Addressing Children of Key Populations

Transcription

1 Addressing Children of Key Populations July 10, /10/18 1

2 Agenda 8:00-8:15 Introduction Overview of Considerations for Addressing Children of KP 8:15-8:25 8:25-8:35 8:35-8:45 Tanzania Ethiopia Côte d Ivoire 8:45-8:55 8:55-9:10 9:10-9:30 Where are the gaps? West & Central Africa Data Review Next Steps / Survey Q&A

3 Goals for today Purpose of the Webinar Follow-up from Children of KP webinar hosted by USAID in May Release USAID considerations addressing care, treatment and support for children of KP. Review current country models for children of KP and facilitate sharing and learning among field colleagues and local partners. Inform future agency guidance and technical support to country programs to advance KP, PMTCT/Pediatric and OVC program integration, applying a family-based support model.

4 Defeating AIDS but missing children The attention to key populations - MSM, IDUs, SWs, prisoners, and residents in hot spots - are entirely adult referenced. MSM, IDUs, SWs, and prisoners may well have children whose needs could be overshadowed. *Piot P, Karim SSA, Hecht R, et al. Defeating AIDS advancing global health. Lancet. 2015; 386: *Sherr L, Cluver L, Tomlinson M, et al. Defeating AIDS but missing children. Lancet. 2015; 386: 1035.

5 Voices of Key Population Parents There is not a single sex worker-led organization in Kenya that support children of sex workers. The reason is that most groups are focused on addressing the issues faced by sex workers themselves. - Sex worker from Kenya I just want to live and raise my children, be a loving husband and not be afraid to die or go to jail. I think I have that right, and really want to use it. - Injecting drug user from Russia I didn t have money to send my son to high school I approached the government office that offers bursaries to disadvantaged children But I couldn t I say I hustle as a sex worker and I am a man So I gave up. Now my son is working on small farms in the village. I pity him. And I am upset that he missed out on high school education. - Male sex worker from Kenya While a large body of research has shown that problematic drug use does impede parenting skills, there are a wider range of experiences of functional drug using adults and their families that research has historically ignored. - Researcher on PWID and families My children need to know that I m working for them. - Sex worker from South Africa Children of Key Populations Taskforce. From Shadows to Light: Advocacy Report for Children of HIV-Affected Key Populations, Coalition of Children Affected by HIV/AIDS, October 2016.

6 Key Issues for Children of KP. Inadequate or siloed KPsensitive services for children. General stigma & discrimination, and its effects on children, including its results in self-stigma (internalized stigma). Lack of KP-sensitive child care, protection & safeguarding services, which fit the realities of key population parents lives, and which are bias-free. Exclusion from safe, bully-free educational services and opportunities from early childhood through adolescence. Legal barriers & the lack of legal advocacy support, which lead to: a) inability to register birth or identity, b) problematic or forced registration of KP, c) criminalization of parents d) child endangerment by authorities and e) lack of protection from/response to child abuse. *Making the Children of Key Populations a Priority for Equitable Development, Advocacy Briefer, Coalition of Children Affected by HIV/AIDS, 2016.

7 Children of KP: Gaps in Programming A targeted and integrated approach for KP and their children, through KP, PMTCT, Pediatric, and OVC programming is needed.. These children are missing from programs, assessments, models of care, and research. KP parents more likely to participate in HIV interventions if the needs of their children are met first. Supporting these children helps families link to services. These children face a double burden: the effects of HIV/AIDS and social exclusion. Stigma results in lower access to education, health, social assistance and protection. Tailored approach to addressing children of FSWs, MSM, PWID and TG. No one size fits all model given varying vulnerabilities and circumstances among families of KP.

8 Guiding Questions What is the burden of children of KP? Why should they be a priority? What are the data gaps exist for enumerating the number of children of KP? What are the biggest barriers to addressing children of KP? How do we address the lack of evidence base and data gaps? Are there indicators that currently exist to track children of KP? What types of differentiated service delivery models and platforms can be used? Do countries have existing tools addressing KP and their families? How do we estimate expenditures and resources need for addressing children of KP?

