FHI Pediatric Summary Strategy-Not for Distribution

8/16/2019 FHI Pediatric Summary Strategy-Not for Distribution

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Family Health International’sSummary of Pediatric HIV Prevention, Treatment and Care Strategy

December 2006


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Introduction

FHI’s comprehensive response to childhood HIV/AIDS provides HIV preventionincluding PMTCT and HIV treatment and care for children and their families; mitigates the

impact of HIV/AIDS not only for children living with HIV/AIDS but their siblings and

family; and strengthens the global response to the overall needs of children and familiesaffected by HIV/AIDS.

FHI’s approach to working with children possesses several key features:

• family/household -centered1;

• decentralized; and

• spans an integrated continuum from expanded prevention to care and treatment.

FHI actively takes services to children and adolescents; optimizes under-five care/child

survival activities (e.g. growth monitoring, malaria prevention, basic sanitation,immunization and linked vitamin A supplementation), and supports maternal health

initiatives. Our approach links with community services such as community home basedand OVC care, and focuses on ensuring the continued good health of the mother and thefamily. FHI fosters a district and country- wide approach.

Figure 1

1 A household or family centered approach reflects that AIDS affects families, not just individuals. In this

approach, children, their parents, and other family members access care and treatment services within one

specific unit or as part of linkage and referral systems. The index client provides an opportunity to bring

the rest of the family to access services.


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FHI’s pediatric HIV/AIDS strategies over the short, medium and long term are rooted in a

comprehensive Prevention-to-Care and Support-to-Treatment Continuum (PCST)

(see Figure 1). The PCST approach demonstrates FHI’s capacity to provide seamless andinterconnected delivery of services to those who are uninfected, those living with HIV,

and those who are living with AIDS, while also addressing the needs of specific

populations, such as children, youth, women, and OVC.

FHI has learned that providing high-quality pediatric HIV/AIDS care in resource-limited

settings is feasible. Although FHI supported ART programs reach a substantial number ofchildren, the overall response continues to lag behind. FHI recognizes the gap and fully

supports the call to step up comprehensive pediatric HIV treatment and care alongside

prevention across all our HIV programs.

This summary strategy paper focuses on FHI’s plan to support the rapid scale up of

pediatric HIV clinical care and treatment activities in FHI’s HIV program globally. It

outlines critical short and medium term actions to demonstrate FHI’s commitment to

ensure that at least 15-20% of people receiving ARVs in our programs are children aged< 15 years.

Background

Full coverage and high quality PMTCT programs can substantially reduce the number of

children infected with HIV. Yet, less than 10% of the women who require PMTCTinterventions currently have access to these services. For those children who contract

HIV infection, effective HIV care and treatment programs can extend the life of children

well into adulthood. Despite recent increases in the number of adults on antiretroviraltherapy (ART), the number of children receiving treatment is entirely insufficient. Of

those on ART in sub-Saharan Africa, only 7% are children.2

Current efforts worldwide

are not serving the needs of this most vulnerable population adequately.

In addition to the high risk of rapid disease progression among infants and young

children, a host of factors result in the deaths of HIV infected children. The following are

key challenges to providing quality pediatric AIDS services:

• Lack of advocacy and political will.

• Limited scale of prevention efforts and scarce local capacity to implement largescale intervention even when resources are available.

• Lack of both access and large scale interventions to life saving interventions suchas cotrimoxazole preventive therapy and ART.

•

Cumbersome pediatric ART formulations.• Small scale pediatric AIDS care services.

• Insufficient access to HIV care services and health facilities for children.

• Inadequate child and youth friendly health facility infrastructures.

• Low quality laboratory services and availability of CD4 and PCR equipmentlimited to a few zonal and regional sites.

2 UNAIDS 2006


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Integrated Network Model

Increasing access to care and support for childrenand their families requires strategies that createmultiple entry points. FHI programs accomplishthis goal by implementing an integrated networkfor service delivery. These networks linkspecialized hospitals with general hospitals,primary health care centers, community-basedorganizations, home-based care services, mobile VCT units and the private sector to createmultiple entry points to care and treatment. Since

community based organizations may be the first toidentify a child helping need, referral systemslinking clinical and social support, play a key rolein facilitating entry to networks. Referral systemsalso have a critical role in coordinating the rangeof children’s needs including education, food,protection, and shelter.

