Treatment and Laboratory/ Care and Support

2008 HIV/AIDS Implementers’ Meeting

Kampala, Uganda 3-7 June 2008

7 June 2008 Treatment

Rapporteur Presentation

Treatment and Laboratory/Care and Support



Treatment Snapshots

• When and What to Start







When and What to Start as First-line Therapy? (#838)

• Adult National Antiretroviral Treatment (ART) Guidelines (Raizes E)

– WHO (2006)



Conclusions

• PEPFAR focus countries’ published guidelines are consistent with the most recent (2003 or 2006) World Health Organization (WHO) guidelines

• 13 of the 15 PEPFAR focus countries initiate ART in asymptomatic HIV-infected individuals below 200-250 cells/mm3

• WHO guidelines: “Consider treatment [at 200-350 cells/mm3] and initiate before CD4 count drops below 200 cells/mm3.”





Conclusions

• Since publication of the 2006 WHO guidelines, 8 countries have revised their treatment recommendations– Preferred 1st line regimens now include AZT or tenofovir– The dose of stavudine has been reduced– 2nd line ART is consistent with the WHO guidelines; 10 countries

recommend virological confirmation• For six of the remaining 7 countries, first line regimens continue to

include stavudine• TDF and 3TC recommended in 5 countries if hepatitis B is present• TDF in second line in 8 countries







• Botswana: Policy, Cost and Programmatic Implementation and Implications of Using a Higher CD4 cut off (Sheperd)

• CD4 250 cells/ul – 20,000 additional people estimated to immediately qualify; impact on cost?

• Moved from d4T/AZT to tenofovir






• Transition Challenges of Tenofovir roll out in Zambia (Mwango A)

– Lab capacity, procurement and forecasting, changes in clinical practice, administrative preparedness, and provider trainings were necessary for implementation of new guidelines

– Unanticipated popularity of regimen




• Namibia (2007) WHO stage 3 /4, CD4 <200 (general population), CD4 <250 (pregnant women). First line AZT/3TC/NVP (alternatives: AZT/3TC/NVP, d4T/3TC/NVP). If the CD4 threshold is raised, challenges of treating advanced patients first, increasing cost, need for improved infrastructure, and improved adherence strategies

• Recently d4T to AZT (CD4<250; considering 350)

• Predictable increase in anemia – cost of transfusions and EPO

• Concern regarding cost of overall programme, especially with increasing > 350

When and What to Start as First-line Therapy? (#838) Katjitae I





• WHO Guidelines, Cost and Implementation for Adults and Pediatrics (Gilks C)

- Harmonized ART Policy Guidance for adults, adolescents, pregnant women and children

- Revised WHO clinical staging of HIV for adults and children (2006)

- All infants < 12 months should be treated

7 June 2008Care, Treatment and Support


When and What to Start as First-line Therapy? (#838 )



<12 months >12 months

Stage 4 All All

Stage 3 All All except TB/LIP/OHL and Thrombocytopenia

consider CD4%

Stage 2 All CD4 guided

Stage 1 All CD4 guided

When to Start ART – Infants & Children





WHO Guidelines, Cost and Implementation for Adults and Pediatrics (Gilks C)

– Revised WHO clinical staging of HIV for adults and children (2006)

• Issues for earlier initiation (CD4 <350): estimated 10-30% more eligible patients will lead to decrease in “coverage.”

• Nevirapine (NVP) contraindicated in women with CD4>250






WHO Guidelines, Cost and Implementation for Adults and Pediatrics (Gilks C)

– Revised WHO clinical staging of HIV for adults and children (2006)

• If treat all pregnant women with combination ART, women may be on it for life given SMART data; also what to use? NVP contraindicated, use second line with PI or 3 NRTIs?

