1. The Unfinished Business of Pediatric HIV Case Finding: Intensifying Efforts to Diagnose HIV-Infected Children and Adolescents July nd International AIDS Conference Amsterdam, Netherlands

2. Testing strategies must be very targeted to find HIV+ children quickly
Finding HIV+ children is more difficult relative to finding adults given low pediatric prevalence
Estimated HIV Prevalence for adults and children - Eastern and Southern Africa, 2017
1 in 169 children are HIV+
1 in 15 adults are HIV+
Nigeria - 1 in 382
Uganda - 1 in 217
SA - 1 in 59
Swaziland - 1 in 40
40% of population in ESA are children <15 and the rest are adults
Children:
Pop = 194 mm
CLHIV = 1.14mm
Prevalence = 0.59% -> 1 in 169
Adults:
Pop = 275mm
Adults LHIV = 18.2 mm
Prevalence = 6.61% -> 1 in 15
Testing strategies must be very targeted to find HIV+ children quickly
Source: CHAI analysis using World Bank Population Data and PLHIV from UNAIDS 2018, ESA countries only,

3. Majority of 180k new infections
…and we’re now also faced with a harder-to-reach group of infants and children
Majority of 180k new infections
HIV-exposed and positive infants
HIV+ women who don’t access ANC services at all
Women who seroconvert after testing negative in ANC
Women who drop off from PMTCT programs
Majority of unmet need for peds & adolescents
Adolescents with complex behavioral challenges
Children being missed in very high volume settings like OPD
Asymptomatic (or well) children not coming to the health facility
UNAIDS 2018 Estimates:
New infections among children (0-14): 180,000
Children and adolescents
An approach that targets this hard-to-reach heterogeneous group of mothers, infants, young, and older children is needed

4. An optimal mix of testing strategies to maximize identifications is needed
High Volume
Community Testing
Low-yield; screening needed given risk of massive volumes
OPD
Underutilized; high volume, screening impacts yield
Index Testing
underutilized, High-yield potential
Low Yield
High Yield
Inpatient Testing
Nutrition, TB
High yield but limited volume
Low Volume

5. MALAWI: Improving index case testing interventions has potential for massive increase in testing and identification 1
Bottlenecks were addressed...
…and index testing jumped ~5x from 191 to 895
Children ages 0-14 identified; 80 sites
All HIV+ clients should be given a Family Referral Slip (FRS)
Guidelines
FRS issuance low due to knowledge gaps on who should be given an FRS
Bottleneck
3.8x
Notes:
SOP for Issuance of Family Referral Slips (FRS) at HTS Rooms
SOP for Completing the Family Referral Slip
SOP for Clients Returning for HTS with a Family Referral Slip
Success of SOP in increasing FRS usage led to national review and official ministry adoption in June 2017.
Once adopted, the SOP was disseminated nationally by government and implementing partners
-The issuance of slips and the number of people returning for testing with slips has nearly doubled since national adoption and dissemination
-- Issuance has increased from 41,105 (2017 Q2) to 72,551 (2018 Q1)
--Numbers tested via FRS have increased from 6,196 (2017 Q2) to 15,995 (2018 Q1)
Index Case Testing has more than doubled since national adoption, and yields still remain high (>10%)
Testing volumes and yields remain high after national scale-up of FRS SOPS; but still major opportunity to improve return rates (~22%)
SOPs developed to provide clear guidance on issuing FRS
Intervention
Pre-Mentorship (Q2-Q3 2016)
Post-Mentorship (Q2-Q3 2017)
Yield rates dropped slightly, from 9.9% to 8.2%; but identifications still increased