• Constraints with human resources; specifically a lack of nurses, clinicians, andcommunity care providers who are trained and familiar with child, orphan or

pediatric HIV issues.

• Lack of regular, supportive supervision, mentoring and monitoring.

• Persisting stigma and a low level of community treatment awareness with regard

to children, causing reluctance among many mothers to allow HIV testing of theirchildren and themselves.

• Poor collaboration between child related health facilities such as MCH and under5 service providers, PMTCT, pediatric wards, and orphan support organizations.

FHI’s Pediatric Strategy

What are we planning to do?

Family Health International’s (FHI) Global Pediatric clinical care and treatment strategy

positions FHI as a key player to support international and national goals and global healthexpectations in the scale up of access to pediatric prevention, care and treatment services.

Our initial efforts will complementour existing activities with the

implementation of comprehensive

PMTCT programs and pediatricAIDS programs in countries wherewe are currently active. FHI has

been quite successful in the rapid

increase of access and utilization ofquality clinical care and treatment

services. Building on this

experience, FHI will use contextspecific capacity building

approaches to sustain and increase

the number of children receiving

care and support. In this effort, FHIwill use an Integrated Network

Model to improve health systems.

The goal of the pediatric clinical care and treatment strategy:

To contribute to the achievement of international goals for universal access to quality

HIV care and treatment for infants, children, and adolescents.

Our initial objectives for FHI-supported HIV prevention, care and treatment programs are

that by end of 2007:

v For PMTCT

• Coverage and access of PMTCT is increased by decentralizing scale up to states, provinces, regions and districts


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• 90% of women will be offered, and 80% will accept HIV testing at all FHIsupported PMTCT sites

• At least 2 sites per country are implementing a ZDV-based PMTCT prophylacticregimen

• 10% of individuals newly initiating ART are pregnant women, or women in the

early post partum period (6 months)

v For Pediatric Clinical Care and Treatment

• All FHI Country programs with clinic based prevention, treatment and care

programs will have operational plans for pediatrics [with Country specific targets]

• 80% of HIV exposed and infected infants have access to Co-trimoxazole preventive therapy

• 80 % HIV exposed infants have access to infant diagnostics as stipulated in thelocal guidelines and for the level of care

• 15-20 % of people on ARVs in FHI programs are children aged < 15

How will we do this?

To achieve these objectives, FHI will be active at global, national and local

implementation levels.

At global level, FHI will quickly explore, re-evaluate, and forge new strategic

relationships as well as solidify current partnerships with other global and internationalleaders in childhood HIV and AIDS. FHI will continue to actively participate at the

Expanded UN Inter-agency task team. We will invest in, build on and offer FHI’s ART

and PMTCT sites as operational research and learning sites for quick and systematic

introduction of newer technologies (e.g. DBS DNA PCR), and expand treatment for

children. We will address imminent limiting factors to expansion and monitor outcomes of pediatric HIV treatment and care programs. We will also invest in additional services and

tools to support treatment and care activities such as developing:

• An integrated Strategic Behavior Communication strategy that includes de-stigmatization, demand creation, community mobilization, and provider training;

• Pediatric counseling and testing protocols;

• A minimum package of pediatric prevention and care and treatment;

• Specific pediatric adherence toolkits including SOPs for pediatric adherence;

• SOPs for family-centered care;

• A robust functional HMIS (standardized simplified M&E tools, patient cards,registers) and databases; and

• Guidelines for pediatric palliative care, nutrition, and adolescent care.