• TDF not recommended in children/adolescents, in pregnancy and breastfeeding?; cost vs d4T






Side Effects and Toxicity





Renal Dysfunction

• Renal disease – very high baseline renal insufficiency, mortality on ART strongly correlated (especially early) - routine renal screening? – warning signal (Bolton, session B7, Wed morning)

• Women, age, WHO ¾, Hb<8• Renal dysfunction pre-ART common and carries a very

high mortality, even with mild dysfunction





Creatinine clearance calculated by Cockroft-Gault equation

Mortality by Baseline Renal Function25,249 patients initiating ART in Lusaka, Zambia





Resistance in Patients on ART

• Nigeria:– Cross sectional analysis of patients with detectable

viral load and history of ART prior to entry– Almost 2 years on unmonitored therapy– Gentoyped – multiple nucleoside reverse

transcriptase inhibitors (NRTI) and non-nucleoside reverse transcriptase inhibitors (NNRTI)





0

5

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% o

f p

atie

nts

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# NRTI muts, mean = 3.35 [preART 3.5, noART 2.95]

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0 1 2 3 4 >4# of NNRTI mutations, Mean 2.08 [preART 2.17,noART 1.86]

NNRTI DRMsNRTI DRMs

Number of Drug Resistance Mutations (DRMs) in the Reverse Transcriptase Gene





ART Response Post Single-dose Nevirapine (sdNVP) (McConnell)

• Follow-on from CROI• Reassuring that NNRTI suppressive regimens

are potent beyond 6 months• But what about the ones who need treatment?





Successful Response at 48 Weeks (n=760)On-treatment analysis - Failures carried forward

0%

25%

50%

75%

100%

Unexposed 1 to 6 7 to 12 >12

Time since NVP exposure (Months)

Su

cce

ss

(n = 106) (n = 51) (n = 153)(n = 450)

87%

64%*

82% 86%

* P < 0.001 vs unexposed





Community Based and Other Methods for Reducing Patient Default

• Good adherence can be achieved using trained antiretroviral drug (ARV) clients and other devoted community members; Planned and consistent home visits as well as social support are crucial for both the client and family members

• Peer educators for default tracking can be successful in rural districts to return patients to care and support ART initiation and support.

• Pharmacy refill records are a useful adherence assessment tool. An analysis comparing pharmacy refill rate and self-reported adherence and barriers to adherence is in progress.





Community Based and Other Methods for Reducing Patient Default

• A community-based adherence model utilizing patient Community Health Volunteers and local religious leaders may help improve adherence and retention in care.

• Interventions delivered by community volunteers offer an attractive opportunity to supplement formal health services. Community program activities need to be routinely validated and information collected must be simple.

• A low-cost,“real time” default tracing system is feasible to maintain retention in treatment and care using a mobile phone follow-up system.





Challenges in Delivery of Care and Treatment to Most-at-Risk Populations (MARPs)

• Building HIV/TB Care for Detained Injecting Drug Users (IDU), Jakarta, Indonesia (Magnani R, #1282)– IDUs responsible for 55-60% HIV infections nationally, 1/4-

1/3 of inmates are IDUs, HIV prevalence among inmates 10-17%, higher among IDUs (40-50%)

– Inmate release and transfer leads to formidable challenges, especially for treatment adherence

– Increase in number of inmate deaths suspected to be related to HIV/AIDS led to call for help





Challenges in Delivery of Care and Treatment to MARPs

• Building HIV/TB Care for Detained IDUs, Jakarta, Indonesia (Magnani R, #1282)– Intervention package: diagnostic and clinical services, condoms,

adherence counseling and support, addiction counselng, post-release coordination with community-based non-governmental organizations working with IDUs and people living with HIV/AIDS (PLWHA)

– 19% screened were TB +, of those TB +, 31% were HIV +– Use of NGOs crucial to undertake “sensitive” activities

government may not want to address





– Population prevalence 1.3% (2006 DHS, people in prostitution 35.3 % (ISBS ‘06), people in prostitution condom use 95% with clients, 51% with boyfriends

– Median age 29, 34 out of 53 had other girlfriends, fiancées or spouses. 26 out of 53 were financially supported by girlfriend

– Risk perceptions inversely related to trust in partner, people in prostitution unwillingness to use condoms was most frequently cited barrier

