Pediatric Working Group Interagency Task Team on Prevention and Treatment of HIV Infection in...

Pediatric Working Group

Interagency Task Team on Prevention and Treatment of HIV Infection in Pregnant Women,

Mothers and their Children

July 2011

Prioritizing Pediatric HIV Diagnosis, Care, Support and

Treatment

Contents

Current state of pediatric HIV & AIDS

Global initiatives in the fight against HIV in children

Why prioritize children?

Bottlenecks and challenges

Priority interventions

Pediatric HIV disease remains a major global health issue

The burden of pediatric HIV disease is high, despite PMTCT 2.3 million children currently living with HIV

This represents 7.5% of the total number of people with HIV

370,000 new pediatric infections globally in 2009 This represents 15% of the total number of new

infections each year

Mortality in untreated children is very high 260,000 deaths in children with HIV annually Without treatment, 50% of infected children will die before

age 2

Treatment and PMTCT interventions can reduce MTCT rates to <5% But in 2009 only 50% of HIV+ pregnant women had access

to PMTCT And 30% of those received suboptimal prophylaxis with sd-

NVP Overall, pregnant women have the poorest access to

treatment with only 15% of those who are eligible on ART

Source: Universal Access Report, 2010

Interventions to test and treat children lag significantly behind adults

Early infant diagnosis (EID) is essential to identify infected infants But despite significant scale up - only 15% of HIV-exposed

infants have access to EID

Treatment is a life-saving intervention and all infected infants and children < 2 years are eligible for treatment Only 28% of children in need of treatment are on ART

(compared to 37% eligible adults) Access for infants is even lower

Adolescents living with HIV are a growing group in need of services.

Source: Universal Access Report, 2010

Contents






Treatment 2.0 – re-galvanizing efforts to reach universal access for adults and children

Treatment 2.0:

Is a global initiative to re-galvanize efforts to achieve universal access for adults and children living with HIV and maximize the impact of HIV treatment on HIV prevention to avert 10 million deaths by 2025

Treatment 2.0 comprises five key pillars:1. Radically simplified HIV treatment with optimised drug

regimens in once daily combinations2. Prioritize point-of-care and other simple-to-use

diagnostics3. Reduced costs of commodities4. Improve and decentralize service delivery5. Strengthen community mobilization

The Global Plan to Eliminate Mother-to-Child Transmission (eMTCT) of HIV and Keep Mothers and Children Alive:

Is a new effort to reduce new HIV infections in children by 90% or to fewer than 40,000 new pediatric infections globally over the next 4 years Increased efforts to improve access to maternal treatment, to PMTCT and to infant testing

Elimination of MTCT – reducing new HIV infections in children by 90%

These new global initiatives offer a real opportunity to address HIV/AIDS in children

Both Treatment 2.0 and eMTCT provide an unprecedented opportunity to address the burden of pediatric HIV and AIDS Elimination of MTCT will result in far fewer infected

children EID scale up is necessary for global programme

evaluation, and as more HIV-exposed infants are tested, more infected infants will be identified

As treatment becomes simpler and more decentralized, it will become easier to provide access to children living both in urban and rural areas

Even as the most effective PMTCT interventions are widely scaled-up, there will be a continuing need for pediatric treatment – both for the 2.3M children already infected and for those that become infected despite PMTCT services

Contents







Each day that goes by, almost 800 HIV-positive children die because of lack of access to testing, treatment and care

With treatment, children with HIV can survive into adulthood and live healthy and productive lives

Recent innovations include the introduction of infant diagnosis using dried blood spots and the development of affordable pediatric fixed dose combination ARVs which improve quality of care for children living with HIV and greatly simplify ART

Mortality from pediatric HIV contributes significantly to overall child mortality especially in high-burden countries. In order to achieve MDGs 4 & 6 by 2015, we must take action now

Contents






Polic

yPo

licy

Bottlenecks occur at all levels to limit accessto ART for children

• Low level of political commitment• Limited funding • Poor understanding of child-specific issues

• Low level of political commitment• Limited funding • Poor understanding of child-specific issues

• Vertical programming not well linked to MCH• Slow uptake of new pediatric drugs • Few linkages from testing to treatment, so poor

retention

• Vertical programming not well linked to MCH• Slow uptake of new pediatric drugs • Few linkages from testing to treatment, so poor

retention

• Too few pediatric equipped sites • Too few pediatricians to manage disease burden• Low uptake of supportive interventions