At country level, FHI will support national and district-led technical and managementleadership for a scaled up pediatric response in the countries where we work. Partnerships

with the Ministry of Health (MoH) and a core team of national experts/catalysts (local

Pediatric AIDS and PMTCT experts and researchers) will strategically influence local policies and practices, as well as directly support FHI programs. Illustrative areas of FHI

support will include:


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• Policy and guidelines formulation;

• Seconding technical staff at national and/or district level to spearhead pediatricscale up efforts - if acceptable and feasible in a given host country;

• Advocacy for equitable and free access in rural and urban areas, from tertiary to primary levels of care and across a continuum from facility to community;

• Working with district teams to develop scale up plans for pediatric AIDS careservices and PMTCT;

• Supporting and strengthening district pediatric M&E and data managementsystems aligned to country supported adult HMIS and in line with the ‘threeones’;

• Educating communities through targeted marketing;

• Developing educational materials;

• Strengthening CBO capacity to identify & serve children.

• Building awareness of pediatric HIV care, through strategic behavioralcommunication (SBC) processes;

• Ensuring full involvement of PLWHA;

• Increasing the number of community based organization contributing toidentifying, supporting and referring children; and

• Ensuring the sustainability of scale up through intense technical support includingon-site training and mentoring to foster sustained local capacity.

Finally, at facility-level , FHI will invest in, build on and strengthen our existing PMTCT

and clinical care/ART programs to reach children. This priority will hinge on related andcomplementary strategies:

• Adopt a family centered, child focused approach including access to all HIVservices for children;

• Activate entry points to HIV testing and disease management ( Figure 2);

• Build decentralized capacity for HIV care services - across services at a givenfacility, between levels of care, and across cadres;

• Dove-tail pediatric HIV treatment and care to strengthened follow up of mother-

infant pairs in PMTCT;

• Build infant diagnosis capacity, expanding testing for children and facilitatingaccess to other laboratory services;

• Strengthen monitoring and evaluation at facility levels;

• Develop site specific strategic behavioral communication processes;

• Strengthen and expand pediatric care/ART expertise across multidisciplinarycadres;

•

Advocate for task shifting where feasible and acceptable;• Define and support functional collaboration and referral mechanisms between

services; and

• Perform operational research.


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Figure 2: Maximizing Entry Points into Pediatric HIV

Care & Treatment through Capacity Building & Facility-

Level Decentralization

Pediatric OPD/ Special

Clinics (TB, Skin,

Malnutrition)(diagnostic testing and counseling

for sick children, staging, CTZ)

Lower level

health

facilities/IMCI(Identification/diagnosis

, staging, CTZ, FU for

stable, +/- ART

initiation).

Adult HIV Care

& Treatment

Services(systematicallyinvite

patients to bring in

children for screening

and services)

Pediatric IPD(diagnostic testing and counseling

for sick children, staging, CTZ,

pre-ART workup, monitor and

manage side effects of ART)

Mentorship

Pediatric HIV

Care &

Treatment

Services

Pediatric HIV

Care &

Treatment

Services

Community:

OVC Support ServicesHome care services

Support Groups & PLHA Associations

CBOs/NGOs/FBOs

Women groups

(identification, referral)

MCH/PMTCTStrengthen MCH clinics to provide

structured HIV services (ID,

diagnosis, CTZ) ØMultipleentry points

identify

children &

families

ØRoutine

testing in high

yield pediatric

sites & existing

high-contact

points

These facility-level strategies in turn must be complemented by community level action.

FHI will form strategic partnerships with geographically co-located partners providingcommunity home based and OVC care, prevention education, and safety nets. Such

partnerships enable access to wrap around services for children and their families. They

engage public and private sector partners, communities, and especially families. Thisapproach:

• Facilitates an integrated comprehensive network model of care and plug allexisting gaps for children;

• Affirms a comprehensive response to childhood HIV/AIDS as one whichsimultaneously addresses HIV prevention including PMTCT, and HIV treatment

and care for children and their families; and

• Strengthens the global response to the needs of children affected by HIV andAIDS.

Recognizing that rapid execution of this plan will require substantial investment,

especially at facility/implementation level, we favor a two pronged approach.

1. A set of minimum activities will be initiated at all PMTCT and ART

implementing sites as soon as is feasible.2. At the same time, all facility-level strategies will be implemented in selected

countries and at selected high performing PMTCT & HIV clinical care/ART sitesdesigned to trigger district-wide services scale up, (e.g. through outreach to

primary health centers in peri-urban and rural areas). These strategies will likely

yield results within 6 months.