– BF willing to get tested, however few have

Knowledge, Attitudes and Condom Use Practices Among boyfriends of people in prostitution, Bamako, Mali (Fofana F, #1703)






• Why IDUs are still not receiving healthcare, Ukraine (Kurpita V)– HIV prevalence 1.64% concentrated epidemic IDUs (up to 60%), people in

prostitution (up to 32%), men who have sex with men (MSM) (up to 8%)– Of those on ART <2% are IDUs, 85% of those lost to follow-up (LTFU) are IDUs– Multiple obstacles: political, financial, limited access to care, geographic separation

of care sites, high stigmatization– High prevalence of co-morbidities in IDUs (85% hepatitis C co-infected), psychiatric

illness, lack of knowledge of HIV and drug addiction in medical professionals– Increasing number of non-opiod users, need more evidence re interaction of ARVs

and other drugs







1.532.39

0.210.73

5.55

7.89

2.05

3.3

7.43 7.58

9.24

5.49

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10

In 3 regions Donetsk Kyiv Mykolayiv

active IDU, % active hepatitis, % active TB, %




• Prevention and Sexually Transmitted Infection (STI) Management with High-Risk Populations, India (avahan) (Menon H)

– Challenges to scale up: geographic spread, mobile/hidden nature of populations,

– Rapid roll out of infrastructure, by end of year 4, 280,000 covered (people in prostitution, MSM, IDU), $58/person/year

– Three staged approach to achieve scale (establish infrastructure, intensify coverage and quality, maintain coverage)

– Strategy of microplanning to know population peer deals with – Flexible management: different contexts require different solutions– Lessons learned: focus on scale, define standards but promote innovation, use

data, quality is critical, listen to the beneficiaries

• Challenges in Uganda (Madraa, E)– MSM population not well studied, still marginalized, difficult to reach population– People in prostitution still face obstacles such as stigma





Ethiopia: Retention and Mortality During Six Months of ART

• Retrospective • n= 321, 59% female, average age 34 years; • At 6/12: 72% still in care; 18% died (linked to CD4/

mobility/weight); 8% LTFU, 1% transfer: • Distance from facility linked to being male, advanced

disease, higher age• Decentralization important – deal with distance, earlier

diagnosis intra-facility linkages





Gender and HIV and Outcomes on ART

• South African study; • Retrospective, n = 6 500 ART adults over 3

years; 66% female (ratio changed slightly over time)

• Women were younger, higher CD4 (80 vs 95), better body mass index (BMI), lower WHO





Survival to Death or Loss to Follow Up

Adjusted analysis showed survival advantage for women

[HR =1.22 (1.06 - 1.39) p=0.004]

Male

Female

Log rank test

p=0.0033





Gender and HIV and Outcomes on ART

• Time to 100 cell increase – again, women more likely and faster (clinical significance?)

• Women more likely to get viral load suppression at 10/12 (no difference at 4/12)

• Men access treatment later and sicker; worse virological and immunological data

• Suggest: focus men on men as a vulnerable group?; workplace voluntary counseling and testing, ‘male friendly’ clinics;

• Pick up drugs at post office





• ART-LINC: Effectiveness of cotrimoxizole (CTX) prophylaxis on survival and program retention in African highly active antiretroviral therapy (HAART)-treated adults with baseline Cd4>200 cells/ul

• Data from ART-LINC collaboration, survival model• Outcome: Death or LTFU (gone for 6 months)• CTX, CTX before or during CTX,vs CTX after ART,

followed up (ART and CTX considered equal across arms); retention 75%

• Multivariable analysis: Mortality not different

ART – LINC Collaboration





Session L9

• Rwanda (Tene): Clinical and immunological outcomes in children in a decentralized programme

• 1988 children on ART (55%>5 years); 11%<1 year

• Median follow-up – 14.6/12; Higher lost to follow up if not started on ART (OR 3.3)





