Family Health Internationals

Summary of Pediatric HIV Prevention, Treatment and Care Strategy

December 2006

Introduction
FHIs comprehensive response to childhood HIV/AIDS provides HIV prevention
including 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 families
affected by HIV/AIDS.
FHIs 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 based
and OVC care, and focuses on ensuring the continued good health of the mother and the
family. FHI fosters a district and country- wide approach.
Figure 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.

FHIs 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 FHIs capacity to provide seamless and
interconnected 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 of
children, 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 FHIs plan to support the rapid scale up of
pediatric HIV clinical care and treatment activities in FHIs HIV program globally. It
outlines critical short and medium term actions to demonstrate FHIs 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 PMTCT
interventions 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 antiretroviral
therapy (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 large
scale intervention even when resources are available.
Lack of both access and large scale interventions to life saving interventions such
as 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 equipment
limited to a few zonal and regional sites.
2

UNAIDS 2006

Constraints with human resources; specifically a lack of nurses, clinicians, and

community 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 their
children and themselves.
Poor collaboration between child related health facilities such as MCH and under
5 service providers, PMTCT, pediatric wards, and orphan support organizations.

FHIs Pediatric Strategy

What are we planning to do?
Family Health Internationals (FHI) Global Pediatric clinical care and treatment strategy
positions FHI as a key player to support international and national goals and global health
expectations in the scale up of access to pediatric prevention, care and treatment services.
Our initial efforts will complement
our existing activities with the
implementation of comprehensive
PMTCT programs and pediatric
AIDS programs in countries where
we are currently active. FHI has
been quite successful in the rapid
increase of access and utilization of
quality clinical care and treatment
services. Building on this
experience, FHI will use context
specific capacity building
approaches to sustain and increase
the number of children receiving
care and support. In this effort, FHI
will use an Integrated Network
Model to improve health systems.

Integrated Network Model

Increasing access to care and support for children

and their families requires strategies that create
multiple entry points. FHI programs accomplish
this goal by implementing an integrated network
for service delivery. These networks link
specialized hospitals with general hospitals,
primary health care centers, community-based
organizations, home-based care services, mobile
VCT units and the private sector to create
multiple entry points to care and treatment. Since
community based organizations may be the first to
identify a child helping need, referral systems
linking clinical and social support, play a key role
in facilitating entry to networks. Referral systems
also have a critical role in coordinating the range
of childrens needs including education, food,
protection, and shelter.

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

90% of women will be offered, and 80% will accept HIV testing at all FHI
supported PMTCT sites
At least 2 sites per country are implementing a ZDV-based PMTCT prophylactic
regimen
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 the
local 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 international
leaders 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 FHIs 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 destigmatization, 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 management
leadership 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:
5

Policy and guidelines formulation;

Seconding technical staff at national and/or district level to spearhead pediatric
scale 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 care
services and PMTCT;
Supporting and strengthening district pediatric M&E and data management
systems aligned to country supported adult HMIS and in line with the three
ones;
Educating communities through targeted marketing;
Developing educational materials;
Strengthening CBO capacity to identify & serve children.
Building awareness of pediatric HIV care, through strategic behavioral
communication (SBC) processes;
Ensuring full involvement of PLWHA;
Increasing the number of community based organization contributing to
identifying, supporting and referring children; and
Ensuring the sustainability of scale up through intense technical support including
on-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 and
complementary strategies:
Adopt a family centered, child focused approach including access to all HIV
services for children;
Activate entry points to HIV testing and disease management ( Figure 2);
Build decentralized capacity for HIV care services - across services at a given
facility, between levels of care, and across cadres;
Dove-tail pediatric HIV treatment and care to strengthened follow up of motherinfant pairs in PMTCT;
Build infant diagnosis capacity, expanding testing for children and facilitating
access 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 multidisciplinary
cadres;
Advocate for task shifting where feasible and acceptable;
Define and support functional collaboration and referral mechanisms between
services; and
Perform operational research.

Figure 2: Maximizing Entry Points into Pediatric HIV

Care & Treatment through Capacity Building & FacilityLevel Decentralization
MCH/PMTCT
Pediatric OPD/ Special
Clinics (TB, Skin,
Malnutrition)

Strengthen MCH clinics to provide

structured HIV services (ID,
diagnosis, CTZ)

Pediatric IPD
(diagnostic testing and counseling
for sick children, staging, CTZ,
pre-ART workup, monitor and
manage side effects of ART)

(diagnostic testing and counseling

for sick children, staging, CTZ)

Adult HIV Care

& Treatment
Services

Pediatric
Pediatric HIV
HIV
Care
Care &
&
Treatment
Treatment
Services
Services

Mentorship

(systematically invite
patients to bring in
children for screening
and services)

Lower level
health
facilities/IMCI
(Identification/diagnosis
, staging, CTZ, FU for
stable, +/- ART
initiation).

