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

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

3. HIV Burden in Kenya

4.
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 “ ” 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.

5. 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
The Goal
Objectives

6. 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

7. 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.

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

9. 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

10. 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.

11. IDENTIFICATION IN KENYA
This involves testing of the child either EID or PITC.
KAIS 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.

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

13. 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.

14. 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

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

16. ART Pediatric Patients

17. ART Adult Patients

18. 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%

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

20. 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]

21. 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.

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

23. 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

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

25. We need focused Acceleration.

26. 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”.

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

28. 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

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

30. 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

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

32. 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.

33. 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.

34. It’s Friday and cold, but go to work!