Paediatric HIV Care and Treatment in Kenya

Transcription

1 Paediatric HIV Care and Treatment in Kenya Dr Lennah Nyabiage MBChB, MMed (Paeds) Paediatric HIV Symposium, Pride Inn, Mombasa 24 th April 2018

2 Paediatric HIV Burden in Kenya Total population 43million Population< 15 yrs 18million 2015 HIV Estimates No. of HIV + Children 98,000 Unmet ART 20,400 ART Coverage 81% 5/14/2018 2

3 150, , ,000 PLHIV by Gender and Age Group Nationally Male Female 7% of PLHIV in Kenya are children (<14 yrs) 90,000 70,000 50,000 30,000 10,000 (10,000) Source: Spectrum Estimates 2015

4 Pediatric ART Scale up and Coverage ,439 62,836 71,116 79,422 81,019 81,332 79, , , ,618 23,164 28, ,500 8, /14/2018 4

5 Homa Bay Kisumu Nairobi County Siaya Migori Mombasa Kakamega Nakuru Busia Kiambu Uasin Gishu Trans Nzoia Kilifi Bungoma Turkana Machakos Kisii Kajiado Makueni Kitui Kwale Meru Kericho Narok Vihiga Nyamira Nandi Bomet Murang'a Taita Taveta Laikipia Embu Nyeri Tharaka Nithi Baringo Mandera Nyandarua Kirinyaga West Pokot Elgeyo Marakwet Garissa Samburu Isiolo Tana River Wajir Marsabit Lamu Pediatric ART Coverage & Unmet Need by County 10,000 39% PEDS CLHIV, 18% unmet Need (5 Counties) Top 20 Counties contribute 90% of PEDS LHIV Top 20 Counties have 81% Unmet ART Need for PEDS 27 Counties contribute 10% of PEDS LHIV 27 Counties have 19% Unmet ART Need for PEDS 9,000 8,000 7,000 6,000 7 counties > 100% coverage 15 counties >80% coverage 11 counties 60-79% coverage 13 counties <60% 5,000 4,000 3,000 2,000 1,000 0 FY17 TX CURR Unmet Need 5/14/2018 5

6 Paediatric HIV Case Identification Early infant diagnosis HIV positive index client testing Special clinics: TB, malnutrition Orphans and vulnerable children In patient High risk exposure Sick children with unknown HIV status 5/14/2018 6

7 Early Infant Diagnosis Trends in PCR Positivity : HEI Screening at Immunization Clinics: % Total PCR pos on initial DBS 8.0% 7.0% 6.3% % PCR Pos 5.3% % 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 12,000 8,000 4,000-8,816 Infants received Penta 1 7,873 1,381 Data from 5 Counties in Western Kenya 316 1,697 None HEI Known HEI New HEI Total HEI 19% if all HEI are new PCR Positivity by age ( ) % 2484 PCR Pos % Pos 6% 6696% 800 <2m 2-9m 9-12m 12-24m 15% 20% 15% 10% 5% 0% Significant PCR Pos numbers Decreasing PCR Pos Higher positivity with late identification Missed opportunities for HEI identification at Immunization clinics 5/14/2018 7

8 Nairobi Homa Bay Kisumu Siaya Migori Kakamega Mombasa Nakuru Kiambu Kisii Kitui Turkana Busia Uasin Gishu Trans Nzoia Bomet Bungoma Kilifi Machakos Narok Meru Muranga Vihiga Makueni Nyamira Kajiado Kericho Nandi Laikipia Kwale Kirinyaga Nyeri Nyandarua Tharaka Nithi Baringo Embu Elgeyo Marakwet Taita Taveta West Pokot Lamu Samburu Isiolo Garissa Marsabit Tana River Mandera Wajir Total PCR Positives 2017 by County: (n = 2868) Pos % Pos /14/2018 8

9 HIV Testing in Children Kenya data: HIV testing yield (<10 yr old) Total Tested HIV Positive % % % 4.0% % 0.5% % 0.0% 5/14/2018 9

