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 ContextEarly 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

SITE

S

Methods (2) The full EID service was reviewed at each site

At each site, the full EID service continuum was examined:

SCO

PE

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 EI DEst. 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

0200400600800

1000120014001600

Monthly 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

wee

ks

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

AcknowledgementsUNICEF (HQ, ESAR, NAMIBIA CO)

USAIDUS Center for Disease ControlClinton FoundationI-TECHWHOGRN