6. ZIMBABWE: Yield was 2x greater amongst those screened, identifications increased by 69%, but coverage was low 2
Bottlenecks were addressed…
…and testing increased by ~70% from 415 to 712
All children in OPD should be offered an HIV test
Guidelines
Children ages 5-14 identified; 16 sites
Testing coverage low due to high volumes, limited test kits, and HR
Bottleneck
69%
Number of children of children tested pre-intervention was 415; and post intervention was 712.
OPD screening was adopted in the National Operational and Service Delivery Manual and HTS Guidelines and is being scaled nationally, but uptake coverage needs to be improved
During its development in Zimbabwe, the algorithm predicted the HIV status of 79% of study participants and demonstrated the potential to reduce the number of children who need to be tested in order to identify one child by 60%1
Has the child ever been admitted to the hospital?
Has the child had recurring skin problems?
Have one or both of the child’s natural parents died?
Has the child experienced poor health in the last 3 months?
For adolescents aged 5-19; have you experienced any symptoms and signs of an STI such as vaginal/urethral discharge or genital sores?
KS: How long did it take HCWs to administer each questionnaire? What level of health facilities was this administered in? Any takeaways on challenges?
It was recommended that screening be conducted by lay cadres when possible to not overburden nurses.
Feedback from HCWs indicated that administering the algorithm took 3-10 minutes depending on the client (e.g. if there was hesitation and the client needed further explanations on the need for the screening it took longer).
This was implemented in 2 hospitals 14 clinics/ polyclinics.
Challenges included the capacity to screen all children (~only 5% screened) and ensuring that those who screened positive received an HIV test.
Question: 1. Do we know why health workers were not able to screen all children, and why the uptake was so low? Uptake was low due to attrition and rotation of trained staff to different entry points. Time/ space were also mentioned as challenges to conducting screening.
2. Why was screening not administered to children below 5 years? Ministry still recommends that all children under 5 be offered routine PITC and their exposure status be checked.
HCWs were trained to administer a 5-question screening algorithm to clients, aged 5-19, attending OPD
Intervention
Yield was 12.7% among those screened, but coverage was only 5%

7. UGANDA: A comprehensive testing approach resulted in ~40% increase in identifications, but some strategies remain underutilized 3
Bottlenecks were addressed...
…and testing increased by 12% from 7689 to 8647
Minimal guidance on pediatric testing in national policy, and no operational guidelines
Guidelines
Children ages 0-14 identified;
35 UB focus facilities
Children were not prioritized at facilities for HIV testing due to lack of clear guidance
Bottleneck
HTS curriculum rolled out to >70% high-volume sites, but opportunity to improve underutilized strategies exists
Testing strategies:
Priority entry point testing
home based testing
flexi-hour testing for adolescents
adolescent friendly services
index client testing
special campaigns to test children of key populations
Coverage
Program operated
by 4 IPs in 23 (previously 19, 21) districts that were found to hold 53% of Uganda’s total pediatric scale-up potential
CHAI’s role is to provide coordination, M&E, and reporting support
Entry Point Assessment Results for Testing Uptake
IPD: increased from 13% to 25%
TB: decreased from 98% to 93%
Nutrition: decreased from 98% to 63%
OPD: increased from 15% to 16%
District Prioritization Exercise Results
In Phase I, we conducted a district analysis that showed that 76% of the children not on ART could be found in 30 districts. 53% of the children not on ART were found in 19 (now 23) of these 30 districts, and were prioritized under the Unfinished Business Program due to the high potential for impact.
Revised HTS policy and implementation plan, Peds HTS training curriculum, testing volunteers, facility and district prioritization
Intervention
IPD TB Nutr OPD EID Total
Contribution of 23 UB districts to national identifications has gone up, while the 111 non-UB districts has decreased

8. CHAI is working with ministries to develop an “optimal testing mix” of strategies
Reachable Population
Target Coverage Rate
Expected Yield
Identifications
Methodology
The number of children eligible to be tested through a certain strategy
(e.g. the number of children admitted to an inpatient ward)
For each strategy, estimates for reachable population, coverage rate and yield are calculated for Baseline (2017) and targets are set through 2020
The percent of eligible children tested through this strategy
The positivity rate found through this strategy

9. UGANDA MODEL: A targeted set of testing strategies could help initiate 44,700 children and achieve 95% Pediatric ART coverage by 2020
Projected number of initiations to be achieved by strategy and overall achievement by 2020
OPD screening and Index testing will result in the most initiations
Some children will graduate/be lost
Scale-up of targeted testing strategies would identify 68,784 children between We’re overshooting the number of children who need to be initiated in order to reach universal coverage as not all will be linked, and among those already on ART some will graduate and others will be lost.
Identification numbers by strategy, year and overall
OPD , , , ,920
IPD/ Nutr/ TB , , , ,990
Index Testing , , , ,673
EID , , , ,627
Key Pops/ OVC ,574
Total , , , ,784

10. How do we get to the finish line?
Be more strategic: The right testing mix may vary by context. Use data to prioritize mix of testing strategies, set identification targets, re-assess regularly, and adapt to evolving context.
Scale-up underutilized strategies: Finish the job in sick wards, optimize OPD testing, improve index testing, and consider making self-tests available to parents/caregivers.
Adopt a comprehensive approach to case-finding: Support policies with clear operational guidelines, provide training and mentorship, use analysis to inform and update strategy.
Improve coordination: Improve coordination, especially with faith-based and community organizations. Ideally, all partners should be informed by, and working towards one comprehensive strategy.

11. Thank You.