• Uganda (Musiime): Response of children to ART: urban vs. rural

• 24 and 48 week data; • Similar outcomes, rural presented sicker





Trend of Mean CD4 count for children over 5 yrs

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Outline: Laboratory data

• Laboratory Infrastructure

– Quality Systems

– Early Infant Diagnosis

– Training





Laboratory Strategy

• Maputo Declaration– National governments to support laboratory systems

as a priority by developing a national laboratory policy within the national health development plan that will guide the implementation of a national strategic laboratory plan

– Develop national strategic laboratory plans that integrate laboratory support for the major diseases of public health importance including HIV, tuberculosis, and malaria




Kampala Uganda 3-7 June 2008

Laboratory Strategy

• There is a need to integrate laboratory services instead of having program specific laboratory services

(John Nkengasong)

• There is a need for a laboratory coordinating mechanism for stakeholder collaboration and commitment to strengthen national level efforts to improve laboratory services

(Jack Nyamongo #756)





TB/HIV • High proportion of pulmonary tuberculosis (PTB) cases are not identified by the health

system, most of HIV+ cases are eligible for ARVs Majority of identified PTB cases are smear-negative

• Creative approaches such as TB screening during home-based HIV testing initiatives should be considered, and the need to strengthen laboratories for more culture back up in TB diagnostic process

(Laserson K.F et al; abstract #358) • Routine measurement of standardized indicators is useful to maintaining quality of

mycobacterial culture system (Patama Monkongdee #1238)

• Concentration of sputum improves detection of mycobacterium tuberculosis (MTb) by about 31%

• Fluorescent microscopy reduces reading time four fold(Girmachew Mamo #784)





HIV Incidence

• Countries should strongly consider application of incidence assays in HIV surveillance systems to monitor incidence in populations over time

• However, BED incidence must be adjusted using published data, or preferably local adjustments to correct HIV incidence for assay misclassification

(Andrea Kim #383)





Early Infant Diagnosis (EID)

• Utilize a pilot phase to develop vital in-country technical skills, laboratory capacity, and development and testing of systems

• A coordinated multi-partner effort is useful in rolling out the service

• Integration of services into existing health systems with strengthening of linkages to care and treatment centers facilitates sustainability and maximizes coverage of the program

• Engage national and facility authorities in each step of implementation

(John Gamaliel #1567)





Early Infant Diagnosis

• Creation of a laboratory QA program during development of EID program allows for detection/correction of testing errors and ensures accurate results returned for infant treatment

• The appointment of Lab project coordinator with a specific responsibility to review laboratory data and perform site visits facilitated the timely reporting and quality of the EID diagnostics.

(John Gamaliel #1567)





Quality Assurance

• Must identify appropriate authority at national level to run QA programs

• Important to encourage participants to use external quality assurance (EQA) results to improve their performance

• QA program and quality management systems (QMS) complement one another to support quality laboratory testing

(Wilai Chalermchan)

• Require dedicated quality officers at labs





CARE AND SUPPORT

7 June 2008Care and Support




Outline

• Adult care

• Palliative care

• Pediatric care

• Counseling & Testing (CT)

• Tuberculosis and HIV (TB/HIV)

• Food and Nutrition

• Orphans and Vulnerable Children (OVC)

• Key observations





Adult Care





Retention in care: pre-ART

• Everyone recognizes retention as problem, but little attention at this conference.

• 119 HIV+ patients enrolled in 5 health centers (HCs), 99% referred to antiretroviral treatment (ART) site for staging, but only 33 (28%) went within 3 months (Ubarijoro, S, # 727)

• Piloted clinical staging and CD4 testing at 3 HCs in 2007; 39 patients enrolled, only 3 ART-eligible, and all successfully referred (Ubarijoro, S, # 727)





Pregnant Women and CD4 Testing & ART Initiation: Jose Macamo Hospital (El-Sadr, W, Session F11)

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Quarter 2006

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CD4 count done

eligible for ART based on CD4

eligible for ART and receivedCD4 result

registered at ART clinic

started ART





Quality Improvement pilot results: HIV Quality Improvement (HIVQUAL) in 12 hospitals in Thailand, 2002-2005

Session E9 (Fox, K, #1352)

Median % of eligible patients receiving services

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CD4 testing ART PCPprophylaxis

TB screening

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Documents for Scaling-up HIV Prevention, Care and ART at Primary Health Centers

• WHO/PEPFAR (Ellerbrock, T, Session G3)

DocumentPrimary Target

Audience Content Summary

Operations Manual Staff at primary health centers (PHC)

What is needed to provide HIV services and how to implement these services.

