A Programming Framework Scale up of HIV-related prevention, diagnosis, care and treatment for infants and children A Programming Framework

CONTENTS Background: Putting HIV care and treatment for children in context Components of the care package: Interventions to aid child survival in the context of HIV Key Strategies: 7 Strategies and action points for scaling up HIV diagnosis, care, support and treatment for children Resources and Tools: Links to key resources

I. BACKGROUND HIV burden among children 2 million children (under 15 yrs old) have HIV 90% live in sub-Saharan Africa Nearly 370 000 children were newly infected in 2007 Most infections could be avoided through PMTCT interventions

BACKGROUND HIV affects child survival Without treatment, 50% of children with HIV die by age 2 (30% by age 1) About 270 000 children died of causes related to HIV in 2007, most from sub-Saharan Africa Those with HIV are more likely to die from common childhood illnesses (respiratory infections, TB, malaria, undernutrition, etc.), including those who survive the first year of their life - Treatment refers to co-trimoxazole and ART

BACKGROUND Scope of the Programming Framework To guide governments in resource constrained settings scale up HIV prevention, diagnosis, care and treatment for children who are exposed to or who have HIV Focuses on the needs of countries with a high HIV burden

BACKGROUND Guiding Principles for peds care and treatment Urgency Life-long Care High-quality care Family-centered Care Universal Access

II. COMPONENTS OF THE CARE PACKAGE All children 1. Interventions for all infants and children to aid survival 2. Survival interventions for infants and children who are exposed to HIV HIV exposed children HIV pos children 3. Survival interventions for infants and children who are infected with HIV

1. Interventions for all children to aid survival Newborn care, including Skilled care at birth Early initiation of exclusive breastfeeding Early postnatal visit Prevention interventions, including Exclusive breastfeeding up to 6 months of age Good maternal nutrition Growth monitoring Complete, timely immunization Treatment interventions, including Oral rehydration therapy for diarrhoea Prompt treatment for pneumonia and malaria

2. Survival interventions for infants and children who are exposed to HIV Antiretroviral prophylaxis (maternal and infant) Provider-initiated HIV testing, including infant viral testing Early and regular clinical assessment Co-trimoxazole prophylaxis Counseling and support around nutrition and infant feeding Care, treatment and support for family members

3. Survival interventions for infants and children who have HIV Early antiretroviral therapy and follow-up care Adherence and treatment support Regular clinical and laboratory monitoring Psychosocial support TB screening, prevention and management

3. Survival interventions for infants and children who have HIV (cont Nutrition, infant and young child feeding Macronutritional support, vitamin supplementation, regular growth monitoring Management of severe malnutrition Prevention, active early detection and management of opportunistic infections Pneumonia, diarrhoea, malaria Additional Immunizations Image is of a 6 month old (Ishmael) receiving a polio vaccine during Sierra Leone’s Mother and Child health week.

III. STRATEGIES FOR SCALING UP Enhance government leadership, ownership and accountability Integrate and decentralize delivery of HIV prevention, diagnosis, care and treatment services to children Enhance early identification of infants who are exposed to or have HIV Ensure reliable procurement and supply management Bolster laboratory capacity Strengthen community-based capacity for care and support Strengthen monitoring and evaluation systems

1. Enhance government leadership, ownership, and accountability Initiate a rapid, systemic situational analysis of current programming, including an assessment on pediatric interventions Update pediatric treatment targets Ensure that management and coordination structures address pediatric care and treatment

2. Integrate and decentralize delivery of HIV prevention, care, support and treatment services to children Integrate HIV diagnosis, care, treatment, and support for children into: Existing HIV care and treatment services Existing maternal, newborn and child health programs Decentralize: Interventions to lower-level health systems where applicable Utilize communities for early identification and provision of care

2. Integrate and decentralize delivery Simplified approaches to dosing and use of simplified formulations such as FDCs help to decentralize pediatric care Pediatric Dosing Chart example

