Post on 01-Jan-2016
Challenges to identifying HIV-exposed infants, scaling up early infant diagnosis & linkage to prophylaxis, treatment and care programs
Charles KiyagaNational EID Coordinator
Ministry of Health – Ugandackiyaga@gmail.com
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Following infants throughout entire EID process highlights key challenges in the entire EID Cascade
Identify and test exposed infant
Provide results & guide through test algorithm
Enroll positives in ART
Clinic
Retain alive in care/
treatment
1 2 3 4
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Different factors contribute to the Challenges in the EID process
Identify and test exposed infant
Provide results & guide through test
algorithm
Enroll positives in ART Clinic
Retain alive in care/
treatment• HCWs not sensitized to identify exposed infants
• Weak system for referral for DBS testing from on-site capture points
•No system for referral of PMTCT mothers to EID testing
• No system for capturing babies outside the HF
• Ineffective clinic flow & limited HR capacity
•Poor documentation and tracking systems
• Inconsistent counseling
•Limited integration of infant care into visits
• Long result turnaround times
• Poor system for referral of positive infants to ART clinics
•Limited integration between EID and ART Clinic teams
• Limited integration of infant care into testing process, leading to attrition
• Not initiating infants on ART when eligible
• Not identifying exposed infants before 3 months of age
Pote
ntial
cau
ses
of lo
ss
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Given the rapid disease progression of HIV in infants, basic care and prophylaxis must be provided to infants throughout the EID process
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Infant Retention Continuum at 3 Regional Referral HospitalsSept 2007 – Feb 2009
EID review revealed that only 40% (98 of 244) of tested infants were eventually enrolled into care & treatment
39% of positive infants never received results 35% of positive
infants receiving results were never enrolled into care 42% of positive
infants in care & treatment were lost
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Drivers of Loss: Not capturing exposed infants
• Limited sensitization and awareness among HCWs
Healthcare workers not proactively identifying and referring exposed infants
• Lack of a formal referral system for EID testing from ‘entry points’ within health facility and off facility Exposed infants referred from different wards/clinics
for on-site DBS testing are not reaching the testing point Lack of referral or sample collection from the
community (immunization outreaches)
• Lack of referral system for exposed infants identified before or at birth
HIV+ pregnant women identified at ANC or maternity not bringing infants for DBS testing at 6 weeks
Identify & test exposed infant
Provide results & guide through test
algorithm
Enroll positives in ART Clinic
Retain alive in care/
treatment
3 421
Exposed infants never tested
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Strong, formalized PMTCT-EID linkages are needed to capture exposed infants before birth
Referral from PMTCT: Data from one hospital revealed that over 80% of HIV+ pregnant women never brought their babies back for testing and care after delivery
Linkage between PMTCT and EIDHospital, Jan – Dec 2008
Less than 20% of PMTCT mothers could be linked
to tested infants
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Drivers of Loss: Exposed infants not receiving results and completing testing algorithm
Identify & test exposed infant
Provide results & guide through test
algorithm
Enroll positives in ART Clinic
Retain alive in care/ treatment
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• Sub-optimal clinic flow with multiple follow-up points Caregivers unclear where to return for results EID services with insufficient space and staffing
• Poor documentation and tracking systems Key information not kept in single comprehensive
longitudinal register— one must sift through many registers and charts
Lack of an appointment system to trigger follow-up
• Lack of consistent counseling and care provision Weak counseling on importance of test results, testing
algorithm, and the need for regular care Lack of care provision undermines importance of infants
returning regularly
• Long sample and result turnaround times
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39% of positive infants never receive results
OPD
JCRC Lab (Kampala)
Laboratory in OPD
ART Clinic
Courier to Wakiso Town
DBS
Sam
ples
Test Results
Posta Uganda
Immunization
ANC/PMTCT
Lower Level HCs
Immunization Outreaches
Legend Patients Results Samples
Clinic Systems: At Namayumba Health Center IV there was no centralized follow-up and care point
DBS SamplesDBS Samples
Posta Uganda
Courier from Wakiso Town
Impact of Centralizing EID Services only in the Lab
Caregivers of infants tested at ANC or ART Clinic do not know where to return for results and follow-up
Caregivers of infants tested at the lab in OPD receive no counseling or sensitization during sample collection