10 Pediatric SMART testing: Increasing efficiencies in pediatric HTS 1 When a patient goes to the HIV Testing Point, s/he is issued with a P-SMART CARD 1. Patient issues with smart card Identifiers Patient information Upon first time issuing the following client details are written onto the P-SMART Card: Patient Identification Details Patient Demographics The following details of the last visit are stored on the patient card? Patient Identification Details Patient Demographics Clinical Observations Time Stamp Data 2. Service provision Identity authentication service delivery including HIV diagnosis 2 HTS Provider Offers Service to the client 3 After successfully administering the testing service, the patient card is inserted into the card reader/writer 4 The card reader/writer is connected to a smart phone hosting the HTS application or a computer with a EMR instance 3. Write to smart card Connect card to EMR/Mobile device Update clinical information & time The testing details are written onto the card and the record sent to respective EMR, i.e. Onsite Local EMR of Cloud based EMR. The service provider returns the card to the owner 4. Return smart card to client & educate

11 % Achieved Paediatric Clinical Cascade: Sep % 100% 80% 60% 40% 20% 100% % achieved Number Timely identification 81% 70% 120, ,000 80,000 60,000 40,000 20,000 Same day ART initiation pref. within 2 weeks Retain on ART Adherence support Timely viral load Target: 95% viral suppression 0% Estimated CLHIV Current on ART Virally Suppressed 0 5/14/

12 Gaps in Paediatric HIV Treatment Pediatric< 15 years ART regimen distribution APR 17 Viral load suppression rate by regimen <15 years 19% 15,799 8% 0% 6, ,429 41% % % % 100% 90% 80% 70% 60% 50% 40% 30% % % 26,412 0 NVP EFV LPV/r 0% 32% Total VL< 1000 VL>1000 % suppressed NVP EFV 1st line PI Source: Pediatric ARV stock, NASCOP VL Website GBV related support ARV regimen for age Dose adjustment Disclosure Caregiver literacy Transition process 5/14/

13 Probability of Retention by HIV Disclosure Status Retention on ART ART vs non ART Family clinics Caregiver literacy and support Disclosure Structured transition to adolescent Account for attritions UCSF FY 17 Q1 report 5/14/

14 Laboratory: Access To Viral load Testing Map for VL and EID networking in Kenya National performance 2017 VL & EID Test # Tests done Rej Rate # sites VL 1,088, % 2,149 EID 109, % 2,766 4 TATs for VL and EID 2017 VL EID Number of central testing Labs VL = 10 EID = 8 of the 10 VL labs + 3 POCs

15 Suppression rates (% of total tests) Viral Suppression by Age: % 90% % 70% 60% 50% 40% % % 10% 0% <5 5 to <10 10 to <15 15 to < Suppressed Age (years) Not suppressed

16 Challenges in Achievement of Viral Suppression in Children Patient factors Unstable caregiver Stigma Disclosure Retention on ART Access to timely VL testing Long TAT for lab results Clinical decision support systems Health systems Viral Suppression HCW factors Delayed disclosure Inadequate skills Diagnosis of co morbidities Suboptimal regimen Sub optimal dose 5/14/

17 What is the primary reason for this consultation: Second line treatment failure Clinical Evaluation: history, physical, diagnostics, working diagnosis (excluding the information in the table below) A 14 year boy on ART for 10years. He was diagnosed with PTB and treated in 2006; HIV was also diagnosed and enrolled in care in WHO stage III. Started on HAART in 2006: D4T/3TC/EFV. Mother died when he was 2 years old and his father is on care. 2 months history of cough and body rashes. The cough is not associated with chest pain or night sweats. Has lost weight despite good appetite. Rashes are papular in nature, itchy and leaves a dark spot after healing. The rashes are spread all over the body and more on the hands and trunk. AAFB and Gene xpert done which was negative. Currently in standard four and performing below average in class. Clinical Decision Making Support MOH led regional technical working groups Capacity building Case review Mentorship Coordinated feedback to sites Timely reports and switches Specialists pay a key role here! 5/14/

