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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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)?

12. 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

13. 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