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Coupled with comprehensive monitoring and evaluation (M&E) and reporting systems,

these approaches will provide development partners and donors with accurate and timely

information about pediatric HIV/AIDS care. The FHI approach will engage multiplesectors and partners and is designed to be replicated and taken to scale, while retaining a

participatory approach that builds ownership of project activities.

In order to ensure the success of the above strategies, people must be aware that pediatric

prevention and care and treatment services exist and that they are free. We must actively

stimulate demand and combat the incorrect perception that there is little demand for pediatric HIV/AIDS services.

In pursing these goals FHI fully subscribes to WHO’s public health approach. FHI uses

standardized and simplified ARV regimens based on the best available scientificevidence to achieve a durable response and preserve future treatment options. FHI also

acknowledges the need to strengthen health systems (policy, funding, human resources,

and service management and information and monitoring systems) in a manner that

benefits all persons and not just for HIV care. Finally, FHI supports the urgentdevelopment and execution of policies that ensure free and universal access to ART.

FHI focus countries have well established programs reaching a large number of people

and have demonstrated ability to produce results. They possess relatively secure funding

over the next 2-3 years and have expressed buy-in and interest of management and

technical staff. Lessons learned from consultations, inter-facility meetings, conferencesand technical assistance visits will inform decisions, policies and guidelines at the district

and province levels, and will be scaled up to all of our facility-based HIV programs

within one year.


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ART Outreach Model

In this model, doctors and/or pharmacy

staff from district or provincial hospitals ordistrict health offices travel to healthcenters on specific days to offer ARTservices. During these clinics, nurses and

clinical officers are mentored to provide patient follow-up. ARVs dispensed are

either transported from the hospitals orstored in the health centre depending onavailable infrastructure. Samples for

specialized laboratory services aretransported to the hospitals on specific

days. The Team will combine this model

with other ongoing outreach services likeimmunization or under five services in

settings where there is demand for ART but the requisite infrastructure to deliver

the service is unavailable.

ANNEX

Illustrative examples of FHI’s Contribution at Country, Regional and Global Level in

Response to Pediatric AIDS

Status of FHI’s programs There is renewed institutional and global consensus about the

need to prioritize children in HIV prevention, treatment and care programs. FHI is well-

positioned to work with partners in supporting and expanding pediatric care andtreatment services. In the last two years alone, FHI has reached over 4 million people

with care and support services. FHI can also be credited with developing over 1,260

counseling and testing (CT) sites in 25 countries in Africa, the Latin American and

Caribbean region and Asia- Pacific. Since 2004, more than 1.5 million individuals havereceived CT at these facilities. To date, we have provided HIV clinical care to over a

quarter million clients at FHI supported sites globally. We have helped to rapidly scale up

programs to provide ART in 18 countries and have directly provided treatment to over

63,000 people at 167 sites – roughly 10% of the President’s Emergency Plan’s treatmentachievements to date. We have provided prevention of mother-to-child transmission

(PMTCT) services to at least 380,000 pregnant women at over 270 sites. FHI currentlysupports comprehensive pediatric care and treatment activities in all 10 countries

delivering ART in Africa and Asia. Detailed illustrations of FHI’s Pediatric response to

date at the country level are illustrated in the text below.

Recognizing the gap in pediatric HIV care and treatment, FHI’s country programs have

adopted a variety of approaches to step up pediatric clinical care & ART service delivery.

• Zambia has articulated a Pediatric-specific HIV strategy that hinges on

expanded child counseling andtesting; infant HIV diagnostics;

building capacity for pediatric HIVmanagement; attention to availability

of drugs and other commodities for

testing, OI prevention andmanagement as well as ARVs; and

nutritional management. By the end of

June 30, 2006 of the 21,082individuals who were receiving

antiretroviral therapy at ZPCT

(Zambia Prevention Care and

Treatment) supported sites; 1,344(6.3%) were children. FHI Zambia has

also expanded adult and pediatric

ART through outreach to primaryhealth centers in peri-urban and rural

areas.


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• Tanzania, Zambia and Nigeria have used a three-tiered ART decentralization modelaimed at rapidly building the capacity of primary health centers, while optimizing

quality service delivery.