9 Family Dynamics & Household HIV Risk. High prevalence of HIV, KP part of families and have children Poor uptake of FP, Option B+, and EID services HIV transmission to children, poor active casefinding and treatment coverage Children vulnerable due to stigmatization of parents, poor uptake of OVC services

10 Priority OVC sub-populations. Children with loss of 1 or both parents due HIV/AIDS Children of HIV+ FSWs Children of HIV+ PWID Children living with HIV-infected parents OVC Children of HIV+ MSM HIVexposed infants HIV-infected children Adolescents 10-18yo of all KP

11 7/12/

12 Goals and Objectives USAID Considerations: Addressing Children of KP 1. Highlight key considerations, including data points, for the design of effective treatment, care and support models targeting FSW mothers and their children. 2. Share information on current working models as well as service packages with priority interventions which may inform program development and service planning. 3. Provide recommendations for monitoring and evaluation, including targeting considerations, data collection and reporting and expected outcomes in order to enable program assessment and adaptation.

13 Package of Services Office of HIV/AIDS: Children of KP Taskforce. Addressing Children of Key Populations. U.S. Agency for International Development, Global Health Bureau, July 2018.

14 . Working with children of KP requires a sensitive approach The very act of identifying children of KP can increase vulnerability. Important to proceed with caution. Do No Harm: Requires a cautious approach to avoid forced removal/separation of children from parents, rehabilitation centers, imprisonment, or worse. Critical to develop a Risk Mitigation Plan. When working with KP and their children, ensure direct service provision is offered in ways appropriate to the population that offer safe spaces where people are treated with dignity and respect, without judgment and stigma. Active meaningful participation of KP in design of service delivery models.

15 Long-term Goals and Impact. Goals and Impact for KP and their Children Continuous engagement of KP and children in design/adaptation of accepted models of care Improved parental capacity (health, socio-emotional well-being, knowledge/skills, economic security) to meet children s critical needs Improved well-being among children of KP (health, nutrition, education, protection, socio-emotional) per PEPFAR essential indicators Improved coverage of HIV services for KP and children Reduced violence against KP and children and improved response (health, psychosocial, protection) Lessons learned and model of care and support for children of KP documented and disseminated with relevant data 95% HIV+ KP and children access HTS and receive results; 95% of KP, CLHIV and ALHIV access and adhere to treatment; 95% are virally suppressed

16 HIV Combination Prevention for Children of Key and Vulnerable Populations in Tanzania: Sauti Project Sauti Project / Dr. Albert Komba, Chief of Party albert.komba@jhpiego.org

17 Sauti Project in Tanzania GOAL: Contribute to improved health for all Tanzanians through sustained reduction in new HIV infections Provides biomedical, behavioral and structural prevention, HIV Testing & Linkage, and family planning to key & vulnerable populations (KVPs) Female sex workers & their sexual partners Men who have sex with men Adolescent girls and young women Other at risk populations living in hotspots Children of KP & PLHIV Working in 14 regions with high HIV burden Targets for Oct 2017 Sept 2018: Test for HIV 1.14 Million, Diagnose 36,560 Stakeholders: Government of Tanzania & 18 Civil society organizations

18 SAUTI S OVERARCHING STRATEGY To Saturate 80% of Key & Vulnerable Populations (KVPs) with a core package of combined biomedical, structural & behavioural interventions BEHAVIOURAL Peer Educators Curricula Based BIOMEDICAL HTS,HIVST, FP, PrEP, Comm ART, Screening for STI, TB, Alcohol/ Drugs, GBV KVPs participate in a core package of vulnerability-tailored STRUCTURAL Economic Empowerment Cash Transfer client- and community-centered combination HIV prevention and FP services traceable linkages to care, treatment and other referral services