• Too few pediatric equipped sites • Too few pediatricians to manage disease burden• Low uptake of supportive interventions

Ope

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2,30

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with

HIV

356,400 children on

ART

Globally, only 28% of

children in need received

ART

Infr

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ture

At policy level, there is a need to advocatefor child rights and fund child interventions

Incorporate child protection elements into the national discourse and legislative procedures

Ensure appropriate funding allocation for pediatric activities within national and donor budgets for pediatric HIV programming

In operations, address access to child FDCsimprove integration and decentralize care

Focus on integration to strengthen MCH through investments in pediatric treatment and prevention

Improve access to quality affordable pediatric fixed dose combinations

Strengthen management capacity at national level

Decentralise diagnosis, care, support and treatment

Through infrastructure, strengthen humanand physical resources and capacity

Build up human resource capacity to manage pediatric HIV Task shifting to nurses and other personnel enable scale-up of

treatment services in areas with pediatrician shortages Empower all treatment sites to manage children in a family

centred approach Offer supportive interventions especially for vulnerable

populations such as adolescents

Six challenges, and six interventions for betteraccess to pediatric testing and treatment

Infants are hard to diagnose yet very vulnerable

Expand access to Early Infant Diagnosis (EID)

Too few pediatric specialists

Task shift pediatric ART

Fragmentation of the ARV market by many similar products

Rationalise pediatric ARV formularies

Meet special needs of adolescents

Increasing number. of adolescents with particular needs

Increase pediatric retention

Too many children are LTFU – all along the care continuum

Set higher targets for pediatric testing and treatment

Access to pediatric treatment lags partly due to low targets

1

2

3

4

5

6

Contents






Priority intervention 1: Expand access to EID

Key Challenge: Infants are the most vulnerable to disease progression, and EID is essential to diagnose infection in infants

Access to EID is currently limited (15% exposed infants globally) but is an essential 1st step to begin pediatric treatment

Diagnosis of HIV infection in infants <18 mos. requires PCR or other types of virologic testing

Innovative technologies and improved communication strategies are now available to scale-up access to EID services even in resource-constrained settings

Priority intervention 1: Expand access to EID

Several countries have successfully scaled up EID programs and improved access to treatment for infants using centralized PCR, sample transport, electronic result return and strong linkages to care

To increase EID coverage, different entry points for HIV exposed infants need to make active referrals

Task Shift pediatric ART

Key Challenge: There are too few pediatric specialists in resource limited countries – task shifting is critical to increase access

Shortage of pediatricians in developing countries limits scale up of pediatric HIV care and treatment

Task shifting to alternative personnel including to nurses is a cost-effective way to address human resource gaps while maintaining a high standards of care

Effective task shifting includes adjusting policy, defining clear roles and appropriate supervision

Most of the evidence to date on task shifting in HIV has focused on adult services. Care must be exercised in task shifting to account for special issues associated with diagnosing, caring for, and treating children.

Priority intervention 2: Task shifting for pediatric ART

Priority intervention 2: Task shifting forpediatric ART

Multiple resource-limited countries (see map) have been able to demonstrate successful ART initiation by training non-physician health workers

NIGERIA: Nurse ART treatment helped reduce waiting time by 4 hours (Udegboka et al, 2009)

LESOTHO: Nurses treated both children and adults, leading to increased enrollment of patients, increased enrollment of children in care and decreased numbers of adults with very low CD4 counts (<50). (Cohen, Lynch et al. 2009)

SOUTH AFRICA: Compared outcomes between nurse and doctor-led management of adults (neither group had previous HIV experience) found no difference in mortality viral failure or immune recovery. (Sanne, Orrell et al. 2010).

ZAMBIA: Good pediatric outcomes reported in clinics managed by clinical officers and nurses (Bolton-Moore Mubiana-Mbewe et al. 2007)

UGANDA: Both nurses and clinical officers demonstrated strong agreement with physicians in assigning clinical staging and deciding whether to initiate antiretroviral therapy (Vassar, Kenya Mugisha et al. 2009)

MOZAMBIQUE: Non-physician caregivers achieved higher levels of adherence to ARVs in the first 6 months after initiating ART and were less likely to be LTFU than those seen by physicians (Sherr, Micek et al 2010)

Rationalize pediatric ARV formularies

Key Challenge: The pediatric ARV marketplace has become fragmented by numerous duplicative products, which threatens sustainability