Tier 1: Provision of a package of core services in health centers that

provide basic outpatient services comprised of HIV, CT, PMTCT,

HIV care and support, and referral servicesTier 2: Expansion of services in health centers that offer a mediumlevel of services such as TB and malaria testing and inpatient care

that include ART patient management and core services

Tier 3: ART initiation at district level hospitals with services in

multiple specialties, and providing the full package of HIV care and

treatment

• The Rwanda program has taken advantage of PMTCT services that are alreadyfairly decentralized to strengthen follow up of mother-infant pairs. Rwanda is

providing Co-trimoxazole (CTZ) preventive therapy to an impressive 95% of its

PMTCT infants. Relative to infants initiating CTZ prophylaxis, > 50% of infants inlongitudinal PMTCT care are tested for HIV at 9-18 months of age.

• The Global HIV/AIDS Initiative in Nigeria (GHAIN) has spearheaded PediatricHIV Care and Treatment within a family-Centered Model of Care in order to

extend the benefits of therapy to this underserved population.

• In Ghana, in collaboration with the PMTCT technical working group, operationsresearch is underway to look at the logistical and human resource implications for

dried blood spot (DBS) sample collection, transportation, results interpretation and

reporting. Ghana’s Korle Bu Teaching Hospital, historically funded by FHI, is also participating in the KIDS-ART-LINC, a study collaboration seeking to define

prognosis of African pediatric patients treated with HAART in resource-poor

settings; compare experiences between different settings, delivery models and typesof monitoring; and finally, compare prognosis in resource-poor settings with thatobserved in industrialized countries. In Manya Krobo district, district based staffs

have been trained to determine CD4% for children using simple hematological

parameters and CD4 counts without expensive equipment.

• In India, USAID and FHI in collaboration with partners have developed culturallyspecific materials and protocols for the counseling on HIV testing, disclosure, and

support for children.

• FHI Cambodia has produced culturally specific child targeted information materialsfor children affected by AIDS. These materials help children living in families

affected by HIV/AIDS to understand the changes that are taking place in their

families; to feel more confident to share their feelings with others; and to developskills that will help them cope with problems.

• In Kenya FHI is working closely with the National AIDS & STI Control program

(NASCOP) and stakeholders to finalize low literacy materials targeting caregivers

of children known to be HIV infected, and heath care workers providing treatmentand care services for children and their families. FHI Kenya is also piloting anintegrated model of MCH and HIV care service delivery using structured


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longitudinal HIV care linked to immunization visits. The pilot project will

document the benefits for prevention and care and treatment.

• Vietnam is at the very early stage of implementing its Family-centered Continuumof Care (CoC) model and is beginning to integrate pediatric ARV therapy intodistrict level OPC. FHI Vietnam is also supporting USG and Ministries in

developing Vietnam’s OVC strategy.• Finally, Vietnam and Kenya are implementing models of pediatric HIV care that

includes and extends social support services for HIV-infected children, orphans and

other vulnerable children.

FHI has also made contributions at global and regional levels.

• Globally FHI participates on WHO’s expanded Inter Agency Task Team (IATT) onthe prevention of HIV infection in pregnant women, mothers and their children.

FHI continues to participate in international meetings convened by UNICEF,

WHO, ANRS and others to accelerate progress in pediatric HIV care and treatment.

• FHI is a member of ANECCA’s steering committee and through a subagreement

with the Regional Center for Quality of Health Care (RCQHC), produced theHandbook on Pediatric AIDS, a widely used resource for pediatric HIV care.Through a sub agreement funded by USAID/ECA through the ROADS project,

JPHIEGO is packaging ANECCA training materials into a generic Pediatric

Comprehensive care/ART training curriculum. The existing curriculum has already been adapted by several African countries. In Tanzania, FHI with EGPAF hassupported the adaptation of a national pediatric training curriculum. In Uganda

(through ANECCA), FHI supported the design and proposal to the national AIDS

Control Program, for a national pediatrics clinical mentorship program. A pilot is to be funded to start in EGPAF-supported PMTCT programs formerly supported

through FHI.

Documents

FHI Pediatric Summary Strategy-Not for Distribution