19 SAUTI PROJECT BENEFICIARIES Key Populations (KPs) FSW: Female ages 18 and above who exchange sex for cash/goods as primary source of income (>50%) } MSM: Male ages 15 and above who engage in sexual relations with other males regardless of the motivation AGYW: Female out of school, sexually active ages PFSW: Sexual Partners of female sex workers HIV Vulnerable Populations (VPs) OHSP: Other Hotspot Population (e.g. men in mobile occupations, mine workers, fishermen, truck drivers, female in transactional sex, etc.) Children (of KVP): male and female under 15 Prevalence >>Children (0-14 yrs.): 0.4% >> Adults (15-49 yrs.): 4.8% >> Adults (15-64 yrs.): 5.1%

20 Sauti Core Package of Services Intervention FSW MSM AGYW PFSW OHSP Peds of KVP 1. Biomedical Risk assessment and counseling X X X X X X HTS / Index testing X X X X X X HIV Self Testing X X X FP counseling and services X X X STI screening X X X X X X* STI periodic presumptive treatment X X Condoms Promotion Provision X X X X X X* TB screening X X X X X X GBV screening X X X X X X Alcohol and drug screening X X X X X X* Escorted referral Care & Treatment X X X X X X Clinic, GBV services, RCHS Community ART to stable PLHIV X X X X X Pre Exposure Prophylaxis X 2. SBCC Demand creation X X X X X X SBCC group education X X SBCC individual education X X 3. Economic Empowerment Saving and Loaning and Parenting X Cash transfer program X 5. PLHIV and Alcohol support groups X X X X X 6. SASA! X X X X X X

21 Sauti s KVP-Focused Service Delivery Models (WHO Building Blocks) WHEN Social Behaviour Change Communication (SBCC)/Gender As needed, monthly for support groups Linkage to Care As needed, and following national guidelines Biomedical Package HIV testing services (HTS) for those who test negative, retesting should be done after 4 weeks and, thereafter, routine HIV testing should be offered every 6 months PrEP monthly then every two months WHERE Community and homes Community and homes WHO WHAT Peer Educators/ Empowerment Workers Peer led behaviour change education (curriculum-based), Demand creation for combination prevention services, HIV self-testing distribution, PLHIV support groups, PrEP support groups Nurse, Clinicians, Peer Educators HIV Care & Treatment, genderbased violence care, Intrauterine Device, and Permanent FP methods At hotspot venues (e.g. brothels, guest houses, bars, night clubs, fishing, mining communities, plantations, truck/taxi drivers parking) and homes Nurse, Clinicians Core package: HIV testing (provider initiated), HIV selftesting, Family planning, Syndromic screening of TB, gender based violence, STI and Alcohol/drug use, Syphilis testing, Expanded package: STI periodic presumptive treatment (PPT), PrEP, Community ART initiation & refills for stable clients (provided in some districts only)

22 Sauti s Approaches for Targeting Children Accessing at risk OVCs through MVC registers at ward level, Targeting children of KVPs in the SBCC/WORTH+ and hotspots Targeting children of identified PLHIVs Non-KVPs Testing peds at orphanage centers Targeting street children (who do not belong to the above) Using list of HIV positive mothers from care & treatment clinics (CTC) for index testing*

23 Key results to date I (FY17 Q1-Q4 & FY18 Q1-Q2) HTS progress to target, All Peds HIV+ progress to target, All Peds 300, , , , ,000 50, ,213 26,308 FY17 APR 238, ,828 FY18 SAPR 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, ,832 3,546 1,038 1,174 FY17 APR FY18 SAPR All Peds All Peds All Peds All Peds Programmatic Assumption: Estimating Children of KVPs About 60% of FSW reached through SBCC intervention have at least one child; therefore for FY18 KP Prev FSW target of 50,000+, it is estimated that Sauti will reach a minimum of 30,000 Peds of FSW (Note: Though majority of FSW are mobile and do not travel with their kids) 7/10/18 23

