Integrating global HIV services with primary health care: a key step in sustainable HIV epidemic control.

Ending the HIV epidemic relies in part on integrating stand-alone HIV programming with primary health-care platforms to improve population-level health and ensure sustainability. Integration of HIV and primary health care services in sub-Saharan Africa improves both outcomes. Existing models support both integrating primary health care services into existing HIV services, and incorporating HIV services into primary health care platforms, with optimal programming based on local contexts and local epidemic factors. Person-centred differentiated service delivery, community-based interventions, and a well supported health workforce form the backbone of successful integration. Strategic financing to optimise HIV and primary health care integration requires well-coordinated partnerships with host governments, private sector companies, multilateral stakeholders, development banks, and non-government organisations. Programme success will require increased flexibility of international donors' implementation guidance as well as involvement of local communities and civil society organisations. As we seek to end the HIV epidemic by 2030 amidst a constrained global economic climate, integration of HIV programming with primary health care offers an avenue of opportunity and hope.

Getting Treatment and Care Services Right for Children and Adolescents to Reach High Viral Suppression.

In August 2014, PEPFAR and the Children's Investment Fund Foundation launched the Accelerating Children's HIV/AIDS Treatment (ACT) initiative with the aim of doubling the number of children on antiretroviral treatment in 9 African countries. Increasing rates of pretreatment drug resistance and use of suboptimal treatment regimens and formulations result in poor adherence and high rates of viral failure. Supporting adherence and ensuring appropriate treatment monitoring are needed to maximize duration of first-line treatment and enable timely sequencing to subsequent lines of antiretroviral treatment. Although timely antiretroviral treatment is the core of clinical care for infants, children and adolescents living with HIV, ensuring a broader package of biomedical and non-biomedical interventions is also required to address highly prevalent comorbidities among children living with HIV. Providing such a comprehensive package has been challenging for health care workers who lack the necessary skills and confidence to care for pediatric populations. Efforts to simplify clinical management and specific training and mentorship are needed to address these challenges. In this article, we review the progress made during the ACT initiative and the persistent challenges in achieving and maintaining virological suppression across the age spectrum. We identify innovations needed to build on the success of the ACT initiative. Despite the challenges, achieving high levels of virological suppression in children and adolescents is possible. The complexity of pediatric HIV treatment can be offset as antiretroviral regimens become more effective, tolerable, and easier to prescribe and administer. Meanwhile, basic programmatic elements to address comorbidities as well as support health care workers remain critical. In this article we review the progress made through the ACT initiative, as well as identify innovations needed to address persistent challenges to viral suppression across the age spectrum.

Family Testing: An Index Case Finding Strategy to Close the Gaps in Pediatric HIV Diagnosis.

Despite significant advances in pediatric HIV treatment, too many children remain undiagnosed and thus without access to lifesaving antiretroviral therapy. It is critical to identify these children and initiate antiretroviral therapy as early as possible. Although the children of HIV-infected adults are at higher risk of infection, few access HIV testing services because of missed opportunities in existing case finding programs. Family testing is an index case finding strategy through which HIV-infected patients are systematically screened to identify family members with unknown HIV status. By specifically targeting a high-risk population, family testing is a pragmatic, high-yield, and efficient approach to identify previously undiagnosed HIV-infected children and link them to care before they become symptomatic. Despite this, incorporation of family testing into national guidelines and implementation of this case finding approach is variable. In this article, we review the evidence base for family testing, describe its challenges, and provide guidance and sample tools for program managers aiming to integrate family testing into existing health systems.

Confronting Challenges in Monitoring and Evaluation: Innovation in the Context of the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive.

The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), which was launched in 2011, set a series of ambitious targets, including a reduction of new HIV infections among children by 90% by 2015 (from a baseline year of 2009) and AIDS-related maternal mortality by 50% by 2015. To reach these targets, the Global Plan called for unprecedented investments in the prevention of mother-to-child transmission of HIV (PMTCT), innovative new approaches to service delivery, immense collective effort on the programmatic and policy fronts, and importantly, a renewed focus on data collection and use. We provide an overview of major achievements in monitoring and evaluation across Global Plan countries and highlight key challenges and innovative country-driven solutions using PMTCT program data. Specifically, we describe the following: (1) Uganda's development and use of a weekly reporting system for PMTCT using short message service technology that facilitates real-time monitoring and programmatic adjustments throughout the transition to a "treat all" approach for pregnant and breastfeeding women living with HIV (Option B+); (2) Uganda's work to eliminate parallel reporting systems while strengthening the national electronic district health information system; and (3) how routine PMTCT program data in Nigeria can be used to estimate HIV prevalence at the local level and address a critical gap in local descriptive epidemiologic data to better target limited resources. We also identify several ongoing challenges in data collection, analysis, and use, and we suggest potential solutions.

Community strategies that improve care and retention along the prevention of mother-to-child transmission of HIV cascade: a review.

INTRODUCTION: While biomedical innovations have made it possible to prevent the vertical transmission of HIV from mother to child, poor retention along the prevention of mother-to-child transmission (PMTCT) cascade continues to limit the impact of programmes, especially in low-resourced settings. In many of the regions with the highest burden of HIV and the greatest number of new paediatric cases, the uptake of facility-based care by pregnant women remains low. In such settings, the continuum of care for pregnant women and other women of reproductive age necessarily relies on the community. There is no recent review capturing effective, promising practices that are community-based and/or employ community-oriented groups to improve outcomes for the prevention of vertical transmission. This review summarizes those studies demonstrating that community-based and community-oriented interventions significantly influence retention and related outcomes along the PMTCT cascade. METHODS: Literature on retention within prevention of vertical transmission programmes available on PubMed, Psych Info and MEDLINE was searched and manuscripts reporting on key prevention of vertical transmission outcomes were identified. Short-listed studies that captured significant PMTCT outcome improvements resulting from community-based interventions or facility-based employment of community cohorts (e.g. lay counsellors, community volunteers, etc.) were selected for review. RESULTS: The initial search (using terms "HIV" and "PMTCT") yielded 430 articles. These results were further narrowed using terminology relevant to community prevention of vertical transmission strategies addressing retention: "community," "PMTCT cascade," "retention," "loss to follow up" and "early infant diagnosis." Nine of these reported statistically significant improvements in key prevention of vertical transmission outcomes while meeting other review criteria. Short-listed articles reflect diverse study designs and a variety of effective interventions. Two interventions occurred exclusively in the community and four effectively employed community groups within facilities. The remaining three integrated community- and facility-based components. The outcomes of the included studies focus on knowledge (n=3) and retention along the PMTCT cascade (n=6). CONCLUSIONS: This review captures an array of promising community-based and community-oriented interventions that demonstratively improve key prevention of vertical transmission outcomes. Though the strategies captured here show that such interventions work, the limited number of rigorous studies identified make it clear that expansion of community approaches and complementary reporting and related research are sorely needed.