In Patient Testing Program at University Teaching Hospital, Lusaka, Zambia

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In Patient Testing Program atUniversity Teaching
Hospital,Lusaka, Zambia
International Center for AIDS Care and Treatment
Programs Annual Meeting, March 2006 Dar Es
Salaam, Tanzania

• Mary Katepa-Bwalya
• 8th March 2006

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Zambia Country Profile

• Population 10,3 million
• One of the poorest countries in the world
• Per capita GDP 280
• 80 of the population afflicted by poverty
• One of the countries most affected by HIV
• HIV prevalence about 16
• 30 of pregnant women are HIV positive
• 28,000 infants born with HIV each year

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University Teaching Hospital

• Tertiary hospital in Lusaka, Zambia
• Medical and nursing schools
• Adult and pediatric ART clinics

Site of pediatric inpatient testing initiative
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Pediatric COE at UTH

• Provide high quality comprehensive HIV care and
  antiretroviral treatment to HIV exposed and
  infected children.
• National and Regional learning and training
  center for pediatric care in Zambia.
• Center for operational research and clinical
  trials.

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Center of Excellence

• Out-Patient Facility One stop Center
• Within the Department of Pediatrics and Child
  Health at UTH
• Funded by the Centers for Disease Control and
  Prevention
• In collaboration with ICAP, Columbia University
• Technical assistance also provided by Boston
  University
• Family Centered Approach
• Multidisciplinary Team
• Clinicians (physicians, nurses, clinical
  officers)
• Counselors
• Social Workers
• Nutritionists
• Pharmacists
• Laboratory technicians

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The Inpatient Testing Initiative

• Traditional HIV testing models overlook the
  special needs of infants and children
• Rapid disease progression in HIV-infected
  children (50 mortality by age 2) creates an
  urgent need to identify HIV-infected infants
• Parents may not identify risk and/or symptoms of
  HIV few children attend stand-alone VCT centers
• Provider-initiated testing is particularly
  important in pediatrics
• Hospitalized children at high risk for HIV
  infection

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Goal of the Inpatient Testing Program

• Goal
• To incorporate HIV testing as a routine part of
  medical care for all infants and children
  admitted to inpatient services at UTH.

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Objectives of the Inpatient Testing Program

• Objectives
• To increase the number of inpatient children
  being counseled and tested for HIV.
• To increase early identification of HIV-exposed
  and HIV-infected children.
• To increase the number of children assessed and
  enrolled into HIV care and treatment at UTH.
• To increase the number of children on ART.

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Program Implementation
First Point of Contact AO1, AO5, AO7 - Counseled
Tested and Confirmed
Not Tested
Ongoing Counseling
Negative
Positive
STOP
Initial labs ordered and drawn on the ward
Discharged before baseline labs drawn
Review Results _at_ follow-up appointment
(Childrens clinic and/or HIV Clinic)
Draw baseline labs at Review Clinic
Ongoing Care and Treatment
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Program Implementation

• All first point of contact wards are targeted
  (e.g. Admission ward (AO1), Isolation ward (AO5)
  and Nutrition Ward (AO7).
• 4 counselors from the Family Support Unit offer
  CT from 0800-1600 on these wards.
• All inpatient wards and multidisciplinary team
  staffers are sensitized.
• Counselors conduct group counseling and
  individual counseling.
• Counselors and nurses work together to maintain
  records that can be used throughout a childs
  admission and for follow-up.

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Program ImplementationFollow-up

• Counselors follow-up patients who have deferred
  testing and/or were missed at the first point of
  contact (e.g., night time admission).
• Once identified as exposed or HIV-infected
  physicians order baseline labs and CD4 counts.
• Follow-up for ART eligibility then occurs at the
  childrens review clinic unless they are admitted
  for a lengthy stay.

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Pediatric Inpatient Testing Program

• Met with enormous success during 6 month
  implementation phase
• High rate of acceptance of HIV testing by parents
  of hospitalized children
• Good follow-up into outpatient system for those
  identified as HIV antibody positive
• Availability of counseling staff has facilitated
  introduction of inpatient testing
• Given high admission numbers, counselors will not
  be able to meet test demand
• Incorporate HIV counseling and testing into
  routine aspect of care provided by all
  clinicians, particularly nurses and physicians

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Children admitted and counseled
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Children Counseled and TestedSeptember
2005February 2006
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Proportion of Children Tested Who are Positive
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Age Breakdown of Children Tested December 2005
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Multidisciplinary TeamPhase II

• Provider initiated testing present as an opt
  out service available at UTH.
• Multidisciplinary team would be involved in CT
  and disseminate opt out approach.
• Counselors will focus their efforts on counseling
  and engaging children into care.
• All team members have responsibility to address
  HIV in their routine care of the patient..
• This allows the family to receive the same
  message and approach from multiple points of
  contact.

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Barriers (reason for refusal)

• Majority of children and caretakers agree to
  counseling and testing with two major exceptions
• Caretaker defers decision until she receives
  consent from her husband and/or other caretaker.
• Child is too ill (caretaker too distracted) to
  carry out appropriate counseling.
• Limited human capacity counselors only work day
  shift Monday Friday.

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Accomplishments

• Introduction of routine CT in first contact
  wards.
• Developed a follow up system for inpatients not
  CT at first contact
• Follow up of children previously tested for
  assessment and enrollment into care
• Currently 900 children in care
• 600 children on treatment

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Lessons Learned

• Adequate staffing is essential on all levels of
  the multidisciplinary team.
• All health workers need to offer testing for HIV
  as routine services to increase enrollment into
  care and treatment.
• More than half the children who are HIV positive
  are infants.
• Hospital statistics need to be reviewed prior to
  assigning counselors in order to target peak
  locations and times.
• ME system should be in place from the beginning
  to be able to report statistics and track
  patients.
• Sensitization and group counseling is essential.

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Pediatric Advocacy Next Steps and
Recommendations

• Build capacity expertise in care Tx of
  paediatric HIV/AIDS
• Opt-out testing to be offered as part of
  routine services offered by the department
• Increase infant diagnosis capacity
• Enhance development distribution of a
  stand-alone pediatric ART guideline (HW HBC)
• Dev. Training modules for care Tx of
  paediatrics HIV/AIDS for the health workers as
  well as the community (HBC)
• Keep children on governments agenda