24 Key results to date II (FY17 Q1-Q4 & FY18 Q1-Q2) 200, , , , , ,000 80,000 60,000 40,000 20,000 - ALL Peds Cumulative HTS (N=174,981) 174,981 49,984 14,441 21,319 27,151 2,635 Q1 Q2 Q3 Q4 Q1 Q All Peds, HIV Yield and CTC Enrollment (N=2,171) 88% 82% % % 81% % % 1.9% 5.3% 6.1% 1.8% 0.6% Q1 Q2 Q3 Q4 Q1 Q % 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% FY17 FY18 FY17 FY18 Average Yield: 2.9% Average Enrollment 81% 7/12/

25 Key results to date III (FY17 Q1-Q4 & FY18 Q1-Q2) FY17 APR HTS FY18 SAPR HIV+ & Yield by Ped Type, FY18 SAPR KVP Peds non KVP Peds 88% 12% 77% 23% 1, KVP HIV+ Peds % 0.7% Non HIV+ - KVP Peds KVP Peds Peds of KVP represent 12% of the HTS and 23% of the HIV+ Peds Yield among Peds of KVP is twice as higher than the yield among Peds of non KVP 7/12/

26 Key results to date IV (FY17 Q1-Q4 & FY18 Q1-Q2) Age Distribution among KVP Peds HTS, FY17 APR Age Distribution among KVP Peds HIV+, FY18 SAPR 2.5% KVP Peds Yield by age group, FY18 SAPR Tested 1-4 Tested 5-9 Tested % 46% 26% 29% 37% 35% 2.0% 1.5% 1.0% 0.5% 0.0% 2.0% 1.2% % Highest yield was in ages 1-4 yrs Majority of KVP peds tested and tested HIV+ were ages 5-9 yrs 7/12/

27 Key Findings/Lessons Learned Strengths: Peer-led community-based services increase service utilization by KVPs and their children Limitation: Disaggregation by KVP Vs. non - KVP Peds started only recently, so trends cannot be examined for now M&E Tracking mother-child pair has not been implemented yet Based on the existing FSW population size estimates, the current Peds HIV+ target (treatment gap) can not be solely met by only testing the children of the HIV+ moms Key challenges: Law/legal environment affects reaching KVPs children High KP mobility (children not staying with the mother) Lack of policy for community ART to newly diagnosed HIV+ clients (adults and children) Opportunities: Upcoming collaboration with OVC to offer additional services to children of KVP Stronger partnership with C&T services and partners to offer HTS to those HIV+ moms who were missed by the PMTCT services 7/10/18 FOOTER GOES HERE 27

28 Services under Kizazi Kipya Project Phase I Services provided directly by Community Case Workers (CCWs) to caregivers FSW Case management and care plan development and monitoring CHF/TIKA Nutrition assessments, counseling, and support Basic childhood development skills Services provided directly by LVs: Economic strengthening (WORTH Yetu including money management and micro-enterprise skills) Referral & linkages provided by CCWs: Referrals and linkages to appropriate health and social services and to HIV services HIV-related services provided by CCWs (direct services and referrals, in coordination with Sauti): Link to Sauti HTC If HIV+, ensure treatment initiation [Sauti leads post-test treatment initiation linkage] Follow up missed CTC appointments Link to PLHIV support groups Provide basic ART adherence and disclosure support Direct services provided by Community Case Workers (CCWs) to children All Ages Enrollment in case management, assessment and care plan development Nutrition assessments, counseling, and support CHF/TIKA Child protection identification and reporting of child abuse cases, follow up and case conferencing HIV related services provided by CCWs (direct services and referral, in coordination with Sauti) All Ages Administer HIV risk screening, services, and adherence assessment Link all children of FSW to Sauti HTC Accompany HIV+ children to CTCs for treatment initiation Trace and follow up HIV+ children who miss appointments Provide ART adherence and disclosure support, monitor and address adherence barriers Age-specific additional services 0-9 yrs Provide accompanied referrals to ensure that HIV-exposed infants receive Early Infant Diagnosis Strengthen caregiver skills in early childhood stimulation yrs Provide HURU menstruation kits and sessions; puberty booklets for in-school girls and boys yrs Sexual reproductive health knowledge and skills (out-of-school girls, through Wazesha Groups and from health care workers) Vocational scholarships, livelihoods training and start up kits (out of school girls and boys, through Wazesha Groups) 7/12/