The CHAI-UNITAID program has served as one mechanism to decrease cost of pediatric treatment by pooling procurement and rationalizing choices of pediatric ARVs, however this program is ending in 2012

In order to ensure the sustainability of pediatric HIV treatment programs pediatric ARV formularies should be optimized around the least number of products and programs should phase out outdated formulations and regimens

Priority intervention 3: Rationalize the pediatric ARV formulary

Priority intervention 3: Rationalize the pediatric ARV formulary

The optmization of the pediatric formulary is essential not just to decrease costs but also to ensure sustainable and assured access to current and new pediatric drugs

Governments should be encouraged to rationalize their pediatric formulary and identify single-drug products and syrups that can be phased out in favor of cheaper, easier to use dispersible FDC formulations

To secure uninterrupted supply of pediatric ARVs national HIV programs and their partners should consider

Rationalizing pediatric ARV formulariesAccelerating the phase out of old

formulationsParticipating in pooled procurement /

coordinating buying mechanisms

Meet special needs of adolescents

Key Challenge: Current programs do not address the needs of a growing adolescent population

More children with HIV are now surviving into adolescence and adulthood

Adolescents living with HIV face a unique set of challenges not met through pediatric or adult focused programs

Adolescent specific services are needed to address both physical and psychological needs of this group

Priority intervention 4: Provide services for adolescents

Whether infected at birth or later in life, adolescents

living with HIV face a variety of unique challenges that the

health sector is only now beginning to recognise

Important areas of focus for this special population include: Mental health Transition from pediatric to adult care Sexual reproductive health issues

Meaningful involvement of adolescents living with HIV is essential to the design, delivery, evaluation of treatment, care and support services.

Priority intervention 4: Provide services for adolescents

Increase pediatric Retention

Key Challenge: Too many children are lost along the continuum of care

Over 50% of positive pediatric patients are estimated to be lost across the between testing and initiation of treatment

Children have particular vulnerabilities that make pediatric retention a more complex issue

Priority intervention 5: Improve pediatricretention

.

Source: CHAI 2010

(Pediatric HIV)

1 Testing here refers to Early Infant Diagnosis testing only, based on a 5-country analysis of all patients from sites available to CHAI (n=4970) in Cameroon, Ethiopia, Kenya, Swaziland, and Zambia.2 Based on 8-country analysis of all patient charts from sites at which data were made available to CHAI (n=18,077) in Cameroon, Dominican Republic, Ethiopia, Kenya, Nigeria, Rwanda, Swaziland, and Zambia.

Strategies to improve pediatric retention in care include:

1. Improving quality of service

2. Enhancing linkages between testing programs such as EID and treatment

3. Focusing on Pre-ART patients

4. Addressing costs of care to families

Priority intervention 5: Improve pediatricretention

Aim higher for pediatric targets

Key Challenge: Target setting is not aggressive and access to pediatric treatment still lags significantly behind adults

Resource-constrained HIV-programs often neglect specific needs of pediatric patients

ART coverage is not equitable and far fewer children have access to ART compared to adults

Setting new and ambitious targets for pediatric treatment prioritizes the need to close this gap and save lives

Targets for testing and treatment should be set at national, district and facility levels

Priority intervention 6: Set ambitious targetsfor pediatric testing and treatment

Priority intervention 6: Set ambitious targetsfor pediatric testing and treatment

Countries should develop and utilize improved national pediatric treatment targets that reflect and include the following:

An overall goal of at least 80% of children in need receiving ART

Sub-national numeric targets based upon the goal of at least 80% coverage

The same access to ART for children as for adults

Specific targets for ART in children under age 2

WHO recommendations for universal testing of infants in high burden settings

Summary

Current state of pediatric HIV & AIDS Pediatric treatment currently is currently lagging and

thousands of children are dying every year

Global initiatives in the fight against HIV in children Ambitious global commitments have been made towards

battling HIV in children, including Treatment 2.0 and the Campaign to eliminate MTCT

Why prioritize children? Expanding access to pediatric prevention, care and

treatment is an essential part of meeting global targets and necessary to prevent 800 deaths/day

Bottlenecks and challenges New technologies and strategies are being developed to

expand access to testing and treatment for all children in need

Priority Interventions Key interventions to increase access to pediatric care and

treatment should be used to help achieve the goal of providing a better future for our children

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