THE DOUBLE DIVIDEND. Presented at 6 th HIV Paediatric Workshop, Melbourne 19 th July 2014

Transcription

1 THE DOUBLE DIVIDEND Action to improve survival of HIV exposed infected and uninfected children in the era of emtct and renewed child survival campaigns: Outcome of Harare Think Tank Consultation Presented at 6 th HIV Paediatric Workshop, Melbourne 19 th July 2014 Dr Chewe Luo MMed (Paeds); MTrop Paed; PhD Team Leader for Country Programme Support UNICEF, HIV section Programme Division New York

2 The Double Dividend is a programming approach to accelerate achievement of the dual goals of Child health and paediatric HIV responses Pediatric HIV services Targeted smart joint interventions Child Health Services

3 Background Launched by UNICEF, EGPAF and WHO and endorsed by African Ministers at ICASA in December key actions agreed to drive the agenda: To mobilise global, political and community leadership To review current child health specific plans and develop a road map for alignment with HIV To monitor progress and evaluate impact

4 Rationale We know what to do but how do we bring it together?

5 Under 5 Mortality (U5M) has improved over the past two decades but more is needed The global number of under-five deaths has fallen steadily since 1990 which is a substantial achievement but, more Global under-five, infant and neonatal mortality rates, Global under-five deaths, millions acceleration is needed to reach the MDG 4 target of 30 deaths per 1,000 live births by 2015 Source:

6 Causes of U5M and HIV attribution Pneumonia 5% Other conditions 13% Non-communicable diseases 8% Injuries 4% ATEGORY NAME] CENTAGE] Pneumonia 13% Malaria 7% Measles 2% Diarrhoea 9% Prematurity 14% Neonatal 44% Birth asphysia and birth trauma 10% Diarrhoea 1% Neonatal sepsis 5% Congenital anomolies 4% Neonatal tetanus 1% Other conditions 3% 3 main neonatal killers to address: 1. Preterm birth 2. Birth complications 3. Neonatal infections More than a third of all U5 deaths due to pneumonia, diarrhoea and malaria (i.e. are preventable!) Data source: Cause of death - WHO. Global Health Observatory dex.html); Child deaths - UN Inter-agency Group for Child Mortality Estimates. Levels and Trends in Child Mortality. Report 2013; Stillbirths - Lawn et al The Lancet stillbirth series (9775) p

7 Multiple direct causes of U5M and the direct and indirect relationship with HIV infection In high HIV burden countries, MDGs 4, 5, and 6 will be reached without actions inclusive of the effect of paediatric HIV population Causes of U5 Mortality Diarrhea Pneumonia Neonatal Causes HIV/AIDS Malaria TB/ Other Under nutrition

8 Estimation of number children living with HIV MAX Adult ART coverage 95% PMTCT coverage 95% Paediatric ART coverage 100% LMIC 21 PMTCT Priority Countries Generalized epidemic countries Source WHO PADO Meeting, Dakar, 2013

9 Wide ART access gap between eligible adults and children 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% > >95 Botswana 88 Namibia 54 Swaziland 38 Zambia 45 Zimbabwe South Africa Kenya Malawi Uganda Untd. Rep. of Tanzania Ethiopia Burundi Ghana Lesotho Côte d'ivoire Cameroon 27 Mozambique Adults (aged 15+) Children (aged 0 14) 15 Angola Chad Dem. Rep. of the Congo 12 Nigeria priority countries 37% decrease in new paediatric HIV infections ( ) Children (33%) were half as likely as adults (69%) to get treatment (2012) 39% of infants had an early HIV test at 6-8 weeks (2012) Little data to understand rate of testing and results through breastfeeding period Sources: UNICEF, UNAIDS, WHO 2013; UNAIDS 2012 HIV and AIDS estimates

10 Harare Partner Consultation: Think Tank meeting April 2014 Defining the operational framework through the lens of 3 countries with different child survival and HIV typologies Nigeria, Swaziland and Zimbabwe

11 10 countries in Eastern and Southern African Region reduced U5MR by 50% or more Decline in under-five mortality rate , by country, ESAR Zimbabwe Lesotho Swaziland Botswana Somalia Seychelles Angola Kenya South Africa Mauritius Burundi Comoros Namibia Zambia South Sudan Mozambique Uganda Madagascar Rwanda Eritrea Ethiopia Tanzania Malawi

12 7 countries in Western and Central African Region reduced U5MR by 50% or more Decline in under-five mortality rate , by country, WCAR Congo DR Congo CAR Chad Côte d'ivoire Sierra Leone Cameroon Gabon Togo Mauritania Guinea-Bissau Nigeria Ghana Equatorial Guinea Burkina Faso Mali Sao Tome & Principe Benin Gambia Guinea Senegal Cape Verde Niger Liberia