“Basic HIV Service Elements at Health Centre Level”

District planners/ managers and partners providing support for PHC

Guidance for an initial assessment and developing a plan to strengthen capacity to provide HIV services. Checklists for monitoring standards.

District Addendum District management team

Guidance for how District Coordinators should provide oversight of HIV services at primary health centers.

Adaptation Guide National team adapting Operations Manual for country

Materials to assist country teams to adapt the Operations Manual to country-specific conditions.

• [email protected] beginning June 20, 2008





188,000 kits distributed from 134 outlets as of March 2008.

Acan, J, # 726

Product Based Components Safe Water Systems Filter Cloth Condoms

IEC materialsBednet Cotrimoxazole





Challenges/Recommendations (Acan, J, #726)

• Commodity supplies: logistics tracking systems• Continued logistics support and training• More than 1 supplier for each commodity• Sustainability – free vs. socially marketed





Effect of Cotrimoxazole Discontinuation on Malaria Among Home-Based AIDS Care Project (HBAC) Participants (Tappero, J, Session B7)

Variable On cotrimoxazole

Off cotrimoxazole

All

Patients, n

452 384 836

Febrile episodes leading to smears, n

87 228 315

Patients with > 1 febrile episode leading to a smear, n (%)

67 (15) 155 (40) 222 (27)

Patients with > 1 positive smear, n (%)

2 (0.4) 47 (12.3) 49 (5.9)

Patients with 2 positive smears, n (%)

0 (0) 8 (2) 8 (1)





Lessons learned from HIVQUAL-T scale-up in Thailand (Fox, K, #1352)

• Partnerships were critical to scale-up success– National healthcare payor – made rapid national scale-up possible– Hospital accreditation association – allowed us to build on existing

quality improvement expertise and link with accreditation process– Provincial and hospital leaders – gave authority to local staff

• Capacity building is an ongoing process– Training, then follow-up supervision, coaching, and peer learning

• Peer learning motivated staff and increased quality by sharing successful practices– Forum participants reported that key factors in implementation

success were support from hospital leadership and sharing experiences among hospitals

• Monitoring the quality of implementation during national scale-up is challenging





Palliative Care – National Pain Policies

• Successful national scale-up efforts for increasing access to opioids, initial steps: (Krakauer, E, #90; Downing, J, #1114; Green, K, #1397; Jagwe, J) – Formation of a government and non-government collaborative

workgroup including the Ministry of Health (MOH), Narcotics Control Authority, and regulatory and professional councils.

– Initial Rapid Situation Analysis (RSA) to determine gaps in access to analgesics.

– Consideration of special populations – pediatric, injecting drug users, incarcerated, and persons living in rural areas.





Palliative Care – National Pain Policies

Sustainability efforts, include implementation of WHO “4 pillars” of a national palliative care program: (Krakauer, E, #90; Downing, J, #1114; Green, K, #1397; Jagwe, J)

1)Policy: National policies & guidelines on palliative care.

2)Medications: Assure access for all to opioids and other palliative medications.

3)Education: Educate clinicians and healthcare officials in palliative care.

4)Implementation: Implement sustainable palliative care clinical and training programs.





