Session 1- Entry Points for Pediatric HIV Services and Identifying HIV-Positive Children

Overview and ICAP Approach: Marie Donahue, MPH, MS, CPNP, Pediatric HIV Specialist for ICAP Tanzania, spoke about challenges in the diagnosis of HIV in children, including laboratory issues regarding limitations of antibody testing, need for virologic tests in young children and clinical factors like limitations of antibody testing and limited virologic testing, as well as psychosocial factors such as informed/parental consent.  She emphasized a family-focused approach to finding infected children, including maximizing PMTCT, MCH care, adult care programs, and testing at community events.  She presented two case studies emphasizing that clinical disease progression such as failure-to-thrive and frequent hospitalizations are often not recognized as HIV-related.

Country Experiences and Challenges: Zambia Inpatient Testing Program:
Nancy Briggs, ICAP Implementation Officer, described the successful creation of a pediatric inpatient testing program, highlighting the increased uptake of pediatric HIV testing because of the provider-initiated testing system and the benefits of using a multidisciplinary team approach early in the care process.  Nancy reviewed challenges to the program such as a lack of space for confidential counseling and testing, and, among providers, fear of patient rejection and fear of the impact that increased numbers of children needing treatment would have on already strained human resources. 

Country Experiences and Challenges: Rwanda:Using Peer Educators to Increase HIV Testing Among Families
Eugenie Ingabire, Care Coordination Field Officer at ICAP Rwanda, described a program in which 29 peer educators (PEs) increased HIV testing among families at 2 Rwandan clinics, in partnership with people living with HIV/AIDS (PLWHA) organizations.  The PEs helped reduce stigma and increased the testing of children tenfold.  Challenges included issues such as the difficulty of drawing whole blood from children (finger prick and DBS were preferable), resistance to testing and referral to care by adolescents, and refusal of some parents to accept their child’s HIV+ results.  Eugenie suggested that, if starting over, the program would develop pre-testing documentation tools and would verify PE literacy levels before finalizing PE selection.

Issues raised during Question & Answer session:

  • The two country examples offer valuable diverse perspectives; Zambia has a high prevalence of about 30%, while Rwanda’s prevalence is about 5-7%.
  • The theme of motivation and involvement of providers seems to be an issue in all ICAP programs; a policy issue that must be addressed.
  • ICAP-Nigeria is  starting a pediatric inpatient testing program.
  • At ICAP-Ethiopia, lack of access to counseling and testing in pediatric programs was identified as a big problem.  A program was begun with a goal of testing 100% of children.  It began with only 2-3 trained staff, who had a heavy workload.  A second training was held for all pediatric ward staff, and led to significant program improvement. Generally, the free testing is done by a nurse.  Patients are happy to be receiving the free testing and are surprised that it is free.
  • In Swaziland, there is much emphasis on pretest counseling, but once a person has received a positive result, services are inadequate.
  • Rwanda
    • The PEs were selected by PLWHA associations, and besides training, they received the following support:
      • A bicycle, raincoat and flashlight, to conduct outreach
      • Registers, pens, backpacks
      • Radios to follow health information
    • Waiting time at community health centers was a major barrier to testing.
    • It was reported that the reduction of stigma is impressive.  The Rwanda program may be a model for Tanzania, where stigma is significant.
    •  The PE approach dispelled the myth that VCT costs a lot of money. 
    • The PE program had significant monitoring and evaluation (M&E) support; all programs should include such M&E integration.
  • Zambia
    • The original vision for the program was that everyone who had contact with the child (like nurses, etc.) would advise testing, but now the program relies primarily on counselor-initiated testing.  So this is not fully routine testing with HIV testing as a routine part of every hospital admission. 
    • It was important to take the counselors out of the family support unit and bring them into the ward, making them a real member of the care team.  This fostered more respect for the counselors among both providers and patients.
    • It was crucial to have buy-in at many levels of the facility; implementation of the program cannot use a simply hierarchical, top-down approach.  The program began with just two counselors who decided how to approach families for testing.
    • Testing was conducted with rapid test kits, allowing 15-30 minutes pertest.
    • Site-level multidisciplinary teams were comprised of doctors, nurses, lab workers, nutritionists, monitoring and evaluation staff, etc. 

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