCC parents did not complete testing for their children) Given continued risk of HIV transmission throughout the breastfeeding period, repeat testing of mothers and children is needed to confirm final HIV diagnosis after risk period is over Long turnaround times for DNA PCR test results mean that some children do not receive their test results and remain unidentified HCW often lack adequate training and confidence for gaining parental consent and administering HIV tests for children HIV testing is not routinely offered for children of HIV-positive adults or those visiting health facilities.

IDENTIFICATION IN KENYA This involves testing of the child either EID or PITC. KAIS 2012 report:- Among known HIV positive women, only one third had taken their children for HIV testing. More than half of all children who had an infected parent, had never been tested for HIV. 60% of HIV-positive children undiagnosed. Our testing coverage for 2014 is 82,713 For every 16 children newly infected with HIV in Africa, 1 child is from Kenya.

EID at a Glance INDICATOR 2012 2013 2014 EID TESTING COVERAGE 64% 71% 56% AVERAGE AGE AT TESTING (MONTHS) 2 3

Missed Opportunites Without timely testing & treatment initiation of HEI 15% die by 2months, 50% will die by their 2nd birthday and 80% by their 5th birthday.

TREATMENT CHALLENGES HIV-related stigma and discrimination prevent caretakers from seeking out ART for children. Higher viral loads in children and more rapid disease progression than adults leaves a short window of opportunity to initiate ART before sickness and death Delayed test results for HIV-infected children lead to significant loss-to-follow-up (LTFU) and poor enrollment in care and initiation on ART Providers lack the skills and confidence to initiate pediatric ART and manage complex dosing and care. Lack of pediatric FDCs. Lack of integration of HIV services for children within care services

ART FOR CHILDREN IN KENYA? Currently we have 69,627 children on ARVs. Compare this against 736,469 adults on treatment.

ART Pediatric Patients

ART Adult Patients

UNICEF conducted a 3-country assessment to examine median age at ART initiation Tanzania: 487 records reviewed Median age at ART initiation: 4.2 years Proportion of children <2 years was 33.1% Zimbabwe: 552 records reviewed Median age at ART initiation: 7 years Proportion of children <2 years was 15.2% Swaziland: 1246 records reviewed from 2010 Median age at ART initiation: 4.9 years Proportion of children <2 years in 2010 was 34.8%

KENYA NATIONAL SURVEYS SHOW MOSTHIV INFECTED CHILDREN ARE INITIATED ON ART AFTER THE AGE OF 2 YEARS.

Already with the current guidelines we are lagging behind with initiating children on treatment, ...and yet there is this palpable push to conduct birth testing and start HIV infected newborns on ARVs. This interest was galvanized by the “Mississippi baby” that showed sustained viral suppression in a neonate initiated on ARV.[1] (The mother defaulted with clinic appointments and when she returned the baby was found to have undetectable viral load despite not being on ART for 5months) (""Mississippi Baby" Now Has Detectable HIV, Researchers Find". NIH. Retrieved 20 August 2014 The Mississippi baby (born 2010) is a Mississippi girl who in 2013 was thought to have been cured of HIV. She had contracted HIV at birth from her HIV-positive mother. Thirty hours after the baby was born, she was treated with intense antiretroviral therapy. When the baby was about 18 months old, the mother did not bring the child in for scheduled examinations for the next five months. When the mother returned with the child, doctors expected to find high levels of HIV, but instead the HIV levels were undetectable. The Mississippi baby was thought to be the only other person, after the "Berlin patient," to have been cured of HIV. As a result, the National Institutes of Health planned to conduct a worldwide study on aggressive antiretroviral treatment of newborn infants of mothers with HIV infections. It was thought that aggressive antiretroviral therapy on newborn infants might be a cure for HIV. On July 10, 2014, however, it was reported that the child was found to be infected with HIV.[1]

CHALLENGES ON VIRAL SUPPRESSION Low rates of long-term, consistent adherence and retention on ART due to dependence on adults for care, lack of HIV status disclosure to child, and stigma. Limited number of child-friendly ARV formulations; existing formulations are difficult to administer, may have a poor taste, heavy pill burden, or require refrigeration. Limited continuous education and support for parents/caregivers in managing lifelong treatment for HIV-positive children. Limited experience with 2nd/3rd line pediatric ARV provision characterized by delays in switching from failing regimens Lack of health care worker training and comfort in monitoring and managing ART in children. Fear and lack of expertise among HCW and parents/caregivers in disclosing HIV status to children. Lack of expertise and training in managing child’s transition to adolescence and addressing the psychosocial, reproductive and sexual health needs during this transition and into adult care.

VIRAL SUPPRESSION IN CHILDREN Viral load monitoring is not routinely offered to children on treatment. Our data reveals that 48169 children are virally suppressed in this country. County data is more revealing. Pediatric ART progress by County.xlsx

Retention to care at 12 months by age category – EMR sites Outcome 0-4 years 5-9 years 10-14 years 15-24 years Active 813 1293 466 1528   (70.33) (75.04) (82.77) (67.76) Died 93 74 32 59 (8.04) (4.29) (5.68) (2.62) LTFU 232 345 65 659  % (20.07 (20.02) (11.55) (29.22) Stopped ARVs 18 11 9 (1.56) (0.64) (0) (0.4) Total 1,156 1,723 563 2,255 100

Kenya - Progress towards 90/90/90 among children* “THE LEAKY CASCADE” *Based on 2014 targets.

We need focused Acceleration.

Over the past 10 years, we have only managed to have 40% children on treatment, yet we are expecting to scale up to 90% coverage over the next 4years. Children (and adolescents) have to be brought to the fore and the challenges specific to this age groups addressed in a manner that would take into account the leaks affecting their cascade. The National program has developed a roadmap for the ACT. This roadmap has 7 thematic strategies that would in-cooperate systems and services necessary to “close the taps and mop up missed opportunities”.

WORK PLAN Leadership/ governance Service delivery Commodity security Health financing Human resource Communication strategy Information mgt &Research

ACT Road Map County Engagement and Planning Development county specific plans What specific actions will be carried out to accelerate achievement of targets along the cascade of care Specific county targets with clear milestones Facility level targets and plans : related to quality improvement at site level Facilities are able to generate their own cascades, identify gaps and implement actions to address the gaps

Road Map County coordination Set up /convene county technical working groups: MOH, other county Government departments Oversight on implementation Performance monitoring Continuous performance reviews

Actions : County Engagements Timelines MOH HQ –County Governance Dialogue for ownership and accountability March –April Technical county interactions: Review of data and gaps Planning Performance reviews From April 2015

Nationally Coordination/ secretariat team County support teams Development of a dashboard with key indicators for county performance monitoring Quarterly national performance reviews

TO MAKE ACT WORK Counties and partners Be accountable for results Be responsible for performance Sub-county engage with facilities & through data analysis , inform decision made. Every service provider to take the initiative to provide PITC services to each child they encounter in the facility and familiarise themselves with Paediatric HIV services. Each parent/caregiver to confirm the HIV status of the child under their care and support the HIV infected child.

EXPECTATION We only have one expectation – that we finally address the headache that has been Pediatric HIV testing, treatment and suppression by working synergistically at all levels and taking responsibility for the children of Kenya. We need to ACT now or forever hold our peace. What service providers need to do.

It’s Friday and cold, but go to work!