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

2. 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

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

4. BACKGROUND HIV affects child survival
Without treatment, 50% of children with HIV die by age 2 (30% by age 1)
About 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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. 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

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

28. 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

29. 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