HIV Testing of Infants and Children - Just the Beginning

Elaine AbramsTrack 1.0 MeetingAugust 12, 2008

HIV Testing of Infants & Children

• Introduction

• Two illustrative programs– HIV antibody testing program for children

admitted to hospital wards at University Teaching Hospital, Lusaka, Zambia

– Early Infant Diagnosis using Dried Blood Spots for DNA PCR Testing, Tanzania

• Successes & Challenges

• Issues for consideration

Why aren’t more children receiving antiretroviral treatment?

• Despite noteworthy successes with the scale-up of HIV services worldwide, the number of children in care and receiving ART remains low– Only 200,000 children worldwide were initiated on

antiretroviral treatment (ART) as of December 2007– Estimated 420,000 new pediatric infections and

290,000 pediatric HIV-related deaths in 2007• The identification and the diagnosis of the HIV-

infected child, whether as infant or older, continue to pose formidable barriers to successful pediatric roll-out.– Furthermore, once diagnosed, multiple impediments

prevent families from engaging in HIV services

Background: Pediatric HIV Care in Lusaka, Zambia in 2006

• Estimated 28,000 children with HIV in need of ART but only 2,500 children on ART, December 2006

• 10,000 -15,000 pediatric admissions annually to University Teaching Hospital (UTH)– Hospitalized children suspected of HIV infection were sent to the

Family Support Unit (FSU), a free standing VCT program for children and families

• Many children died prior to testing• Most children were not tested for HIV

• CDC in collaboration with the MOH, UTH and ICAP supported the development of a Pediatric Center of Excellence (PCOE) for Pediatric HIV Care and Treatment at UTH

• PCOE with ICAP support initiated the pediatric inpatient testing program

Pediatric Inpatient Testing Initiative at UTH

• Counselors at FSU were re-oriented and re-deployed to the admissions ward where all but the sickest children needing intensive care were kept for 10-12 hours prior to admission

• Individualized and group counseling of parents present with their child on the admission ward – Rapid HIV testing of children by counselors; results

within 30-60 minutes• Follow-up counseling and testing on the hospital

wards – Mothers needing to consult with father– Parents of critically ill children who couldn’t be

counseled

29% of children with unknown HIV status admitted to UTH tested HIV antibody

positive (June 2006-Jan 2007)Jan 2006-June 2007

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

admissions

counseled

tested

positive

<18 mo

15,670 13,239 11,571 3,373 2,348

70%29%

87%

85%

0

10

20

30

40

50

60

70

80

90

100

0

250

500

Q2 Q3 Q4 Q5 Q6

Nu

mb

er o

f ch

ild

ren

HIV Antibody Positive PCR tested PCR positive % received PCR

2006 2007

Pe

rcen

t

Of 1276 HIV antibody positive children <18 months of age, 63.2% tested DNA

PCR positive, April 2006-June 2007

Success of the Pediatrics Inpatient Testing Program

• More than 15,000 children were newly tested for HIV and >3000 tested HIV antibody positive– Many with symptomatic disease– Offered HIV services at the PCOE or within the district– Testing and referral of family members initiated

• Young age of children hastened the availability of DNA PCR testing– DNA PCR laboratory established at the PCOE

• Modest investment of resources– Dedicated counseling staff, secure supply chain for HIV

antibody tests– Children were assured access to ART at the PCOE

Challenges Stemming from the Inpatient Testing Program• Large number of HIV-infected children

overwhelmed capacity of HIV care services– Particularly providers and space

• The majority of children were enrolled in HIV care at the PCOE– Poor follow-up after hospital discharge– Delayed initiation of ART– Complexities of assuring PCR results were

provided to each child/family tested

Early Infant Diagnosis (EID) Tanzania

• The CDC and ICAP, in collaboration with other partners, have supported the MOH to initiate and roll-out EID using dried blood spots for DNA PCR testing– Pilot program in Lake Region prior to National

Expansion

• ICAP support has focused on three primary areas: – laboratory capacity

– clinical training and support

– guidelines and tool development

HIV-exposed infants (HEI) identified and tested

ICAP Tanzania (Oct 06-Mar 08)

246264 252

566

403

255237

255

217

406

346

192201237 236

405

345

192

2946 42

7447

2134

9

13

27 27

0

5

10

15

20

25

30

0

100

200

300

400

500

600

Nu

mb

er o

f sit

es

Number of HIV exposed infants (HEI) Number of HEI started on cotrimoxazole

Total number of HEI tested Number of positive PCR tests

Total number of sites reporting

Oct-Dec06 Jan-Mar07 Apr-Jun07 Jul-Sep07 Oct-Dec07 Jan-Mar08

Follow-Up After 1st PCR test ICAP Tanzania

259 12849%

1153

0

200

400

600

800

1000

1200

1400

HIV PCR+ Received results

PCR - Received results

528

46%

54%

did

not

com

e ba

ck f

or r

esul

ts

Successes of the EID program in Tanzania

• Established clinical capacity to identify and care for HIV exposed infants

• Established laboratory capability for EID• Increasing number of infants being tested for

DNA PCR to establish infection status during the first year of life– Should lead to increased number of young

babies on ART• Plan in place to increase laboratory and clinical

capacity to perform EID throughout the country

Challenges confronted in the EID program

• Significant systems barriers– Slow turn around of results

• Limited laboratory capacity• Delays getting results to sites

– Poor follow-up of infants tested for EID• For further exploration• Hypothesized reasons: cost, travel, competing

priorities, unaccustomed to appointment system, death, relocation

– Linkages between PMTCT and infant follow-up care as well as between EID and HIV care and treatment services not fully developed

Conclusions & Questions

• Testing programs for children, including early infant diagnosis, are successfully identifying HIV exposed and infected children

• Engaging HIV exposed and infected children in successful long term follow-up and HIV treatment requires further attention and innovative programming– Importance of building programs that are family-focused and

provide services to adults and children in a cohesive and coherent manner

– Pressing need to transform health systems from an acute care model to one prepared to meet the health needs of children and adults with chronic diseases like HIV