Successful Models for Ensuring Access for Children to Care and Treatment

• Children in pre-ART care are more likely to be lost to follow up than those on ART especially for younger babies – Rwanda (#328)

• Expand care and treatment services with emphasis on early diagnosis and identification of those who need ART – Rwanda (#328)

• HIV infected children in rural areas start ART at a more advanced stage but all responded to treatment favorably in both rural and urban sites. Community mobilization is working to get younger children in for testing - Uganda (#737)





Pediatrics Care

• Tanzania – Pediatric HIV program increased over time and then stabilized causing the city to do an intervention to reach the children. Data is still not clear but pediatric focal points and child friendly services have been established and they are seeing more younger children using the services. Urio (#1401)

• In order to scale up pediatric services to reach 1000 children on treatment in Vietnam in 24 months, all partners needed to collaborate and be coordinated regarding drug quantification, technical assistance, logistics, and the provision of all services. The coordination was vital to get the work done quickly. SCMS (#568)

• Summary of the UNICEF pediatric scale up frame work available for conference participants. UNICEF (1793)





Summary Pediatric Care Issues

• Linkages between the prevention of mother-to-child HIV transmission (PMTCT), maternal and child health (MCH), care and treatment services are vital to ensure the child is receiving all services over time.

• Children respond well to ART in both urban and rural areas when it is provided, despite lower levels of staffing and support.

• HIV positive children not eligible for ART are more likely to be lost to follow up.

• UNICEF programming framework is available to help implementers and countries develop their programs.





HIV Counseling and Testing (HCT) - Key Observations• Focus on HCT has been on linking HIV positive clients to care, treatment and

support services; however, there is a need to renew the emphasis on the prevention aspects of HCT for those who test HIV positive and negative.

• HCT could benefit from being viewed as part of a larger intervention strategy for HIV prevention, care, treatment and support rather than a one-time intervention.

• Project ACCEPT offers Voluntary Counseling and Testing (VCT) services in addition to community preparedness and mobilization, as well as post-test support services with high levels of testing uptake (Morin, S; #1045).

• Strategic information and program data can be used to identify gaps in access to or utilization of HCT services in order to better target services.

• Analysis of data from Tebelopele sites in Botswana showed a lower than desired uptake of VCT services by male clients, so an innovative program of outreach CT services was designed to reach them (Awsumb, B; #447).

• Uptake of HCT remains high when services are most convenient for clients• Offering patients counseling and testing services during their visit to a health facility yields high uptake of

services for patients and patient visitors (Namusobya, J; #1298 and Isabirye, M; #1058).





Variable Result

% of eligible persons who accepted to test

>99%

# of persons counseled, tested and given results

124,964 (28% were non- patients)

# of HIV positive persons identified 16,157 (13%)

# of HIV positive persons enrolled into care within the same facilities

8,525 (53%)

Namusobya, J.; abstract 1298 *As of March, 2008

Results from the Uganda Routine Counseling & Testing (RCT) Approach





Lessons Learned

• Large scale CT activities, such as national HIV testing events, require significant foresight and planning– National HIV Testing and Counseling Campaign, Tanzania

(Swai, R.; #1625)– Know Your Status Campaign, Lesotho (Ngonyama, L.; #1631)





Tuberculosis and HIV (TB/HIV)









Progress in Scaling-up TB/HIV Collaborative Activities• Progress has been made in scaling-up HIV testing of TB patients through provider-

initiated testing and counseling (PITC) (Khan #1244, Mabaera #1147, Mohammed #451, DeCock L1).

• Need to address the challenge of timely linkage of TB patients to HIV care and treatment

– “One-stop shop” approaches for TB and HIV services– Efforts to decentralize HIV care and treatment services to PHC level– Piloting provision of CTX in the TB patients (Omoniyi #1418)

• Evaluation of routine TB surveillance systems has been used to improve program implementation and documentation of scale-up (Mwinga #403, Shah #765, Claquin #1465, Kololo #526)

• Examples of implementation of TB screening and diagnosis in selected sites, however, national scale-up has been slow (Scardigli #1548, Vandebriel #702)

• International agencies have recently made efforts to harmonize reporting indicators to measure progress in TB/HIV collaborative activities





The Way Forward:The Three “I”s of TB/HIV

• “Branding” of the priority interventions for HIV implementers outlined in WHO Interim Policy for Collaborative TB/HIV Activities:

– Intensified TB case-finding among PLWHA• Various TB screening tools are currently in use, no standard• Meta-analysis of existing validation studies in process

