1. Maximizing Linkages to OVC Programs
PEPFAR 3.0 and OVC Programming: Implications and Promising Practices for Impact
OVC Task Force Meeting. Oct 7, 2015
Brenda Yamba
Acting Senior Orphans and Vulnerable Children Advisor
Office of the Global AIDS Coordinator & Health Diplomacy
I would like to thank the organizers for asking me to participate in this session.
My presentation is aimed to provide a practical way to ‘organize’ our efforts in the coming year to improve access to quality care and treatment services for HIV infected children.
Ensuring that PEPFAR programs scale up services to rapidly close the gap in critical services for HIV infected, exposed and affected children is part of our mandate towards reaching an AIDS free generation.

2. OVC Programs link to HIV cascade
CASE FINDING
Keep kids in TREATMENT cascade
Foster comprehensive HEALTH 1. 3. 2.
3 reasons to link with OVC programs – in order to:
Find the HIV + children and adolescents
Getting the kids into treatment, adherence support, and staying on treatment (retention). Support the leaky treatment cascade for HIV+ kids and their families.
Foster comprehensive health and resilience for the infected and exposed children – because their ultimate health is why we want them on treatment – but for complete health of a child infected by HIV – it takes more than treatment.
So now, let’s take each of these three reasons to link with OVC programs and discuss the whys and hows of making these linkages effective. First, let’s look at case finding.

3. 1. OVC programs can help find the kids in need of HIV/AIDS treatment
HIV infected
HIV Diagnosed
Enrolled in Care
ART Eligible
ART Initiated
Retention on ART
Bottom line: link up with your OVC programs. Aim for 100% testing of kids in OVC programs.

4. Partnership between clinic/hospital and OVC program in the community
1. Case Finding
Partnership between clinic/hospital and OVC program in the community
Identify barriers to accessing services
Formalize collaborating strategy for testing kids/families and bi-directional referrals for other services.
Include knowledge of HIV status in the community/household assessment tools.
Identify OVC platforms to link with clinical services
Skilled OVC staff in pretest counseling & follow-up.
So how do I capitalize on OVC programs for case identification?
One of the biggest challenges is communicating, understanding each other and working together. By having a formal local OVC partner

5. OVC Programs link to HIV Cascade
CASE FINDING
Keep kids in TREATMENT cascade
Foster comprehensive HEALTH 1. 3. 2.
OVC programs can do more than help you find the kids who are HIV +, these programs can help you get the kids into treatment and stay there!

6. 2. Keep kids in the Treatment Cascade:
OVC programs can help “plug” the leaky HIV/AIDS treatment cascade for children
HIV infected
HIV Diagnosed
Enrolled in Care
ART Eligible
ART Initiated
Retention on ART
As you know, there is a substantial loss at every step of the cascade with often around half the people at one stage in the cascade not making it to the next step. We have seen the effectiveness of OVC programs in reducing drop out already
Rosen, PLoS Med 2011; Fox, TMIH 2010

7. 2. HOW OVC programs keep children in the Treatment Cascade
Methods proven to increase adherence and retention in children:
Psychosocial Support (child & caregiver)
Caregiver & women’s support groups
Peer mentoring
Individual support
Economic Strengthening of family
OVC program examples of results:
In Zim, 100% of HIV+ <5 retained in C&T – very comprehensive
In Kenya, 95% of HIV+ children linked to care & support.
Some caregivers are undergoing further counseling to enhance acceptance of the results
In Mozambique, OVC community workers linked family members to social support and clinical services and returned 68% of treatment defaulters to ART/clinic.
How do OVC programs have such high rates for retention. It’s the comprehensive services: Randomized trails have shown that PSS support, provided through support groups, peer mentoring and individual support, along with ES increase adherence and retention.
Zim: very comprehensive - health, nutrition, & psychosocial support for OVC 5 years and younger along with family support groups for their families or caregivers. nurse-led monitoring of the children and their caregivers. Centers monitored attendance, child ‘s development, health status, vaccinations and HIV status and reviewed by the nurse supervisor.

8. What you can do to keep children in the Treatment Cascade
Formalize a partnership between clinical and OVC programs
Establish referral system for HIV + children and their caregivers to OVC programs that provide:
Psychosocial support for caregiver & children
Economic strengthening activities like Savings groups
Train OVC staff/home visitors in referring for testing, treatment, and guidance on tx adherence, monitoring and addressing LTFU
What can you do to benefit from the additional support of OVC programs? Make sure very hospital and clinic is linked to an OVC programs that provides PSS and ES. And train the OVC program staff on how to support effective referrals and adherence and retention. Let them know when they don’t come back to the clinic so they can help with follow-up.