18 Management of Treatment Experienced Patients Total with VL >1000 Management of children with VL >1000c/ml 320 No. with repeat VL results Total 191 Repear VL >1000c/ml Percent 124 Switched to second line ART 66% 64% 62% 60% 58% 56% Delays in repeat VL Health system factors Patient factors Adherence Delays in switching of patient regimen Treatment experienced patients Awaiting consultation Availability of drugs UCSF, UMB Timiza FY 17Q1 report 5/14/

19 Strategies to Improve Retention and Viral Suppression Longitudinal Follow up of Patients With High VL 2016 Guidelines Patient level Optimized drugs Systems support Tools for adherence support Counseling & adherence Pre & during ART Peer educators support Assessment tools/ SOPs OTZ initiatives Treatment Simplification DTG Scale up Individualized Treatment plans- TDF/3TC/EFV TDF/3TC/DTG HCW Capacity building Caregiver literacy training Active case management Quality od care check list and dashboards Longitudinal FU of pts with high VL Defaulter management

20 Care Giver Analysis for Children <14 yrs With VL >1000c/ml (Oct 2017) Total with VL>1000 No. with stable care givers HV Pos care giver No with VL results VL <1000c/ml 3579 [VALUE] % % % % WK High VL Audit Oct 2017

21 Differentiated Models of Care Utilizing family Viral Load approach Child _caregiver pair on ART n=222 Viral load suppression for both n=166 (69%) Viral suppression for caregiver only n=51(22%) Viral suppression for child only n=8 (3%) Both child and care giver with Virologic failure N=13(6%) Enroll family in DC model and follow up closely Caregiver training to enhance adherence in child, appropriate regimen switch Family psychosocial assessment, home visit family therapy and support. Appropriate regimen switch UMB Timiza FY 17 Q1 Report: Migori Couunty 21

22 Use of Peers High risk patients - VL >1000 c/ml - LDL but with adherence challenges, - LDL with unstable caregivers Pair at different levels Treatment buddy, Patients neighbor, Community health care worker, HCW - Explore challenges faced by patient - Links patients to appropriate services - Re enforces the importance of adherence Program areas with use of peers: PMTCT: Mentor mothers Adolescents Caregivers High risk clients Patients with VL >1000 KCCB KARP Program: March 2018

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24 Focus on Adolescents HIGH incident HIV infections Implementing adolescent responsive services LOW viral suppression HIGH mortality Loss to follow up Adolescents Health care provider Health system s Outcomes 5/14/

25 OPERATION TRIPLE ZERO (OTZ) ZERO MISSED APPOINTMENT Voluntary enrolment to OTZ Motivation of self & others Pledge to 3 Zeroes ZERO MISSED DRUGS ZERO VIRAL LOAD

26 Scale Up Plan Anchored in MOH Adolescent package of care (APOC) Comprehensive implementation of APOC Bring the adolescents on board (OTZ) Scale up to additional sites 5/14/

27 180, ,000 TB Active Case Finding 179, ,911 KCCB KARP: TB Mortality Audit 140, ,000 4% of those with presumptive TB had TB confirmed 100,000 80,000 60,000 40,000 20,000 0 Total OPD Workload No Screened for TB [VALUE] (3%) [VALUE] (100%) [VALUE] (100%) [VALUE] (4%) [VALUE] (100%) No of Presumptive TB clients No reffered for TB Diagnosis # Investigated # Diagnossed with TB # on TB Treatment CHS FY 16 Q4 Report KCCB FY 16 Q4 Report 5/14/

28 TB/HIV Lessons Learnt Active case finding CCC, OPD, HIV test for all presumptive TB cases Diagnostic work up for HIV pos patients with presumptive TB Additional investigation after neg. gene xpert test Active screening for ART treatment failure All patients developing TB while on ART Special attention to children Capacity building TB easily missed 5/14/

29 Summary Kenya has made progress Unmet needs in several counties Need to implement and monitor strategies to support viral suppression in children and adolescents Scale up TB case identification and timely treatment 5/14/

30 Acknowledgements MOH Implementing partners PEPFAR/CDC KPA Other stakeholders 5/14/

31 THANK YOU 5/14/