With all results given in the lab, there is no post-result counseling or care unless caregiver takes initiative to seek it out No set appt for 2nd PCR No formal referral to ART Clinic
if positive
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4 DaysAverage
(n= 333)
4 DaysAverage
(n= 203)
31 DaysAverage
(n= 194)
Sample Drawn
Dispatched to JCRC
Result arrives at Facility
Caregiver Receives Results
Arrives at JCRC
Average Time between DBS Collection and Caregiver Receiving Results Jinja RRH, Jan 2008 – Feb 2009
On average, caregivers had to wait 69 days to received DBS results
Turnaround Time: Long sample and result turnaround time had an adverse effect on whether caregivers receive results or not
30 DaysAverage
(n= 222)
Sample Tested
Result sent from JCRC
Turnaround Time & Retention: Fewer caregivers receive their results with longer turnaround times, but even in best case percent returning remained low
10-30 Days 31-50 Days 51-70 Days Over 70 Days0%
10%
20%
30%
40%
50%
60%
70%
59%
52%
36% 38%
Percent of Caregivers Receiving Results vs. Turnaround Time
Jinja RRH, Jan 2008 - Feb 2009
# Days between Sample Collection and Result Arrival at Site
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Drivers of Loss: HIV-positive infants not being enrolled into care and treatment
Identify & test exposed infant
Provide results & guide through test
algorithm
Enroll positives in ART Clinic
Retain alive in care/ treatment
1 3 42
• No formal referral system to ART clinics Infants referred from EID testing point to ART Clinic
are only told to go verbally with no tracking by either EID or ART units
• Limited integration or communication between EID testing and ART clinic No meetings between EID & ART teams to follow-up
referred infants
35% of pos infants receiving results were never enrolled
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Drivers of Loss: HIV-positive infants not initiated & retained in care after enrollment at ART Clinic
Identify & test exposed infant
Provide results & guide through test
algorithm
Enroll positives in ART Clinic
Retain alive in care/ treatment
1 3 42
• Not immediately initiating eligible infants on ART Only 45% of eligible HIV+ infants initiated on ART! Some HCWs not aware of current EIT Policy, and
others are reluctant to initiate infants immediately —failure to initiate ART decreases odds of survival • Late identification and testing of exposed
infants 40% of infants tested over 6 months of age, so health
likely to have already deteriorated
• Failure to provide specialized care for exposed infants before results return Many exposed infants receive specialized care only
once confirmed positive
42% of positive infants in care & treatment were lost
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Age and Attrition: 59% of infants were captured at greater than 3 months of age
Capture and diagnosis of infants at a late age can lead to attrition after initiation on treatment due to rapid disease progression
0-3 Months (41%)
16-18 Months (7%)
13-15 Months (11%)
10-12 Months (10%)
7-9 Months (13%)
4-6 Months (18%)
Health Facility Average Age at 1st DBS
Masaka RRH 6.3 months
Jinja RRH 7.6 months
Lira RRH 6.2 months
Overall Average 6.8 months
Having seen the above challenges we undertook to strengthen our EID system, with a package of 6 complementary interventions
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1. Establish “EID Care Point” within either MCH or ART clinic where all exposed infant care/follow-up is centralized
2.Integrate routine care into EID process & establish regular visit schedule
3. Strengthen & standardize counseling for caregivers of exposed infants
4. Improve tracking tools to centralize data & follow infants longitudinally
5. Establish referral system for DBS testing and follow-up at EID care point
6. Establish referral system for care/treatment at the ART clinic
This was piloted in 21 Health facilities of all levels in 8 districts
Assessment of the pilot at several facilities showed high impact across all key areas of EID:
•DBS testing volumes increased by 40%
•Average age at testing reduced by 50%
Testing
•CTX initiation increased every month after implementation, from 80% to 99%
Cotrim
•Percent of exposed infants receiving results increased from 50% to 70%
Retention
•Percent of HIV+ infants linked to the ART clinic increased from 50% to 97%
ART Linkage
Integrated EID into immunization outreaches
Consolidated 8 testing labs into 1 National Lab
Set up new national hubbed transport network
EID program has also implemented other high-impact innovations:Increases access and identification
Reduces sample-result TAT
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Acknowledgements
CDC Uganda for their financial and program support. They also supported my coming here
CHAI for their technical and logistical support
JCRC for doing most of the lab testing
PEPFAR for their financial support
UNICEF for their financial support
The strengthening model has shown the value and feasibility of changing EID from merely a testing
service to a longitudinal comprehensive care package for all HIV-exposed infants
Challenges exist , but “EID system strengthening” model has demonstrated high impact & shown feasibility of implementation