Community:
OVC Support Services
Home care services
Support Groups & PLHA Associations
CBOs/NGOs/FBOs
Women groups

Multiple
entry points
identify
children &
families
Routine
testing in high
yield pediatric
sites & existing
high-contact
points

(identification, referral)

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

FHI will form strategic partnerships with geographically co-located partners providing
community 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. This
approach:
Facilitates an integrated comprehensive network model of care and plug all
existing gaps for children;
Affirms a comprehensive response to childhood HIV/AIDS as one which
simultaneously 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 and
AIDS.
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 sites
designed 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.

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 multiple
sectors 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 WHOs public health approach. FHI uses
standardized and simplified ARV regimens based on the best available scientific
evidence 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 urgent
development 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, conferences
and 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.

ANNEX
Illustrative examples of FHIs Contribution at Country, Regional and Global Level in
Response to Pediatric AIDS
Status of FHIs programs There is renewed institutional and global consensus about the
need to prioritize children in HIV prevention, treatment and care programs. FHI is wellpositioned to work with partners in supporting and expanding pediatric care and
treatment 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 have
received 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 Presidents Emergency Plans treatment
achievements 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 currently
supports comprehensive pediatric care and treatment activities in all 10 countries
delivering ART in Africa and Asia. Detailed illustrations of FHIs Pediatric response to
date at the country level are illustrated in the text below.
Recognizing the gap in pediatric HIV care and treatment, FHIs country programs have
adopted a variety of approaches to step up pediatric clinical care & ART service delivery.
Zambia has articulated a PediatricART Outreach Model
specific HIV strategy that hinges on
In this model, doctors and/or pharmacy
expanded child counseling and
staff from district or provincial hospitals or
testing; infant HIV diagnostics;
district health offices travel to health
building capacity for pediatric HIV
centers on specific days to offer ART
management; attention to availability
services. During these clinics, nurses and
of drugs and other commodities for
clinical officers are mentored to provide
testing, OI prevention and
patient follow-up. ARVs dispensed are
either transported from the hospitals or
management as well as ARVs; and
stored in the health centre depending on
nutritional management. By the end of
available infrastructure. Samples for
June 30, 2006 of the 21,082
specialized laboratory services are
individuals who were receiving
transported to the hospitals on specific
antiretroviral therapy at ZPCT
days. The Team will combine this model
(Zambia Prevention Care and
with other ongoing outreach services like
Treatment) supported sites; 1,344
immunization or under five services in
(6.3%) were children. FHI Zambia has
settings where there is demand for ART
also expanded adult and pediatric
but the requisite infrastructure to deliver
ART through outreach to primary
the service is unavailable.
health centers in peri-urban and rural
areas.

 Tanzania, Zambia and Nigeria have used a three-tiered ART decentralization model
aimed 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 services
Tier 2: Expansion of services in health centers that offer a medium
level 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 already
fairly 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 in
longitudinal PMTCT care are tested for HIV at 9-18 months of age.
The Global HIV/AIDS Initiative in Nigeria (GHAIN) has spearheaded Pediatric
HIV 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, operations
research is underway to look at the logistical and human resource implications for
dried blood spot (DBS) sample collection, transportation, results interpretation and
reporting. Ghanas 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 types
of monitoring; and finally, compare prognosis in resource-poor settings with that
observed 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 culturally
specific materials and protocols for the counseling on HIV testing, disclosure, and
support for children.
FHI Cambodia has produced culturally specific child targeted information materials
for 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 develop
skills 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 treatment
and care services for children and their families. FHI Kenya is also piloting an
integrated 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 Continuum
of Care (CoC) model and is beginning to integrate pediatric ARV therapy into
district level OPC. FHI Vietnam is also supporting USG and Ministries in
developing Vietnams 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 WHOs expanded Inter Agency Task Team (IATT) on
the 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 ANECCAs steering committee and through a subagreement
with the Regional Center for Quality of Health Care (RCQHC), produced the
Handbook 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 has
supported 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.

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