Better Diagnostics Are Needed to Achieve an AIDS-Free Generation

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Presentation at the IAS 2011 conference on 18 July 2011 by Jimmy Kolker, UNICEF.

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  • Similarly, in Namibia 15% of EID sites collected >93% of all samples. Why do mothers so strongly prefer higher-level sites for EID testing of their children? One reason is probably that they prefer to have their infants tested at sites that also offer ART. In supporting Zimbabwe to roll-out POC PIMA CD4, UNICEF has similarly observed that POC CD4 assays have a big impact on improving uptake of ART when they are employed at sites that offer ART, but less impact in increasing maternal ART enrolment if they are employed at sites that have to out-refer to other sites for ART. Take home point: testing and treatment should be decentralized to sites together for optimal impact in improving ART uptake.
  • This shows the process of an M-Health project UNICEF has supported in Malawi and Zambia called results 160 to expedite return of EID results. The project has improved turn-around time by more than 50% at pilot sites in very remote areas, and enabled several sites that had never received a result before to do so. It has also enabled tracking of EID testing progress by program managers at a national and subnational level
  • This is an example of an aggregated web report. The system also sends real-time alerts for poor performance which are useful as a management and quality improvement tool. Key point: we need to expedite POC but we also need to continue to support promising avenues to improve existing systems too.
  • UNICEF’s organization-wide emphasis on equity has from the start placed a high priority on elimination of mother-to-child transmission of HIV as an important target which will be missed unless extraordinary efforts are made to reach those currently not served.“Elimination” means <5% transmission and 90% reduction in new paediatric infections● Provide technical support to governments for eMTCT though the IATT,Equity-focused bottleneck assessmentsCosted national eMTCT plans and Strengthened district management teams.Integrate eMTCT and MDG 3, 4, 5 and 6 = MNCH; Address the impact of stigma and discrimination and the important role women living with HIV and AIDS in the response.●Innovatepoint of care diagnostics, EID care points and mHealth applications Even in countries where scale-up has been good, integration of PMTCT into MNCH programmes has been limited, loss to follow-up is a widespread problem and poor collection and use of data at facility and district levels is a barrier to best outcomes rather than just coverage.  The Elimination of MTCT (eMTCT) provides a strategic opportunity for UNICEF to identify synergies and maximize the contribution of health (HIV, MNCH, SRH, FP and community health workers) and non-health constituencies toward the eMTCT goal. UNICEF itself can provide leadership, as well as motivate champions at global, national and community level, to integrated and link HIV and immunization programmes to maternal and neonatal care. Treatment for own health: prevent orphaning When a mother dies, mortality risk in her infants increases 3x compared to infants whose mothers are alive!HIV response cannot function in isolation
  • Better Diagnostics Are Needed to Achieve an AIDS-Free Generation

    1. 1. 6th International AIDS Society Conference<br />Better Diagnostics Are Needed to Achieve an AIDS-Free Generation<br />UNITAID Satellite Event<br />18 July 2011<br />Jimmy Kolker<br />Chief, HIV/AIDS Section <br />UNICEF Programme Division<br />New York<br />
    2. 2. Percentage of pregnant women living with HIV receiving ARVs for PMTCT 2005, 2008 and 2009<br />
    3. 3. Distribution of antiretroviral regimens provided to pregnant women, in 2007 (59 countries) and 2009 (86 countries)<br />
    4. 4. Paediatric HIV Treatment<br />In 2009, about 356,400 children under 15 received antiretroviral treatment, an increase from only 75,000 in 2005.<br />However, this is only 28% of the 1.27 million childrenin need of ART under the new guidelines are receiving it.<br /><ul><li>The key entry point is widespread testing of HIV-exposed newborns.
    5. 5. Ideally, this would be done as soon after delivery as possible.
    6. 6. Developing a test that would do this is one of UNICEF and partners’ top goals.
    7. 7. EID can also be routine during 6-week immunization visits, hospital admissions or as part of family-based care for parents and older children.</li></li></ul><li>Point of Care Diagnostics in PMTCT and Paediatric Care and Treatment<br />POC assays hold promise to help expand ART to lower-level clinics and reach the unreached<br />This is especially important for access to HAART for pregnant women (CD4) and infants (EID)<br />POC assays are not a solution alone to the poor follow-up of mothers and infants<br />The goal is to strengthen access to and quality of the needed continuum of care<br />
    8. 8. Expanding CD4 Testing in low-level facilities<br /><ul><li>Compelling argument for investing low cost technologies to bring CD4 screening in less capacitated ANC facilities to treat more pregnant mothers with ART.
    9. 9. Zimbabwe is working on a national approach to scale up point of care CD4 machines.</li></li></ul><li>Low utilization EID testing at lower-level clinics:15% of EID sites in Namibia collected >93% of all samples<br />
    10. 10. 8<br />Maximizing Impact of Early Infant Diagnosis<br />BOTTLENECK: Less than 1/3 of infants tested for HIV at birth receiving treatment after one year<br />Without investment through the entire follow-up continuum, the maximum impact of Early Infant Diagnosis (EID) will not be realized.<br />48%<br />131<br />76%<br />34%<br />68<br />29%<br />45<br />32<br />Receive Results<br />HIV+ infants<br />Enrolled in counseling & treatment <br />Infants still active after 1 year<br />Of those who enroll in HIV services, almost 1/3 are no longer tracked at the site.<br />48% of HIV+ infants never received results. Several died prior to receiving results. Not all infants were on CTX.<br />Follow up of infants testing HIV+ Jinia Regional Hospital, Zambia <br />Jan 1, 2008 – December 1, 2009<br />
    11. 11.
    12. 12. 10<br />RESULT: increased # of children correctly identified and enrolled to receive treatment <br />Benefits<br /><ul><li>Speed – Wait time for results is cut in half
    13. 13. Cost – No SMS cost for clinic staff
    14. 14. Scale – Easier scalability using clinic staff’s own phones
    15. 15. Reporting – Web portal provides national view of clinic’s DBS usage</li></li></ul><li>Aggregated Web Reports<br />
    16. 16. Investing in diagnostics in eMTCT and Paediatric care<br />Assess where there is the greatest unmet need<br />Involve providers and clients to assess key bottlenecks <br />Identify evidence-informed solutions and investments<br />Scale-up priority intervention as component of MNCH services<br />HIV testing and counseling<br />CD4 and ARVS including ART for HIV positive pregnant wowen<br />Early Infant Diagnostic technologies and supportive system responses such as SMS <br />

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