1. Monday November 30th 2015 ,Harare Zimbabwe
Impact of Implementing “Test and Treat” policy on Pediatric ART enrolments and coverage in Uganda
Authors: P. Elyanu, Eleanor Namusoke-Magongo, B. Asire, I. Lukabwe, H. Bitimwine, C. Katureebe, P. Achii, V.Mulema, E. Dziubian, N. Namuwenge, E. Namagala, J. Musinguzi
Program Officer for Paediatric HIV Care & Treatment
ACP/Ministry of Health
Monday November 30th 2015 ,Harare Zimbabwe
Thank you very much. I will be presenting to you the “Impact of the Test and Treat policy on pediatric ART enrolments and coverage in Uganda.

2. PRESENTATION OUTLINE Background Methodology Results Conclusion
I will take you through the background, methodology, results and conclusions.

3. BACKGROUND
In 2013, Uganda adapted a “test and treat” antiretroviral therapy (ART) policy for HIV infected children under 15 years
The MOH launched, and disseminated these guidelines to health workers though a 3 day health facility based trainings and mentoring during the period January to December 2014
The guidelines were also disseminated to other key stakeholders through national & regional stakeholders meetings
Read the slide

4. RATIONALE
Based on 2013 WHO guidelines, 83% of the estimated 176,948 HIV infected children in Uganda then would be eligible for ART ( National Spectrum estimates)
Promote “ efficient” use of resources
Removing barriers to ART initiation- “ simplifying ART initiation”
Low access to CD4 among children
Late access to CD4 among children
Delayed ART initiation among children eligible by CD4 alone
Incorrect WHO Clinical staging
Better retention for children on ART compared to those on Pre-ART
Other benefits to children
Read the first bullet. We thought that it would not be proficient use of resources to have H/w’s tease out the 17% who would still need the WHO Cl stage and CD4 results to determine those that are eligible for ART using the 2013 recommendations by WHO. So we agreed that if we removed the barriers to ART initiation, this would simplify ART initiation and more children would access treatment knowing well that most of our HIV clinics are run by nurses or midwives. The barriers are- mention them. We also know from our data that there is better retention for children on ART compared to those in Pre-ART care.

5. Many eligible children would be missed if we used CD4 and WHO staging to determine ART eligibility
Proportion of HIV infected children receiving CD4 test within 3 months of enrolment (Support supervision 2013)
Proportion of HIV infected children who received WHO clinical stage in last clinic visit (Support supervision 2013
Looking at our data at that time, only 43% of children were accessing a CD4 test within 3 months of enrolment and only 52% of the children had a correct WHO CI stage. So many children who are eligible for ART would be missed.

6. METHODOLOGY
To evaluate the impact of this new policy we compared pediatric ART initiation and coverage for the period
June-December 2013 and those initiated between January-June 2014
Sources of data;
was the national ART quarterly reports
Training reports( for training coverage)
Read the slide

7. Timelines for the guidelines adaptation and roll out
Full scale roll out started
Scale up to over 80% of ART sites
TWG meetings to adapt guidelines
Approval of guidelines
Medicines in ware houses
Further planning meeting
Aug 2013
Nov 2013
Feb 2014
Mar
May 2014
July
2014
Mar
2015
Prep documents
Revised guidelines
Roll out plan
Training curriculum/Job aides
Quant. & Procuring
Planning meeting with implementers
Training of trainers
Sites ordered medicines
Launch of the guidelines
This was the time line for the roll out of the guidelines.
After WHO launched the guidelines in June 2013, MOH Uganda convened TWG meetings to discuss the scientific and programmatic aspects of the guidelines. The TWGs consist of Academia, ADP, MOH and representatives of PLWHA.
Once the TWG agreed on the guidelines, approval by the different MOH committees was obtained. Most of these processes went on up to October 2013.
In November; the ministry of health started preparing the guidelines;
We updated the guidelines document,
Developed the roll out plan, training curriculum and Job aides
Quantified and procured the ARV’s
Planning meetings with implementers.
This took up to march 2014.
In Feb 2014
Medicines had arrived in the ware houses. IP’s were to plan their roll out plans and identify trainers with guidance from MOH.
In march 2014
We started to train trainers and IP supported sites to order for medicines. We used PULL system to deliver medicines to the health facilities.
In May We started full scale roll out and achieved full coverage in March 2015.
The guidelines were launched in July 2014;
The delay in the launch was because on the need to harmonize the different stakeholder meeting into one in order to save on finances. It’s also important to note that even though the full scale up was in May, COE’s and special clinics went ahead and implemented the policy as soon as this was declared the agreed position of the country.
The delay in Launch was because on the need to harmonize the different stakeholder meeting into one in order to save on finances. It’s also important to note that even though the full scale up was in May, COE’s and special clinics went ahead and implemented the policy as soon as this was declared the agreed position of the country.