13 The Double Dividend - 4 step framework to facilitate joint Child survival HIV programming 1. Understand 2. Design 3. Deliver 4. Sustain Epidemiology: Review U5M, HIV, co-morbidities, PMTCT, Pediatric HIV Identify gaps in U5M and HIV responses and successes Know your geography and population spread pop in need, areas of convergence and where are your services? Review existing plans, initiatives, platforms and performance; will you meet your target? Define the unmet need and set your targets Define approaches for improving identification of children including at most risk Define areas of unmet needs where joint investment could reduce those gaps; an optimal package of services for children; Define system for referral and follow up including community level Define capacity, mgmt. structure and forecast supply Deliver capacity development and monitoring plan including laboratory and district oversight systems Deliver management structure and additional needs including HR, supply chain and community support Deliver system for referral system and tracking patients Support other health system bottlenecks to enhance performance Review existing resources and leverage joint management approaches with existing child survival programmes Conduct regular programme reviews to assess performance and improve efficiency

14 Jointly review trends and define preventable causes of U5M and intervention coverage 1. Understand Pneumonia 13% Pneumonia 5% Prematurity 14% To help answer the questions: Other conditions 13% What are the major drivers of U5 mortality and contributing comorbidities? Noncommunicable diseases 8% Injuries 4% HIV/AIDS 2% Malaria 7% Measles 2% Diarrhoea 9% Birth asphysia and birth trauma 10% Diarrhoea 1% Sample data from Nigeria Source: CHERG 2013 and UNICEF, Committing to Child Survival: A Promise Renewed; Progress Report 2013 National, Sub-national, State, District, Facility and Community program(s) exist in country and what do they target? Neonatal sepsis Where are services located 5% relative to identified needs? Congenital anomolies 4% Neonatal tetanus Other 1% conditions 3%

15 Source: WHO, UNICEF, UNAIDS, 2013 Global AIDS Response Progress Reporting; UNAIDS 2012 HIV and AIDS estimates * Note: The number of pregnant women receiving ARVs for PMTCT in are not comparable to values for because they are based on previous WHO treatment guidelines and include single-dose nevirapine ** Note: The number of pregnant women living with HIV receiving ARVs for PMTCT for 2013 is the preliminary number and has not yet been fully validated. Jointly review HIV epidemiology and PMTCT service access trends 1. Understand Number (#) Trends in pregnant women living with HIV receiving ARVs for PMTCT, Nigeria, Pregnant women living with HIV Target Trend HIV+ pregnant women receiving ARVs for PMTCT And answer the questions: What points along the PMTCT cascade of services are the strongest and weakest? # of facilities with ANC and PMTCT sites /geographic area of focus? Areas of convergence to accelerate and strengthen response

16 Jointly review Paediatric ART access trends and determinants of coverage Trends in all children (aged 0-14) living with HIV, ART-eligible children and children receiving ART, Nigeria, ART-eligible children (2010/2013 guidelines) Target Trend Children (<15) living with HIV Children (<15) receiving ART And answer the questions: 1. Understand What is underpinning these trends? Where on the Pediatric HIV /post-partum care cascade are services strongest/ weakest? # of Adult ART sites/ geographic area of focus? Number (#) ** # of HIV testing sites/ pediatric ART sites/linkages between sites and child survival interventions? Source: WHO, UNICEF, UNAIDS, 2013 Global AIDS Response Progress Reporting; UNAIDS 2012 HIV and AIDS estimates ** Note: The number of children receiving ART for 2013 is the preliminary number and has not yet been fully validated.

17 Other supportive HIV intervention metrics to be reviewed: 1. Understand EID coverage within 2 months of age Cotrim uptake Infant ARV prophylaxis uptake PITC at 9 mos. (where available) PITC at 18 mos. (where available) PITC in sick child services

18 2. Design Joint planning should be along the care continuum and work within the country context 0 months 6-8 weeks 9-12 months 18 months Screening at birth with BCG Prevention of mother-to-child transmission and maternal and child health postnatal visits Immunization Measles HIVexposed infants Immunization DPT 1, 2, 3 Provider-initiated testing of sick children Paediatric wards, under-5 clinics, nutrition clinics, Community Integrated Management of Childhood Illness Community outreach support and tracking of LTFU Health weeks, voluntary counselling and testing campaigns Source: WHO 2014 adapted from Chewe Luo, UNICEF, presented at ICASA 2013

19 2. Design and starts to align acceleration Design to platforms, initiatives and optimal entry points Ending preventable child deaths Ending paediatric AIDS MNCH ANC L + D Newborn/neonatal care IMCI /iccm Nutrition (CMAM, IYCF) EPI In-patient care Community outreach HIV Adult ART ANC/postnatal/ PMTCT/B+ EID/infant/child HIV testing Paediatric ART services Community-based HIV programmes (currently focussed on OVCs)

20 2. Design Alignment of B+ rollout to IMCI scale up in primary facilities

21 Four priority areas for smart opportunities emerged 1. Strengthening post-natal care: a critical time for maternal and newborn health and opportunity to align with HIV and stronger general health messaging. 2. Immunizations and HIV testing: to increase the identification of HIV positive children in the breastfeeding period and to strengthen provision of immunizations that start to drop off after the 9 month period. 3. Nutrition and HIV: In Under-5, Community outreach, OPD and IP services with IYCF- to increase identification of both maternal and/or child HIV, early signs of malnutrition and improved effectiveness of treatment for malnutrition, and 4. Re-invigorating capacity for Integrated Management of Childhood Illnesses (IMCI) and leveraging B+ system roll out : to strengthen curative care for children in facility care with better linkages to HIV testing for case finding of HIV among sick children and access to paediatric ARTs. HIV-adapted iccm can improve case finding in front-line community settings.

