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PhD presentation

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Janneke Van Dijk

on 10 February 2016

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Transcript of PhD presentation

HIV Service Delivery
Pregnant Woman
Zambia HIV prevalence 14%

Mother to Child Transmission (MTCT) accounts for 21% of all HIV infections

Without interventions the estimated MTCT rates ranges from 15% - 45%

PMTCT coverage in Zambia > 75%
HIV-exposed infant / child
Access to HIV screening depends on timely identification
of the child being at risk
HIV infected child
Linkage to care
MCH, pediatric inpatients, nutrition programs, TB services etc.
Reaching Adolescence & Adulthood
Developments in service delivery and care
providing both acute and chronic life-long care
locally adapted strategies to overcome challenges

Option B
Option A
AZT 300 mg BD
Onset of labour
During labour
AZT / 3TC BD for 7 days

daily NVP from birth to 1 wk after weaning
Option B+
Start HAART for life,
regardless of CD4 count
Rural Realities
in Paediatric HIV Service Delivery

Janneke H. van Dijk
17 September 2013

Early Infant
of Mother
to Child
HIV diagnosis
HIV Care & Treatment
Barriers to Care
Long travel times
26% traveling more than 5 hours
Transport challenges
costs > 5US$ for 53% using motorized transport
Treatment response
Virologic suppression
Disclosure to child
Treatment preparation
60% were eligible for ART at study enrollment
Eligibility Criteria
ART regimens
Overall ART coverage in Zambia > 80%
Estimated coverage of HIV treatment among children 28%
Rural Challenges
Urban - Rural comparison
73% had problems in access to care
ART 79% vs pre-ART 59%, p=0.01
Clinical predictors of mortality underscore the need to identify HIV infected children at an earlier age
Treatment response
Growth patterns
Revised criteria so that children become eligible for ART at less severe stages of immune suppression
Increase access to
pediatric formulations
Simplified dosing, including FDC
Easy to administer
Do not require refrigeration
Suitable for children co-infected
with TB
Effective second-line treatment
for children
17% of children > 10 yrs old in 2009 cohort
33% ART vs 6% pre-ART, p=0.05
Attrition is influenced by both
eligibility for ART and distance to the clinic
Strengthen links between maternal and child health programs
for earlier identification of children
Detrimental effect of long travel times
on virologic suppression
Persistent viral suppression in 87%
within the first 2 years of treatment
13% at least 1 sample with detectable VL
29% persistent detectable VL with
no clinical or immunological failure
43% viral rebound
Weight and height-for-age significantly improved after ART initiation
Underweight 60% -> 25%, Stunted 72% -> 46%
Weight-for-age z-score (WAZ)
Pattern of improvement associated with
level of undernutrition
Height-for-age z-score (HAZ)
Pattern of improvement associated with
age at initiation
Reasons for delay in treatment initiation
family delay (34%), provider delay (29%),
medical delay (20%), combination (26%)
Efavirenz can be used effectively in young HIV-infected children with tuberculosis
EFV dosing strategy needs to be validated and optimized
Factors influencing Adherence
Resource availability
food, finances, transportation
Health literacy
Stability at home and daily routine
Social support and stigma
Cultural and religious beliefs
Memory and cognitive function
Strengthening Adherence
in Macha

Determining psychological and psychosocial treatment readiness
for caregiver and child
Treatment supporters
Family-centered approach
Measure pediatric adherence
Psychosocial counseling for
caregiver and child
Treatment literacy
Increase to 48% disclosure among children > 10 yrs old in the 2013 cohort
Co-responsibility of caregivers and
health care providers
Comparison of mobile and hospital based clinics

67% faced fewer obstacles in getting to the clinic

similar clinical and immunological outcomes

children in outreach group less likely to achieve virologic suppression

potentially due to lower adherence
Disclosure of HIV infection status
Retention in care

Shortages of health care providers
staging, eligibility assessment, dosing, counseling
Lack of (laboratory) capacity for infant diagnosis
and treatment monitoring

Particularly affecting children
Maternal and Child Health
Nutritional services
Sexual and reproductive Health
TB services
Non-communicable diseases
Mental disorders