3. Enhance early identification of infants and children who are exposed to or have HIV Ensure updated policy and technical guidance that follow-up with identified HIV-exposed infants and children Document info on receipt of serves for PMTCT on maternal and child health cards Use DBS to support early diagnosis Implement provider-initiated testing and counseling at sites likely to yield a high volume of positive test results

3. Enhance early identification of infants and children who are exposed to or have HIV (cont.) Use family-centered approaches; secure HIV testing for additional family members Use IMCI and IMAI approaches at peripheral sites with referral for HIV testing Better use CHWs Identify where routine determination of HIV exposure status is feasible and efficient

3. Enhance early identification of infants and children who are exposed to or have HIV (cont.) E.g.: Child Health Card (Zambia) Test Follow-up time Co-trimoxazole Date baby referred to ART; Date initiated; Age of initiation Infant feeding

3. Enhanced early identification of infants and children who are exposed to or have HIV (cont.) Simple tools that explain the process of sample collection for DBS can help ensure high quality samples are collected

Example of EID System (Kenya) Care for child Potential Bottleneck! 1 day Packaging 4 days Sample Collection 2 Week turnaround to receipt of results Potential Bottleneck! ART/PMTCT centre Courier Samples This slide shows how a PCR network using DBS works. What it shows is that results can be analyzed and returned to the clinic within just two weeks. Rapid return of and action on results is essential to minimize morbidity and mortality in infants considering the very rapid progression of disease in this population. However, there are two potential barriers to rapid turnaround of results: the first is that often specimens stay too long at the clinic before they are shipped to the laboratory for analysis, and the second is that even when results – positive or negative reach the clinic, they are not communicated in a timely manner to the patient and caregiver so that appropriate action can be taken. 1 day 1 day 5 days Source: J. Hungu, CHAI Testing lab Courier Results 20

4. Ensure reliable procurement and supply management Coordination of supply stakeholders and linkages with overall supply implementation plans Integrated supply systems based on what exists and already works Ensure children are included in national PSM plans

5. Bolster laboratory capacity Plan for lab service expansion to accommodate early infant testing for HIV Select assays for viral diagnosis Develop systems for timely and reliable use of lab results Provide staff with appropriate education and training to ensure high-quality diagnostic services

6. Strengthen community-based capacity for care and support Integrate community-based approaches into child health and HIV programming strategies Accelerate case-finding through integration into community-health programmes Improve case follow-up and essential care for HIV-exposed newborns and their families Enhance community capacity to provide care and support Promote child survival through nutrition, immunization, malaria, and TB interventions Adapt norms for confidentiality and disclosure to specific local settings

7. Strengthen monitoring and evaluation systems Include core indicators of PMTCT and HIV care and treatment services for children in national monitoring and evaluation frameworks Expand efforts to monitor programme effectiveness and quality

IV. SELECTED RESOURCES AND TOOLS Guidance documents Websites Training curricula Tools

1. Guidance documents referred to in the Programming Framework WHO Guidelines African Network for Care of Children Affected by HIV/AIDS (ANNECA) Handbook Columbia University ICAP Pocket Guide and Clinical Manual Centers for Disease Control and Prevention A range of tools to support programming

2. Websites WHO HIV/AIDS: http://www.who.int/hiv/en UNICEF: http://www.unicef.org International HIV/AIDS Alliance: http://www.aidsalliance.org Mothers2Mothers (m2m): http://www.m2m.org Elizabeth Glaser Pediatric AIDS Foundation: http://www.pedaids.org

3. Training Curricula IMAI/IMCI WHO/UNICEF Complementary course on HIV/AIDS (chart booklet) WHO/UNICEF Infant and young child feeding counseling: an integrated course African Network for the Care of Children affected by HIV/AIDS (ANECCA) An HIV care training curriculum

4. Tools Spectrum software package developed by UNAIDS, used to determine consequences of current trends and future programme interventions with respect to the HIV epidemic For more info, visit http://www.unaids.org/en/KnowledgeCentre/HIVData/Methodology