22 Country examples

23 Jointly review causes of U5M in Zimbabwe 1. Understand Leading causes: Neonatal 34% HIV/AIDS 20% Pneumonia 10% Malaria 8% Diarrhoea 7% Undernutrition is a major underlying cause of child deaths Countdown, 2011

24 Zimbabwe HIV epidemiology, ARV coverage in pregnant women 1. Understand Trends in pregnant women living with HIV recieving ARVs for PMTCT, Zimbabwe, Pregnant women living with HIV Target Trend HIV+ pregnant women receiving ARVs for PMTCT Number (#) , * 2006* 2007* 2008* 2009* ** Source: WHO, UNICEF, UNAIDS, 2013 Global AIDS Response Progress Reporting; UNAIDS 2012 HIV and AIDS estimates

25 Zimbabwe paediatric HIV epidemiology; ART coverage and child survival metrics Number (#) Trends in all children (aged 0-14) living with HIV, ART-eligible children and children receiving ART, Zimbabwe, ART-eligible children (2010/2013 guidelines) Children (<15) living with HIV Children (<15) receiving ART 46, Understand In 2013: ~100,000 HIV+ children in need of treatment <50% on ARTs High % of children with SAM also + HIV 32% stunting 31% EBF Access to neonatal, diarrhea, pneumonia interventions low ** Source: WHO, UNICEF, UNAIDS, 2013 Global AIDS Response Progress Reporting; UNAIDS 2012 HIV and AIDS estimates ** Note: The number of children receiving ART for 2013 is the preliminary number and has not yet been fully validated.

26 Zimbabwe: HIV and EPI 1. Understand Trends in all children (aged 0-14) living with HIV, ART-eligible children and children receiving ART, Zimbabwe, ART-eligible children (2010/2013 guidelines) Children (<15) living with HIV Children (<15) receiving ART In 2013: Number (#) ,000 46,000 34% uptake of PCR in early infancy in % facility deliveries 99% BCG coverage (2012) 90% Measles at 9 months (2012) 61% Vit A at 12 mos. (2012) ** Source: WHO, UNICEF, UNAIDS, 2013 Global AIDS Response Progress Reporting; UNAIDS 2012 HIV and AIDS estimates ** Note: The number of children receiving ART for 2013 is the preliminary number and has not yet been fully validated.

27 Zimbabwe recognized potential DD opportunities Country identified potential joint interventions 1. With 66% facility deliveries and 99% BCG update in a high HIV prevalence country: Infants brought in for BCG should have maternal HIV status ascertained and newborn HIV PCR done for those most at risk (women who were not on ARTs) 2. With the high rate of EPI uptake out to 9 mos. and the high burden of unidentified paediatric HIV: All infants coming in for routine and/or catch up EPI determine maternal HIV status (and test if needed) and obtain infant PCR HIV test if needed. 3. EPI and micro-nutrients supplementation out beyond 12 mos. Usually enhanced through outreach; very little information on any sequential HIV testing during breastfeeding period: Strengthen facility EPI/HIV testing beyond 12 mos.; joint outreach for EPI and HIV testing in high prevalence geographies

28 Zimbabwe recognized potential DD opportunities 4. Given the high % of the general population with stunting and low uptake of proper feeding recommendations: Increase programming around PNC + maternal and infant feeding counselling at each paediatric touch point. Increase routine growth monitoring at each point to identify infant/children at risk of malnutrition. 5. Given the high prevalence of HIV, and particularly in SAM Joint programming at nutrition clinics to include HIV screening. Additionally, children admitted for malnutrition, to be screened for HIV.

29 Conclusion

30 2. Design And by bringing interventions and programs together = greater gains Maternal and infant feeding counseling HIV screening Routine growth monitoring At PN facility and community level Communitybased HIV and general health programmes Reduced population level stunting; earlier identification of at-risk of SAM; increased identification of underlying HIV; improved efficacy of treatment for SAM; improved U5MR

31 2. Design And by bringing interventions and programs together = greater gains Maternal HIV screening and infant HIV testing Maternal HIV screening + birth PCR infant testing PN & EPI/P; OPD (BCG and out to min Identification of newly delivered women who were unidentified HIV +; Increased identification of infants and children with HV; increased EPI coverage out to 24 mos., improved U5MR Communitygeneral health weeks and with HIV screening When child presents with illness check both EPI and HIV

32 Governance structure Next steps No need for new structures; Embedded under the global plan and the child survival working group of the emtct interagency task team Partner consultations on going USG consultation with child survival/hiv experts held on June 25 th in Washington Panel discussion in Johannesburg during the PMNCH forum Follow up on in-country dialogue and provide technical support for programme review and planning