1. HIV and Child Development: Two approaches to integrating ECD Suzanne Andrews, 4Children USA Case studies by: Getachew Tefera, Childfund Josephine Ferla, Catholic Relief Services

2. Millions of children under 5 years of age in low- and middle-income countries (LMIC) are failing to reach their potential in cognitive, language, and social emotional development, which has implications for their educational attainment, physical health, mental health, social citizenry, and economic participation later in life. For children affected by HIV, the risks are even greater. Why focus on early child development?

3.  HIV infection of infants and children is characterized by either a progressive or static loss of previously acquired developmental milestones with cognitive, behavioral and motor manifestations. (Udgirkar & Tullu, 2003)  For children affected by familial HIV, co-varying risks include poverty, disrupted caregiving, malnourishment, abuse and psychological trauma. Uninfected children are more likely to not have their basic needs met, miss developmental milestones, and become HIV positive themselves (Van Rie et al., 2007). HIV increases the risk of developmental delays

4. 1. Early stimulation and other ECD interventions for HIV-affected and HIV-infected children have the potential to dramatically improve development outcomes (Boivin, Bangirana, & Nakasujja, 2013). 2. Creating the conditions for HIV-affected children to not only survive, but thrive requires integrated interventions early in life that target the many risks to which vulnerable children are exposed (Engle, Fernald, & Alderman, 2011). 3. Early identification and early treatment of pediatric HIV are critical to improving both developmental and clinical outcomes for an HIV- infected child (Baillieu & Potterton, 2008). But how do we integrate ECD interventions and HIV clinical care? Integrating ECD interventions and HIV clinical care can improve developmental outcomes

5. 1. ECD Centers with integrated health services: Health worker visits and screenings, medication distribution and care plan for each individual child.  Yekokeb Berhan, Ethopia  Presented by Getachew Tefera, Childfund 2. Clinic with ECD activities and messages: Child-friendly spaces, volunteers providing key messages and early stimulation activities with parents and children waiting for health services.  THRIVE, Tanzania  Presented by Josephine Ferla Two approaches to integrating ECD

6. Bringing Integrated services to ECD centers Reflections from USAID’s largest OVC program Yekokeb Berhan Program for Highly Vulnerable Children, Pact/ Ethiopia REPSSI 2015 Forum “Care, Love and protect from Infancy to Adolescence” Sep 1-3,205 Zimbabwe

7. Delivery Approach CSI/ Case Identified Care and support plan Service delivery at HHs Service delivery at ECD center Services provided by volunteers and (HEW) health extension workers: Better parenting Health education HIV cases managed through referral Other referrals as needed Medication Play Early stimulation Nutrition Follow up

8. Facilitating clinical outreach to HHs and ECD centers

9. INTEGRATION TO QUALITY ECD CLINICAL SUPPORT Bring key stakeholders together ECD Training Community mapping, resource directory, MoUs Refer children who lack access & follow up Health post/HEW and ECD center Mobilize resources to fill gaps Coordination of Care

10. Program adaptations or elements that facilitate ECD clinical integration Original design: Household visited by HEWs Adaptation: Program volunteers and HEWs, initially providing home visits, provide outreach to ECD Centers HEWs signed MOU with community committee to regularly visit ECD centers, provide health services and follow-up with HIV positive children.

11. Results Increased enrollment and retention of HIV+ children. Children’s health outcomes improved. Children’s learning and development improved. Children’s psycho-social well-being improved, they are more assertive and connected to community.

12. Quality assurance (Highlights for monitoring) Setting standards and procedures – ECD management guideline – ECD standards (minimum) – Continuum of care (HCT and palliative care) – Disclosure manual – Stigma and discrimination Monitoring mechanisms – Supportive supervision Volunteers, community facilitators, project officers, project coordinators, MERL officers, regional teams(INGOs) and key government stakeholders – Review meetings Volunteers-HEWs weekly meeting Regular monthly meeting of ECD management committee

13. Opportunities and lessons for ongoing efforts Opportunities – Presence of ECD centers in diverse settings – Government commitment for better health Policies, manuals, guidelines, directives HEWs deployment (financing) – Community care coalition – Replicable and adaptable Lessons – Integrated approach is cost effective and promises better results – Facilitate leverage of knowledge, skill and other resources

14. Ah-hah Moment Integrating health and ECD programming has helped to identify HIV+ children, and supported enrollment and retention in pediatric treatment. Other services offered by the program: shelter, nutrition, health services, and parenting training for caregivers also contribute to improved child development outcomes.

15. HIV and ECD integration in Health Facilities THRIVE project REPSSI 2015 PSS Forum “Care, Love and Protect from Infancy to Adolescence” September 2015

16. Project Overview THRIVE targets vulnerable caregivers and children under five Works in health facilities through RCH/PMTCT clinics Works with local CBOs using community-based volunteers Provides positive parenting messages in RCH/PMTCT clinics Provides early stimulation activities in ECD spaces attached to health/PMTCT sites Early childhood development (ECD) interventions have the most benefit for children who are the most vulnerable and have a mediating effect on maternal mental functioning for HIV-positive mothers (Allen, AB et al 2014) 16

17. Delivery model (principles, rationale & philosophical underpins guiding delivery) Local partner works with Most Vulnerable Children Committee to identify vulnerable children ANC & PMTCT clinics are platforms to deliver Positive parenting messages targeting children under five Trained Community Based Volunteers are linked with the clinics to provide parenting messages ECD spaces are located in these platforms for early stimulation opportunity 17

18. Program adaptations or elements that facilitate ECD clinical integration Positive parenting messages include all aspects of child’s development including breastfeeding, complementary feeding, immunization, positive discipline, early stimulation etc. CBVs use the ANC platform to deliver all integrated information to parents Mid Term evaluation report has reported on increased attendance due to routine visits of HIV positive caregivers; increased efficiency of referrals to other services and increased effectiveness of medical services for children; e.g., reduction in loss-to-follow-up 18

19. Quality assurance (Highlights for monitoring) Parenting manual are used by trained volunteers to deliver parenting messages Beneficiaries’ attendance is monitored and followed through registration book CBVs follow up on interaction between caregiver and a child. Home visits is conducted to few beneficiaries with specific needs. More supervision and support take place during home visits Quality Assurance forms are developed for observing CBVs when conducting positive parenting education and provide feedback Baseline, mid and end - line surveys conducted 19

20. Opportunities and lessons for ongoing efforts Health facilities are still a promising and sustainable practice for integration of HIV and ECD Increase home visit outreach and other platforms to increase dosage Conduct operations research to test effectiveness of integration of HIV and ECD 20

21. ECD Spaces & PMTCT Clinics 21 Photos by Philip Laubner/CRS Children can play and parents can learn how to stimulate their child’s mind through the modeling of lead parents.

22. 1. What are the potential benefits to the clinic or ECD center approach in terms of developmental HIV outcomes? 2. What are potential drawbacks: gaps and challenges that might need to be addressed 3. Three key recommendations for future programs: 4. Do you know of other projects integrating ECD and HIV clinical care? Project, country, organization? Discussion Questions

23. 23 Thank you!