– Isoniazid Preventive Therapy (IPT)• Reduces risk of active TB 33-62% for up to 4 years• Evidence that ART and IPT significantly decrease TB among PLWHA• Pilot and expand IPT programs with expansion of Intensified Case Finding

(ICF) scale-up (Diero #1903)– Infection control to prevent TB transmission

• Infection control needs to be addressed, especially as TB and HIV services are integrated

• Additional guidance and tools are currently being developed





TB screening at ART facility (Mozambique)

Oct-Nov-Dec 2007

Newly enrolled HIV patients screened for TB by enrollment 88%(309/353)

HIV screened patients identified as suspects for TB (at least one sign or symptom positive)

40%(123/309)

HIV screened patients identified as suspects for TB & subsequently diagnosed with TB

19% (23/123) of suspects and 7.4% of all screened patients (23/309)





Food & Nutrition: Linking Nutritional Support with Food Security and Livelihood

Assistance for HIV/AIDS Patients, Families and OVC

• Urgent need to strengthen nutritional support as a critical component of comprehensive care and treatment of HIV/AIDS patients, as well as for women in PMTCT programs and OVC from birth up to 18 years of age.

– Nutrition has generally been under-prioritized and under-funded: strong national commitment by government and partners, including PEPFAR, is imperative.

– Clinical services provide a platform for nutritional assessment, counseling and support for patients and their families, while providing an entry point to link with home-based care, food security and livelihood assistance programs at the community level.

– The Food Crisis will increase the vulnerability of HIV/AIDS patients and their families, including OVC, making clinical and community nutritional support even more critical, and increasing the need to link with existing and new initiatives designed to address food insecurity.





Findings: Orphans & Other Vulnerable Children





A multi-variate analysis of Demographic and Health Survey (DHS) data from 11 countries showed that gender, region, and wealth – rather than orphan status –

affect school attendance.

Fig. 1: Regression estimated determinants of school attendance

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ETH KEN LES MAD MLW MOZ NAM RWA TNZ UGD ZAMp

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4th wealth quintile

• Concluding – “Policies & programs should avoid a single-minded focus on orphan status” & target based on a “composite of contextualized vulnerability factors” and strive to “combine AIDS specific activities within broader sectoral policies and programmes.”

B8 – 1630 Campbell

Targeting





Evaluations of a range of economic strengthening products underlined the need to tailor interventions to a range of different groups, especially elderly OVC caregivers, and showed that some states are ready to take over the responsibility of cash transfers piloted by others.

Care Village Savings & Loans –E7 – #696 Philbrick] ARK [E #1757 Mokgadi]

Economic Strengthening





Strengthening Frontline Service Delivery

• A twinning project between Tanzania and Illinois-based schools of social work resulted in the development of a cadre of Para-Social Workers to address the needs of OVCs throughout the country [C7 #1627 Mabeyo]

• An evaluation of mentors in Rwanda underlined the importance of limiting the ratio of volunteers to households to achieve positive outcomes for children [F5 #1745 Thurman]





Safe Spaces for Highly Vulnerable Girls

• Multiple Sessions reiterated the need for better research and expanded programs to address highly vulnerable girls (urban, orphaned and/or living outside of family care) and their need for both Prevention and Protection

Biruh Tesfa (Domestic workers & Migrants in Addis slums) [B4 #1094 Erulkar]GBV, HIV & Schools [E4 #351 Banashek]





Lessons Learned

• Significant progress has been made in all fronts of HIV care and support, however, integration and linkage to prevention still needs to be strengthened.

• Care and support interventions are most effective when implemented as a package; programs should move toward more comprehensive approaches.

• Special considerations for pediatric populations need to be made when planning and implementing care and support programs.

• “Build the ship while sailing”: program implementation can often feed into the process of developing and finalizing policy guidelines and tools.

• OVC policies & programs should not target based on singular factors such as orphan-hood and instead use composite vulnerability factors and aim to balance AIDS specific activities within broader sectoral policies and programmes for vulnerable children.