8. Developed and pre tested DOCUMENTS FOR CAPACITY BUILDING
Facilitators manual for the facilitators.
Trainers manual was A1 sized flip chart which the trainers travelled with to train. Eliminated the need for power point.
Desk flip chart with consolidated Job aides
Integrated dosing chart, adults and ped ART, TB medicines and cotrimoxazole
Brochure – which the health workers could carry around in their bags including ladies bags.

9. Results outline Training coverage; facilities and health workers
ART initiation (New initiates)
ART coverage
Read slide

10. ART sites trained by the facility level and number of people trained
The take home point on this slide is that with the new facility based approach, we were able to train more health workers than before when we used the workshop based approach. The last column shows the average number of health workers trained per facility level. Using the workshop based training approach, we would have trained an average of 2-3 health workers per facility per training.

11. Number Of Health Workers Trained
We started with 17,432 h/w’s, some didn’t complete the training, and others were not actively providing a service at the HIV clinic. Among those that provide a service at the ART clinic, the majority of H/W’s trained were nurses (56%).

12. Children 0-14 years newly initiated on Antiretroviral therapy (July’13-June’14)
This slide shows the number of children newly initiated on ART during the rapid scale up phase. The highest increase was among the 5-14yr’s age group that had the biggest number of children in Pre-ART care. The numbers in the other age groups remained almost the same. This is because we were already implementing the “T & T” approach for the under 2’s. However, as you can see, after the rapid scale up phase, the numbers of children newly initiated on treated has gone down almost to baseline. This strongly suggests that in order to identify more HIV positive children who are out there, we must intensify our PITC activities. And according to UNAIDS, 66% of HIV positive children in Uganda are above 5 years, these are children that we will see at the OPD, IP wards and for us to identify them, we must reduced on the missed opportunities for HIV testing at these entry points.

13. ART coverage increased from 22% in 2013 to 32% in 2014 and now 42% in 2015(N= total number of children living with HIV)
ART coverage increased from 22% in 2013 to 32 % in 2014 during the guidelines roll out and now 42% in In yellow is the planned scale up. Our estimates of CLHIV and therefore the numbers for planned scale up have changed from Dec 2014 following the recently released country population data that estimates that the new population is about 3 million less than what it has been known to be. The gap as of 2014 was 68% and has now reduced to 58% with implementation of the policy. Most of the ART treatment gap is children who have not been identified at all. This further highlights the need for aggressive HCT for children in the country.

14. Positive experiences Increased pediatric coverage
By removing eligibility criteria more children are being initiated at public health facilities
Successful training approach.
Site based training
Focus on training health workers to use guideline Job aides.
Trained about 12,000 health care workers
Fast country wide roll out
Read the slide

15. Challenges Low retention; 2-4 years in 1st 6 months
Focus on the “Treat” more than the “Test” partly due to stock out of testing kits
Commodities
Estimated cost increase for pediatric ARV’s
Stock out at warehouse level especially of ABC/3TC due to global supply chain challenges early 2015, resolved in April.
Facility stocks were stable except in 10% of public health facilities
Stock out of testing kits
Read slide

16. CONCULSION
Removing eligibility criteria has operationalized decentralization of pediatric ART at public health setting and improved ART access to children in rural areas.
Thoughtful, careful and as early as possible planning is important.
Funding for commodities, training, delivery of medicines to site.
Reality check: Set realistic targets.
Plan strategies to retain children and adolescents in HIV care and treatment; could be before or during roll out.
HCT must remain focus to ensure more HIV infected children are identified.

17. Mwebaale Nnyo