29 Planned Activities Strengthen collaboration with FSW networks/groups Strengthen collaboration with OVC partners (bidirectional referral of KVP peds) Continue providing evidence to GOT on the benefits of community ART to newly diagnosed HIV+ KVP and their children (e.g. through the roll out of SOAR Dependent Study) Strengthen collaboration with facility-based care & treatment partners (continuum of care) Continue to advocating for community-based partners to access use the list of HIV positive mothers from CTC to conduct index testing Reviewing the M&E tools to enable tracking of motherchildren pairs, and disaggregation of Peds HTS data by KP, VP and Non-KVP 7/10/18 29

30 Care and Support for Children of Female Sex Workers in Ethiopia Dr. Kesetebirhan, HIV/AID and Health Technical Director USAID Caring for Vulnerable Children Activity FHI360 7/10/18 30

31 Program Overview USAID Caring for Vulnerable Children (CVC) works in 126 SNUs in six regions to serve 325,000 OVC & their 171,238 caregivers; Through goal oriented, HIV sensitive & family-centered case management approach To access quality care and support services tailored to their individual needs. Services provided fall under the four PEPFAR core intervention areas of Healthy, Safe, Schooled and Stable Implementation period is May, May, 2022 Partners: Plan Int., Retrak, Ethiopian Society of Sociologists, Social Workers and Anthropologists (ESSSWA), and 22 LIPS/CBOs 31

32 Cadres Case Workers (CWs)/ Community Volunteers Social Service Workers (SSWs) HIV/AIDS & Health Linkage Coordinators Service Delivery Personnel Number Deployed Locatio n Role 12,145 Kebele Provide case management services at the household level 716 Kebele Provide coaching and supportive supervision to CWs (seconded to CCC) 83 HIV/AIDS & Health Linkage coordinators LIP Facilitate linkages between HFs and communities Caseload 20 children (approx. 10 HHs) 20 CWs 3 Health Facilities LIP Project officers 46 Project Officers Woreda Supervise and support SSWs to assure service and data quality, deliver specialized trainings for caregivers/youth 20 SSWs 32

33 Sub-populations being served/prioritized & Enrollment Strategy 33

34 Targeting approach for Female Sex Workers Female Sex Workers (FSWs) are targeted at Drop in Centers (DICs), community level (home based or street based) Identification and enrollment was done through partnership agreements with: PSI s MULU/MARPS HIV Prevention Project Project Hope s Community HIV Prevention and Care and Treatment Program Outreach clinics for MARPs in 86 woredas/districts) with health organizations The process also involved community mapping by Community Care Coalitions (CCCs) CCCs, Case workers and social service workers were trained prior to identification on procedures that prevented stigma, vulnerability assessment and prioritization criteria Total CFSWs enrolled and served with OVC services so far is 12,379 CFSWs are linked to social-economic services (eg., education follow-up, financial capability skills, Savings Groups, counseling, HIV testing etc). Case management activities conducted for FSWs include Needs and strengths identification, Care planning, case implementation and monitoring

35 Key Strategies used to support FSWs HIV Sensitive Family centered Case Management Focused support for Adolescent Girls Strengthened bi-directional referral linkages through Drop in Centers &Health Facilities Economic Strengthening for FSWs

36 Key findings to date: Top 10 needs of CFSWs Needs Prevalence Child does not have a birth certificate 74% Child does not have sources of support 60% Caregiver is concerned about the child s safety 35% The child/adolescent has no marketable/employability skills 32% Infant/child/adolescent is at risk of HIV but has not been tested 22% Child is sad most of the time or seems hopeless 19% Child is not doing well in school 17% Child is not enrolled in school 16% Child does not feel safe at home or at school 16% Child misses school frequently (more than 5 fives in the last month) 12% Infant/child is ill and is not receiving medical care 10% 7/10/18 36

