Impact of Early Infant Diagnostic (EID) Testing for HIV Exposed Infants in Namibia
Dr. Ndapewa Hamunime (MOHSS)Dr. Andreas Shiningavamwe (NIP)
Republic of Namibia
[A-240-0316-12275]
20 July 2010
2
Background• Population ~2million• Surface area of
802,4116km2
• Sparsely populated: population density 2.2/km2
• 35 public hospitals, 34 health districts
• 11.5% of GRN budget spent on health
• Newly established Medical School 2010
• 95% of drugs, supplies imported
Context and Response
Global Context
Early Infant Diagnosis for HIV linked with HIV care is critical for the survival of HIV exposed infants
Response
• National Early Infant Diagnosis (EID) service launched in late 2005 by the Ministry of Health and Social Services (MOHSS) in collaboration with the National Institute of Pathology Ltd (NIP) Windhoek
• Significant investment in EID has taken place since 2006
• As the service has scaled up, program evaluations continue to be used to guide programming to maximize infant care
Namibia has rapidly responded to HIV positive infant vulnerability with EID and infant treatment
Methods (1)A selection of 25 EID collection sites across all 13 regions were reviewed
SIT
ES
Methods (2) The full EID service was reviewed at each site
At each site, the full EID service continuum was examined:
SC
OP
E
EID Sample Collection
Point(s) (& cotrimoxazole)
Result Return to Infant
HIV Care for HIV + Infants
Testing at NIP Windhoek
PMTCT
Family testing of PLHAs
Infants on Wards
Identification of Exposed Infant
Result Return to Site
PCR 1 Negative Infants:
Follow up
Vaccination
Sample Transport to Processing laboratory
20063 20066 20069 200612
20073 20076 20079 200712
20083 20086 20089 200812
20093 20096 200990
50
100
150
200
250
Scale up of EID Sample Collection (via DBS) EID collection sites, EID samples, and EID coverage have increased dramatically over time
Site ever collecting a DBS sample for the national program
2006
EID Collection Sites over Time (sites)
• Since 2006, sites offering EID have grown dramatically:
• EID was available in all regions by the end of 2006
• EID is available at all 79 ART sites and over 200 PMTCT sites
• Over 31,900 EID samples have been tested since the start of the service
• In 2008, 86% of HIV exposed infants accessed EID
0
300
600
900
1200
1500
EID Samples tested in public sector
Monthly EID Samples Volume over Time
2007 2008 2009
2006 2007 2008 2009
Early Identification (1)Over time, more of the HIV exposed infants receiving an EID test are getting tested early
2006 2007 2008 20090%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
32.60%
47.70%53.80%
61.20%
Tested ≥ 6 mTested 2 ≤ x <6 mTested in first two months of life
• Namibian Algorithm encourages EID testing at 6 weeks
• Because of Infant health deterioration, early testing is key
• In early years of the service, only 50% of infants tested were tested in their first two months of life
• Every year, a larger portion of infants tested had their first EID sample collected in the first two months of life
Portion of Infants EID Tested by Age Band at PCR 1
Early Identification (2) However, more must be done to take advantage of high PMTCT coverage for earlier EID
• In 2008, Namibia had a 92% PMTCT coverage
• Of infants receiving their first EID tests, over 90% of them were coded as coming from PMTCT
• However, only 49.6% of all infants tested were tested in their first two months of life
We are working hard to further reinforce the linkage between PMTCT and early EID testing and exposed infant care
0
3000
6000
9000
HIV est Know HIV PMTCT EIDEst. HIV Pos
Pregnant Women1
Accessed PMTCT1
Known Pos1
EID
49.6% <2m
Coverage of PMTCT Service (2008)
(1) UNICEF, UNAIDS, WHO. Towards Universal Access 2009,Vienna: 2009.
Tested ≥ 6 mTested 2 ≤ x <6 mTested in first two months of life
EID Sample Transportation and ProcessingA centralized transportation system, and one Central PCR laboratory has allowed for smooth processing
• Efficient sample transport system linked with local NIP laboratories (who manage intake) allows for rapid transport (mean <1 day from sample collection to arrival at local NIP)
• Centralization of EID along with strong lab organization and management ensures high throughput and fast turn around time
Technicians rotate and process samples daily – processing volumes of ~1,000 -1,300 EID samples/monthly
Turn around times from sample collection to result completion are consistently <10 days
0
200
400
600
800
1000
1200
1400
1600Monthly EID Sample Volume (samples)
2006 2007 2008 20090
7
14
21
28
2006 2008 20092007
Mean Turn around Time (days)
Collection to local NIPLocal NIP to analysis
Referral to HIV Care and TreatmentExamining HIV positive infant follow up at individual sites gives indications of attrition challenges
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006 2008 2009(n=203)
2007(n=293) (n=439) (n=50)
Infants <12m enrolled never initiatedInfants <12m initiated >6m after enrollingInfants <12m initiated ≤6m after enrolling
2006 2007 2008 20090
10
20
30
we
eks
HIV Pos Infants Enrolled at ≤12m of Age at 25 Reviewed Sites since 2006
Mean Time between enrollment and ART Initiation of Infants enrolled in HIV care (weeks)
• EID is critical because it allows for the earlier identification of and care for HIV positive infants
• Portion of HIV positive infants put on ART within 6 months of enrolling is increasing
• Mean time between enrollment and initiation of HIV positive infants is steadily decreasing
Conclusions and Programmatic ImplicationsProgram reviews and analyses can inform future program interventions
• High PMTCT and EID coverage• Dramatic increases in EID
volumes• Decreasing age at testing• Centrally managed program• Consistent and fast sample turn
around time• Strong technical capacity• Partner collaboration
EID Strengths
Ever Present Challenges
• Higher than optimal average age at testing
• More support for follow-up of HIV exposed infants, referral of HIV positive infants to HIV care, and clinical care for infants testing positive particularly with regards to ART initiation
• Strengthen private sector involvement
Efforts to Strengthen the EID in Namibia
Linkages between PMTCT, DPT1 vaccination and early EID testing at sites reinforce through mentoring and supervision
EID test sites increased from 242 to 292 since review
A new automated EID equipment procured and installed at NIP
Community engagement and defaulter tracing system strengthened
Acknowledgements
UNICEF (HQ, ESAR, NAMIBIA CO)
USAID
US Center for Disease Control
Clinton Foundation
I-TECH
WHO
GRN
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