9. OVC Programs link to HIV Cascade
CASE FINDING
Keep kids in TREATMENT cascade
Foster comprehensive HEALTH 1. 3. 2.
Finally, the third way OVC programs can support children in ACT is by fostering comprehensive health.

10. 3. Foster Comprehensive Health for HIV + children
HIV infected
HIV Diagnosed
Enrolled in Care
ART Eligible
ART Initiated
Retention on ART
Getting and keeping HIV +kids on treatment is essential for good health. But that alone won’t be enough for them to be truly, completely healthy. Once again, that is where the OVC program can help fill that need.

11. Why children affected by AIDS need attention to comprehensive health
Elevated risk of
Mental health issues – depression & anxiety
School drop-out
Stunting
Developmental delays
Abuse
Death e.g. when a mother dies, the chance of her child dying within 24 months increases 10 fold.
HIV impacts children and families in so many ways. Depression increases often compromising adherence, but also impacting their ability to learn and progress in school. HIV infected children and even exposed children generally have compromised brain development. HIV also necessitates adequate nutrition but causes poor absorption which can, especially in the early years, result in stunting and developmental delays.
But these are all things with which OVC programs deal. This is our bread and butter.

12. HOW to Foster Comprehensive Health
Early stimulation – training for mothers via mother support groups, in-home or peer mentoring
Economic strengthening (e.g. savings groups) to support improved nutrition and access to treatment
Nutrition interventions
Psychosocial support, triage
Help kids stay in school and succeed – gives hope (mentoring,
Building hope and resilience

13. Contributions to PEPFAR Central Initiatives
DREAMS will maximize the PEPFAR OVC program to mitigate the social effects of AIDS and therefore reduce HIV risk behaviors and risk exposure among adolescent girls through evidence-based interventions including:
Education subsidies
Social asset building
Parenting/caregiver programs
Cash transfers
Combination socio-economic approaches
Parenting/Caregiver: Having a positive relationship with a parent, caregiver, or other caring adult is a consistent protective factor for young women and girls against a variety of negative health and social outcomes. Skills building programs involving parents and caregivers have shown promise to change HIV related sexual behaviors among youth.
Cash transfers have demonstrated consistent effects on biological and behavioral outcomes.
Education: Girl students are especially vulnerable to school dropout. Educational subsidy is an effective intervention for keeping girls in school [38, 39] and is correlated with reduced sexual risk behaviors and higher HIV testing acceptance. Education also has a myriad of other positive effects in the lives of girls and young women.
Combination socio-economic approaches: Approaches that combine economic and social empowerment interventions have more consistent effects on both behavioral and violence outcomes.
ACT will maximize the PEPFAR OVC program’s capacity to “strengthen children’s resilience” by:
Addressing socio-economic barriers in vulnerable families and therefore support increased treatment entry and retention in children and adults
Scaling up evidence-based interventions
Linking community and clinical services
Enhancing family-centered care
Strengthening the measurement of quality improvement, cost analysis, and outcomes.

14. The Core Package Parenting/Caregiver Programs
Cash transfers, either unconditional or with schooling conditions
Combination socio-economic approaches
Educational subsidy
The Core Package
Strengthening the Family
Parenting/Caregiver: Having a positive relationship with a parent, caregiver, or other caring adult is a consistent protective factor for young women and girls against a variety of negative health and social outcomes. Skills building programs involving parents and caregivers have shown promise to change HIV related sexual behaviors among youth.
Cash transfers have demonstrated consistent effects on biological and behavioral outcomes.
Education: Girl students are especially vulnerable to school dropout. Educational subsidy is an effective intervention for keeping girls in school [38, 39] and is correlated with reduced sexual risk behaviors and higher HIV testing acceptance. Education also has a myriad of other positive effects in the lives of girls and young women.
Combination socio-economic approaches: Approaches that combine economic and social empowerment interventions have more consistent effects on both behavioral and violence outcomes.

15. Example: Cameroon Framing OVC Strategy within HIV Care Continuum
Health Systems Strengthening
Core services for OVC
OVC found positive
Linkage to clinical care
Support for retention and adherence
Core OVC services
Facilitate access to HIV/AIDS –related clinical services, e.g. HTC, care, and support
Household economic strengthening
Promote supportive family environment
Comprehensive SRH education and condom programming for adolescents.
Family counseling to facilitate disclosure and client education.
Food supplements for clinically malnourished OVC
Core OVC services
Adherence counseling and psychosocial support
Food supplements for clinically malnourished OVC
Core OVC services
Adherence counseling and psychosocial support
Case management to track and refer those LTFU
Food supplements for clinically malnourished OVC
Support transition from pediatric to adult treatment services
Core OVC services