37 Key findings to date: HIV testing of CFSWs at DICs Indicators Overall Percent having children 47 Number of children 74 Number of children tested 59 Percent children tested 80% Number referred by CVC for testing 34 Percent referred by CVC for testing 58% Number tested positive 5 Number of children delivered before mother 53 started ART Number of children delivered before ART, 5 Positive Yield in children delivered before ART started 9% for FSW Number delivered after mother started ART 6 Number delivered after mother started ART, 0 Positive Yield in children delivered after mother started 0% ART Previously if a sex worker has a child she was referred to health facility for comprehensive support Most DICs on the process of transitioning to a new model of care where FSWs having children can be provided testing service at the DIC; Data is from 3/16 DICs, May, 2018 This shows that children of HIV+ FSWs born after mother started ART are at greater risk of un diagnosed HIV 7/10/18 FOOTER GOES HERE 37

38 Service package being provided (direct and via referrals) Psychosocial support Social protection Children of Sex workers and Caregivers Legal support Education Child protection Health and nutrition 7/10/18 38

39 39 Health Linkage to OVC Core Services Health, Family Planning and nutrition services, immunizations, HIV testing, treatment and care services, HIV prevention life skills education for adolescents, counselling for HIV+ parents on sero status disclosure to their children Protection Child protection, legal support, Girls mentorship Clubs, gender based violence and positive parenting Education Economic Strengthening Follow up through home and school visits, linkages for scholarships engaging head teachers to waive artificial barriers for schooling Economic strengthening for caregivers and youth; Savings Groups, Financial Capability training, asset transfer and linkages to micro finance

40 Key results to date: HIV testing for FSWs and their Children Jan-Mar 2018 Apr-May 2018 # Referred # Referred & Positivity rate Positivity rate and tested tested CFSWs % 986 1% FSWs % 502 3% To increase pediatric case finding, CVC is scaling up testing of HIV+ CFSWs to all DICs for children born before ART was started. CVC is testing a revised HIV risk screening tool to make it more sensitive 7/10/18 40

41 HIV testing flow- Old Female sex worker Program Initiated Adaptation Children of Female sex worker HIV testing flow- New HIV testing for Female sex worker HIV positive HIV negative Test for HIV Test for HIV Refer HIV positive for Treatment Refer HIV positive for Treatment Assuming 100 FSWs have 200 children, 3% HIV positive yield for the mother and 20% MTCT, this approach will require 300 HIV tests to be performed to get One HIV+ child Test all children born before ART was started as priority Refer HIV positive mother and the child for treatment Do not test the child In this new approach, we will test only 6 children from 3 HIV + mothers and get one HIV + child. This will reduce HIV testing burden by 65% down to 106 and increase test yield for children 20 fold from 1% to 20% 41

42 Key Findings/Lessons Learned Program strengths Program focused on targeted sub populations including CFSWs from the start of program beneficiary enrollment Partnership with DICs as entry points Strong collaboration with community structures Community Care Coalitions- who identify FSWs through community mapping Leveraging OVC services and Case management approach to meet holistic needs of CFSWs Trained Social Service workers and HIV linkage coordinators to facilitate Community and Clinical Linkages, to prepare them work with this difficult subgroup Program limitations/gaps Responding to high demand of female sex workers and their children- Implementing have reached their enrollment target ceilings 7/10/18 42

43 Key Findings/Lessons Learned Key challenges: Earning the trust of sex workers is time taking: most of them don t want to disclose that they have children as that is bad for business if it is know in the community they work in Many CFSWs do not live with their mothers making access difficult. Some FSWs resist testing their children, therefore require rigorous counseling and educating, which takes time Opportunities for improved results Program adaptation to target children of HIV+ FSWs and testing the mother first Priority enrollment to replace those who graduate will be given to CFSWs due to the high due to the high HIV positivity yield Program tools HIV risk assessment tool revised to identify more children by first testing the mother as long as the mother is around 7/10/18 43