Need for:
development of indicators for integrated approaches
integrated medical records & monitoring systems
strengthening referral systems
Increase level of disclosure
Follow guidance on disclosure
using tools

Training of health care providers and counselors to guide the process

Intensified information education and communication to
destigmatize the disease
>90% of children infected with HIV through MTCT
HAART until delivery
if breastfeeding, until 1 wk after weaning
daily NVP from birth to 6 wks of age
Improved coverage and effectiveness of PMTCT programs can reduce the number of infected children
Older age and greater disease severity at treatment initiation in
sub-Saharan Africa

High mortality rate of perinatally infected infants in the first year of life
early diagnosis is an urgent priority
Improve PMTCT uptake
Retain women in care
Male involvement
Support medication adherence
throughout pregnancy & breastfeeding
Include family planning services
Point of care CD4 testing
Available to all pregnant women within walking distance in their communities
More widespread testing of children
at different entry points - PITC
Increased access to easy-to-use low-cost
point-of-care technologies for Early Infant Diagnosis
Cumulative pre-ART mortality was 13.3%
Cumulative mortality on ART 14.4% at 24 months
Factors associated with mortality
younger age, anemia, and lower WAZ score

At least 35% of children progressed to eligibility within 1 year
Task-shifting enables decentralization and scale up of ART services

Can reduce program costs and increase program efficiency

Comply with regulations and policies

Consider motivational strategies for lay-workers

Training, supervision and mentoring of health care workers are of importance to ensure high quality care
Improve Nutritional status
Integrating nutritional assessment
routine anthropometric assessments
use weight-for-age charts

Training health care workers

Referral for nutritional counseling
identifying causes of undernutrition

Provision of nutritional supplementation
therapeutic and supplementary feeding
integrated disease management
partnering with organizations
virologic suppression
Optimal ART regimens

Adherence assessment and counseling

Improve treatment failure detection
simple, low-cost, point-of-care assays
to monitor HIV viral load

Decentralized models of care
Rural challenges in general
Shortages of equipment and drugs
Limited modes of transportation
Food insecurity
Proportion of non-adherent children decreased over time
35% at 3 months to 25% at 24 months

43% consistently adherent
2% consistently non-adherent
55% alternating between adherence and
Improvements in the earlier enrollment & treatment
expected to result in better outcomes

ART provision among children lags behind
"I have come to the conclusion that HIV/AIDS is not entirely about death. People die and will continue to die for one reason or the other. AIDS is also about the living" (Kiza Ngozi)
Improve turn-around time of test results
Continued adherence counseling is critical for the success of decentralized care
Prevention of Mother to Child Transmission - PMTCT
HIV diagnosis - Early Infant Diagnosis (EID)
Care and Treatment
Further improve access & ensure optimal outcomes
Ensure early infant diagnosis
Increase access to treatment services
Integrate nutritional support
Optimize care to attain sustained improvements
Improve retention in care
HIV service delivery is evolving
PMTCT, EID, treatment guidelines, drug regimens
Improve Access
Treatment Outcomes

Early identification of exposed child

Point-of-care diagnostics

Linkage to care
Increase Access
Set ambitious yet attainable time-bound targets
Nutritional Support
Optimize Care
Disclosure to child

Improve access to
optimal treatment regimens

Adherence promotion

Optimize monitoring strategies
Family-centered approach

Decentralized model of healthcare delivery

Use of m-Health tools - cell phone reminders

Intensive monitoring of high-risk patients

Community network support - PLWHA

Patient tracking system
Improve Retention in Care
Ensure EID
Service integration with maternal, neonatal and
child health services
Community support programs:
mentor, support disclosure, promote male involvement, reduce stigma
Challenges to Integrated Care
Policy Level:
vertical programming
lack of policy guidance
under-funding of some program areas
program territorialism
weak referral system
Service Level:
high patient load
staff shortages - insufficient training & skills
resistance to change
inadequate monitoring systems related to integration
Decentralized service delivery

Task-shifting / Task-sharing
Standarized and simplified regimens
and care packages
Political commitment

Budget allocation
Buy-in from

Sector ministers
Build Institutional


Human capacity
Nutrition Programs
& Interventions
daily NVP from birth till 6 wks of age
Full transcript