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EARLY INFANT DIAGNOSIS & TREATMENT

The Swaziland Experience

Makaria ReynoldsCall to Action Project Director

Elizabeth Glaser Pediatric AIDS Foundation

June 17, 2010

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Outline• Mortality of HIV-Infected Children• Importance of Early Initiation of

Treatment• EID in Swaziland• Knowing: Is it really half the battle?• Programming for Early Initiation of

Treatment• Conclusions

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Children Continue to Be Left Behind

Children constitute:

• 10% of new HIV infections each yearo (280,000 out of 2.7 million)

• 6% of the persons living with HIVo (2 million out of 33 million)

• 13% of HIV/AIDS deaths each year o (270,000 out of 3 million)o 90% in sub-Saharan Africa

UNAIDS, 2008

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Mortality of HIV-infected Infants

1 Year = 35% mortality

2 Years = 53% mortality

Newell ML et al Lancet 2004; 364: 1236-43

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Early Initiation Saves Lives

From the Children with HIV Early Antiretroviral Therapy Study (CHER), Violari, NEJM 2008

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Key Steps in Reducing HIV-Related Mortality in Infants

1. Strong PMTCT programs

2. Follow up of mother-baby pairs and tracking exposure status of infants

3. Clinical monitoring & evaluation

4. Test infants early (DNA PCR) and get results back

5. Prompt treatment

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THE SWAZILAND EXPERIENCE

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EGPAF’s Programs in Swaziland

• EGPAF began supporting PMTCXT in Swaziland in 2004

• Technical assistance at the national level

• Support for direct service delivery supporto 47 sites

o All 4 regions

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HIV in Swaziland

• 42% HIV prevalence in ANC

• 1,651 new infant infections recorded in 2009

• Under-5 mortality rate has doubled:– 60 per 1,000 live births in 1992 – 120 per 1,000 live births in 2007

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EID in Swaziland: Background

• 2007: EID using DNA PCR started

• Health care workers trained in DBS collection

• Testing supplies provided by CHAI

• Samples were sent to South Africa for testing

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Establishing Country Capacity to Perform DNA PCR

• Equipment:– Dedicated thermo cycler (PCR machine)

• Two 48-well heating blocks• Auto Puncher

*All equipment was donated to NRL in 2008 by UNICEF (with funds from FC Barcelona)

• Personnel:– 1 dedicated Lab Technician + 1 trainee

• Can test 96 samples/day (each set of 96 includes 8 controls)

– Dedicated logistician/data clerk to manage sample packaging, results communication, data entry, etc.

• Space:– New laboratory building with adequate space for all

equipment and personnel

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Main Impact of DNA PCR Equipment at NRL: Improved Turnaround Time

NRL NICD0

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4

6

8

10

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18

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85% time savings(from 18.1 to 2.7 days)

National EID Program Expansion

Jul-Dec 2007 Jan-Jun 2008 Jul-Dec 2008 Jan-Jun 2009 Jul-pres 20090

1000

2000

3000

4000

5000

6000

1808

2674

3324

4260

5018

Sample Volumes Over Time

> 66% increase in samples run since December 2008

EGPAF sites = 47 (44% of total); EGPAF samples = 6,310 (68% of total)

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Quality Improvement Initiatives in the EID Program

• Regular monitoring of sample quality and communication with sites about issues

• Memos for health facilities on improving sample quality, storage of DBS cards, packaging of samples, etc.

• Information-sharing at EID feedback meetings and Pediatric HIV/AIDS Technical Working Group Meetings

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KNOWING:

IS IT REALLY HALF THE BATTLE?

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• Adopted 2008 recommendation for initiation of ART in all infants– Piloted in 3 sites with good partner support

• Between Aug and Nov 2008, staff reviewed records from 2 high-volume sites to find all HIV-positive infants under 12 months of age

Swaziland: Putting the 2008 WHO Recommendations into Practice

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Data Findings• 124 infants were identified:

• 46 LTFU with no contact information • 10 died • 18 on ART

• Intensive efforts were made to track down the 50 eligible children and initiate them on ART

• Phone communication and/or chart flagging was attempted for the 50 who had not previously qualified for ARVs or who hadn’t returned

10 Died

46LTFU

50 not on ART

18 on ART

124

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Swaziland Active Follow-Up Results

26 InitiatedART

12 LTFU

8 Died

4 Refused

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Contacted

• Phone calls were more effective than chart flagging

• Staff invested significant time in calling patients

• Many clients had incorrect information recorded

• Some infants had died

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This initiative More than Doubled the Number of Infants Initiating ART

October 2008

26 StartedOn ART

18 Alreadyon ART

58LTFU

4 Refused

August 2008

18 Died

Total 124 infants identified:• 47% LTFU• 15% died before initiation• 3% refused• 35% started ART

10 Died

46LTFU

50 not on ART

18 on ART

44

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Getting Results to FamiliesScale-up plans must include site preparation to systematize follow-up and ensure that results get to families:

• Educate staff and caregivers about importance of prompt follow up for diagnosis and treatment

• Recording detailed contact information

• Identify a person who will contact families

• Provide mechanism for follow up (phones and airtime)

• Set up register to easily identify when results are given

• Add program indicators on % PCR results given to families and percent of PCR positive initiating treatment

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Conclusions

• EID is a process, not a lab test

• Scale-up plans must include site preparation to systematize follow-up and ensure that results get to families

• Investment in DNA PCR technology must be connected to an investment in programming to use the test results

• “EID” must be followed by “T”

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THANK YOU!• Mary Pat Kieffer, Mohammed Mahdi,

Caspian Chouraya and all the EGPAF Swaziland Team

• Bhekie Lukhele • Swaziland Ministry of Health

• Swaziland National AIDS Program• USAID & PEPFAR

• Baylor International Pediatric AIDS Initiative

• Johnson & Johnson• Bill & Melinda Gates Foundation

• Abbott Fund• Clinton Foundation (CHAI)

• UNICEF• Collaborating Partners & Donors

DISCLAIMER: This program was made possible through support provided by the Office of HIV/AIDS, Global Bureau Center for Population, Health and Nutrition, of the United States Agency for International Development (USAID), through the President’s Emergency Plan for AIDS Relief, as part of the Elizabeth Glaser Pediatric AIDS Foundation's International Family AIDS Initiatives (“Call To Action Project”/ Cooperative Agreement No. GPH-A-00-02-00011-00). Private donors also supported costs of activities in many countries. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.