44 Planned activities (next 3-6 months) Research on CFSWs FHI 360 will be conducting a qualitative research study in Ethiopia, along with Baseline Survey to better understand the age-specific risk factors children of FSWs are exposed to, particularly those that increase their risk to HIV infection, as well as the barriers they face to access services. The main research objectives are to: Identify and explore the age-specific health and social vulnerabilities of CFSWs Identify and explore the social, cultural and economic barriers FSWs face in accessing health and social services for their children Identify the most effective strategies for identifying, engaging with and retaining FSWs and their children in OVC programs 7/10/18 44

45 Planned activities (next 3-6 months) Services/components that will be added to the current model Finalize baseline assessment and qualitative research to identify and understand needs in depth Quality assessment and improvement actions Tracking service delivery quality Improve documentation and data use at case worker level 7/10/18 45

46 Thank you 46

47 Care and Support for Children and Adolescents of Key Populations in Côte d Ivoire 10 July 2018 Reve/Dr. Gisele Semde, Chief of Party gisele.semde@savethechildren.org 7/10/18 47

48 Program/activity and progress over the last year USAID OVC program in Cote d Ivoire is conducted by Save the Children through a project named REVE. FHI360 is the one leading KP program through LINKAGES project. Sub-populations being served/prioritized, including specific focus on adolescents/agyw of KP? Children of positive female sex workers Adolescent girls of female sex workers Targeting approach for sub-populations Collaborative approach/ Synergy on with KP program to identify children Outreach in KP hotspot 7/10/18 48

49 Program/activity and progress over the last year Key objectives Reduce HIV risk through fully empowerment. Contribute effectively and efficiently to goals; this includes developing a care and support component for children of female sex workers (CFSWs). Geographic USAID OVC program covers 22 districts but start with one local NGO (Espace Confiance) in Abidjan 7/12/

50 Key Results to date Target No specific target for CFSW Key strategies/ activities Discussion with KP program to facilitate/introduce CCs from OVC program in KP hotspots Specialization of some Community Counselors (CCs) to follow CFSW and provide services/including working at night for children identification Providing standard OVC service package with an emphasize on sexual education through life skills session, psychosocial support; caregivers sensitization on child social protection 7/12/

51 HTS Results: SAPR FY18 Children under 15 years old LINKAGES CI Project (Q1 and Q2 FY18 REVE (Mai 2018) Service Delivery Point by Result: Index Testing Community Service Delivery Point by Result: Index Testing Community - Positive F M F Service Delivery Point by Result: Index Testing Community Service Delivery Point by Result: Index Testing Community - Positive M Yield =13.4% Yield =6.7% All positive children are on ART 7/12/

52 Key Findings/Lessons Learned Strengths: Close collaboration between OVC program and KP program Common understanding of role and responsibilities of every program Limitations: Children are not living most of the time with their parent in the same geographic area Difficulty to differentiate CFSW already enrolled in OVC program Opportunities: Focus OVC program on most vulnerable and mitigate HIV impact Serving CFSW through OVC program might be the way to strengthen retention of FSW in KP program Develop a specific Child Protection approach for CFSW 7/10/18 52

53 Planned activities (next 3-6 months) Finalized MoU between REVE and LINKAGES Develop a MoU with Heartland Alliance (other KP progr.) Scale up CFSW identification in 3 other sites ( Abengourou/ Rose Blanche; Bouaké/AIDSCOM; Yamoussoukro/ RSB) Focus Enrollment of new OVC among CFSW to reach annual target Trained specialized CCs on follow up and services delivery to CFSW 7/10/18 53

54 TA needs Share best practices from other countries Develop specific package of activities for CFSW 7/12/

55 West & Central Africa Data Review Greg Rosen USAID/DC, SI Intern 7/12/

56 Where do gaps in ART coverage exist for children? 7/10/18 56

57 Gaps in pediatric ART coverage are geographically observable and related to HIV epidemic types 7/12/

58 Analysis of UNAIDS AIDSInfo Metadata ( ) Outcome variable: ART Coverage (%) Covariates of interest: UNAIDS region, adult (15-49) HIV prevalence estimates, PEPFAR support type Metadata extracted from UNAIDS AIDSInfo database, 2016 pediatric ART coverage estimates modeled against region using linear regression Countries with ART coverage >95% and adult HIV prevalence <0.1 were excluded from statistical analysis UNAIDS metadata extracted Transposed into long-form in Excel Uploaded into Stata for data management/analysis Descriptive statistics and visualizations in Tableau 7/12/

