title: Bottlenecks and opportunities for delivering integrated pediatric HIV services in Nepal.
abstract: BACKGROUND
  In children, integration of HIV in MNCH services has been shown to incr. ease uptake of early infant diagnosis. This article examines bottlenecks and opportunities for scaling up integrated pediatric HIV services in Nepal.
  
  
  METHODS
  This is a descriptive study using both mixed qualitative and quantitative methods, conducted in January 2015 in 19 facilities in five regions of Nepal most affected by HIV epidemic. The qualitative methods comprised in-depth structured interviews with key informants (leadership of The National Center for AIDS and STD Control and National Public Health Laboratory, district management teams, medical officers in charge of health facilities and HIV clinics, frontline staff at antenatal care and HIV clinics and laboratory). The quantitative methods were used to abstract data of HIV-infected pregnant women seen between January and December 2014, HIV-exposed infants aged less than 12 months, and HIV infected children aged less than 15 years who were initiated HIV treatment from 2010 to 2014. Structured tools were used to collect data which were analysed using IBM SPSS.
  
  
  RESULTS
  Of the 19 facilities assessed, 18(98%), 18(98%), 14(75%), and 11(58%) provided prevention of mother-to-child transmission (PMTCT), Expanded Program on Immunization (EPI), pediatric ART and nutrition rehabilitation services, respectively. However, only 1(5%) facility collected onsite dried blood spots (DBS) for PCR HIV testing and 6(32%) facilities provided counselling and referral for DBS. In 2014, of the 121 HIV-exposed infants recorded, only 21(17%) received PCR test. The median turnaround time of the PCR test results was 54 days. Of the 21 records with PCR test, 11(52.5%) were from PMTCT clinics, 7(33%) from Nutritional rehabilitation clinics, and 3(14.5%) from pediatric outpatient clinic.Conversely, 934 children were initiated ART between 2010 and 2014, of which 5% were infants and 29% aged between 1 and 5 years. 298(32%) had comorbidities of which 64% had malnutrition. A total of 534(57%) had tuberculosis (TB) status assessed of which 58(11%) had active TB. Infants had lowest retention (63%), high mortality (17.4%), and loss to follow-up (10.9%).
  
  
  CONCLUSIONS
  Few facilities collect DBS and few children receive PCR tests with limited linkage to ART. This has led to late ART initiation, comorbidities, including TB coinfections and poor outcomes. The results indicate that there are opportunities for improving HIV case finding among HIV-exposed infants in PMTCT, EPI, TB, and nutrition services if provider initiated testing and counselling at the point of service delivery is institutionalized in these settings.
authors.affiliation: aCenter for Research and Development, Kinshasa, Democratic Republic of Congo, Africa bIndependent consultant cUNICEF, country office Kathmandu dNCASC eUNICEF, Regional office South Asia, Kathmandu, Nepal fUNICEF, Health Section, New York, USA gSchool of public Health, University of Lubumbashi, Democratic Republic of Congo, Africa.
authors.forename: Mulamba
authors.initials: M
authors.lastname: Diese
authors.forename: Lexman
authors.initials: L
authors.lastname: Shrestha
authors.forename: Birendra
authors.initials: B
authors.lastname: Pradhan
authors.forename: Dipendra
authors.initials: D
authors.lastname: Singh
authors.forename: Hendrikus
authors.initials: H
authors.lastname: Raaijmakers
authors.forename: Annefrida
authors.initials: A
authors.lastname: Kisesa
authors.forename: Dick
authors.initials: D
authors.lastname: Chamla
authors.forename: Mukengeshayi Abel
authors.initials: MA
authors.lastname: Ntambue
mesh_terms: D000293:Adolescent; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D019033:Delivery of Health Care, Integrated; D059788:Dried Blood Spot Testing / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control / Q000706:statistics & numerical data; D009390:Nepal / Q000453:epidemiology; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy; D012189:Retrospective Studies
chemical_list: D044966:Anti-Retroviral Agents