The CQUIN Learning Network. Adolescents Living with HIV: Legal framework for testing, treatment, and transition, Challenges and Priorities: Uganda

Transcription

1 The CQUIN Learning Network Adolescents Living with HIV: Legal framework for testing, treatment, and transition, Challenges and Priorities: Uganda Teddy N. Chimulwa STD/AIDS Control Program, Ministry of Health, Uganda October 24-27, 2017 Johannesburg, South Africa

2 Outline Epidemiology of ALHIV in Uganda HIV testing services HIV treatment and DSD Sexual and Reproductive Health services Transition services Challenges and priorities 2

3 Epidemiology of ALHIV in Uganda 1.3million people est. living with HIV in Uganda (UPHIA 2016) ; 1.1million on ART (DHIS-2) Children <15years living with HIV 95,645 (UNAIDS, 2016) HIV prevalence for years (1.1 %) is three times those aged years (3.3 %), and almost doubles again between and (6.3%). Adolescent girls and young women are particularly affected (prevalence 1.8 % at years to 5.1% at and 8.5% by years. HIV Diagnosis (1 st 90) 68% Peds/Adols (0-<15) aware of HIV Status ART Coverage (2 nd 90) 68% Peds/Adolescents on ART (0-<15) Viral Suppression (3 rd 90) 75% Peds/Adolescents (0- <15years) Teenage Pregnancy is 25% among years, 44% unmet need for contraception among PLHIV 3 yet 20-50% PLHIV have fertility desires

4 Differentiated Models for HIV Testing Services 4

5 HIV Testing Services for ALHIV Policy/Legal framework Adolescents are priority population for HTS (HTS policy 2016) HTS age of consent lowered to 12 years from 18 years (HIV prevention and control act 2015, HTS policy 2016) DSD implementation guidelines (2017) Linkage of HIV + adolescents to care- Physical escort by; Adolescent peer educators Linkage facilitators Adolescent Health services focal persons 5

6 Differentiating HTS for Adolescents When Where What Who? Mother is HIV + Symptomatic for HIV Malnourished Hospitalized/ in last 6mo TB diagnosis/history Sexually active/history Accidental exposure Drug abuse During VMMC Facility and communitybased IPD OPD Adolescent friendly clinics/corners ANC FP clinics STI clinics OVC Programs Youth centers Institutions of higher learning (if located within the health facility e.g. training schools) Integrated HTS outreaches PITC Index client tracing and testing (KYCS (including holiday campaigns) Special facility campaigns Special/flexible hours, walk-ins or same-day appointments Trained health workers in Paediatric and Adolescent HTS (incl. Lay providers) Adolescent Peer educators 6

7 All PLHIV are eligible for differentiated treatment and care. However, the model and approach depends on their stability

8 Differentiated Care & Treatment for stable ALHIV What When Where Who Comprehensive clinical assessments Every 6 months (twice a year) ART/CTX/FP refills Every 3 months (4 times a year) Facility Facility (pharmacy or through Facility Based Groups) Clinician (MO, CO or NO) Dispenser, nurse, counselor, Expert client Laboratory tests VL- every 6 months Adherence support Facility- Laboratory Every visit Facility Nurse, counselor, Adolescent Peer educator, Expert client 8

9 Differentiated care & Treatment for unstable ALHIV What When Where Who Comprehensive clinical assessments ART/CTX/FP Refills Laboratory tests Adherence support Already in care: Monthly New/naïve: Monthly for the 1st 3 months; Then at 6 and 9 months In care: Monthly until stable New/naïve: Monthly for the 1st 3 months; Then at 6 and 9 months - Baseline tests at initiation - VL: First VL at 6 months; then every 6 months - VL non-suppression: Repeat VL after at least 3 IAC sessions (1 month apart) with 3 consecutive good adherence scores Every visit Facility Facility Facility Facility & Community Clinician (MO, CO Nursing officer) Dispenser /nurse / Trained lay providers (expert client) Lab staff Counselor/ Nurse/ Trained 9 Peer

10 DSD Considerations for ALHIV Adolescents prioritized for facility-based care models-due to their unique status Adolescent-specific clinics or days Age of consent for treatment: Competency for treatment is based on disclosure of HIV status to the adolescent. Done incrementally and full disclosure achieved at 12 years. Adherence preparation conducted before initiation Parental /guardian support and disclosure is critical although not a must for treatment initiation Emancipated minors: (pregnant, married, head of house hold etc.) are considered high-risk and therefore unstable- facility-based care models; no explicit guidance Unique treatment services available to ALHIV: Retention in care: Appointment monitoring, follow up of missed appointments, counseling support, Adolescent specific clinics with friendly providers, adolescent Peer supporters, recreation activities, Adherence: treatment literacy, adherence clubs (e.g. Ariel clubs), adherence counseling and support, adolescent role models, psychosocial care 10

11 SRH for ALHIV SRH service package: clinical care for SGBV, pregnancy testing, prenatal care and maternity care for pregnant adolescents, HPV immunization, breast examination and information on cervical cancer, Information and counseling on health especially growth and development, their rights and responsibilities and referral and follow up, life-skills training, contraceptive choices, emergency contraception, STI screening & management, and HIV testing Age of consent: Reproductive age- 15 years Emancipated minors : Pregnant, married, head of house hold adolescents. considered to be high-risk, able to access to SRH as adults. 11

12 Status of access to SRH services for ALHIV (as at March 2016)- overall, limited access to SRH services by ALHIV except for STI screening & management Indicator Status HIV testing services coverage (positivity of 2.6%) 32% Linkage into care (out of the positives) 45% Female pregnant adolescents 20% PMTCT coverage for Adolescents 47% STI screening, diagnosis and treatment 98% Coverage for FP among Adolescents living with HIV 11% Ref. Annual Adolescent Assessment

13 Transition Services for ALHIV Two facets: Physical transition of the adolescent: occurs incrementally, by 18 years a deliberate transition plan and structured transition sessions are conducted. Final transition occurs by 20 years. Mental transition of the health care provider: where it is the same provider offering services to both adolescents and adults. Challenges: Documentation and tracking transition still a problem- tools do not allow for routine recording and reporting; majority health workers not well trained to facilitate transition Ref. Uganda national consolidated guidelines for HIV prevention, care and treatment,

14 What are the challenges for DSD for ALHIV? Especially in the era of test and treat Consent for testing: The role of the parent /guardian may be underminedyet critical for adherence support Consent for treatment No explicit guidance about age of consent for treatment. It is only implied in the age of consent for testing Inadequate preparation for treatment initiation---a recipe for non-viral suppression 14

15 Priorities for ALHIV specific to DSD Challenges Making community-based care models feasible for stable Adolescents living with HIV Further differentiation of adolescents e.g. by age, risk, socio-economic status (adolescents are a heterogeneous group) Support needed from the network Guidance for case surveillance for each adolescent enrolled in the various DSD models Standardized guidance for differentiating HIV care and treatment for a heterogeneous group Standardized monitoring tools and guidance for transitioning adolescents through various DSD models to adult care 15

16 Acknowledgements STD/ACP Ministry of Health National DSDM TWG PEPFAR EGPAF, Uganda Office All Partners The CQUIN Project Thank you 16