59 Pediatric ART coverage is 29% lower for countries in West/Central Africa Crude and adjusted risk ratio (RR) of ART coverage for children (0-14 years) in 2016, by region (WC Africa vs. Other) [N=106] Bivariate Linear Regression Multivariable Linear Regression* crr 95% CI P-Value arr 95% CI P-Value West/Central Africa , < , <0.001 *Model adjusted for Adult HIV prevalence estimates and PEPFAR support type (LTS, STAR, unsupported) 7/12/

60 Next Steps 7/12/

61 . Children living with HIV-infected parents Children with loss of 1 or both parents due HIV/AIDS HIVexposed infants Priority OVC sub-populations Children of HIV+ FSWs OVC HIV-infected children Children of HIV+ PWID Adolescents 10-18yo of all KP Children of HIV+ MSM Prevention and Treatment Response ALHIV AGYW Young KP Girls engaged in high risk behaviors (eg/ transactional sex) At risk adolescents of KP Children/adolescents of PWID and MSM Children living and working on streets (CLWS) Engaged in sex work CLWS who are children of FSW

62 Geography Phase I countries Identify next phase of countries developing models of care. Burden of FSW, MSM, and PWID Burden of CLHIV, ALHIV and at-risk adolescents HIV prevalence ART coverage Reaching targets? Government buy-in, KP/Clinical/OVC partner mix Phase II countries? WCA Nigeria, DRC Southern Africa South Africa, Lesotho, Swaziland, Malawi East Africa Kenya, Burundi

63 All things data Estimates and targeting by priority sub-populations Standardized and refined M&E targeting and reporting based on estimates. Set testing targets for the number of children of KP tested based on the population estimates of KP living with HIV (correlate with KP_PREV). What kind of data should/can partners report on? Case-finding and linkage to ART, viral suppression, linkage to OVC services. Consider custom program indicators for partners to report on. Refine and standardize data monitoring and collection indicators to set target, monitor burden, coverage and outcomes for KP and their children.. How do we integrate children of KP with ongoing operational research, surveys and hotspot mapping/estimates? Improving clinical and pyscho-social outcomes Ensure treatment coverage for pregnant and breastfeeding KP living with HIV and EID coverage for their HIV-exposed infants (mother/baby pair cascade). Capture clinical cascade outcomes for KP and their children to demonstrate whether they are retained in HIV care, adhere to ART and are virally suppressed. Link all HIV-infected and affected children of KP to OVC services. Include children of KP in family-centered KP-friendly differentiated care models.

64 Recommendations for scale-up. Phased Scale up Plan for Service Delivery Model Targeting FSW Mothers and Children Baseline assessment to understand the needs and challenges. Develop risk mitigation plan and child protection policy in place. Baseline data collection to understand the burden by mapping all HIV+ FSWs at service delivery points and developing a register enumerating their children. Targeted phased approached (select geographic area with modest targets) based on baseline assessment and data collection. Test all children of HIV+FSWs either through referral to facility or community-based testing (if in place). Enrollment into OVC program for services. Continuous review of program data in terms of testing & yield, linkage to care and treatment, retention, and VL suppression. Adapt model for scale up in other high burden geographic areas and for other KP families including MSM, PWID, and TG. Office of HIV/AIDS: Children of KP Taskforce. Addressing Children of Key Populations. U.S. Agency for International Development, Global Health Bureau, July 2018.

65 Survey Link wtzwsvf3e70urz1pp1mgmg-q/viewform

66 USAID/Washington Contacts. Meena Srivastava, Medical Officer Sarah Dastur, OVC Technical Advisor Tisha Wheeler, KP Technical Advisor Allison Ficht, Program Analyst

67 Q&A