A Model for Accelerating Access to Care and Treatment for Children and Adolescents Living with HIV in Nigeria, Tanzania, Uganda, and Zambia: The Faith-Based Action for Scaling-Up Testing and Treatment for the Epidemic Response (FASTER) Initiative

Abstract

The number of children newly infected with HIV dropped by 50%, from 320 000 in 2010 to 160 000 in 2021. Despite progress, ongoing gaps persist in diagnosis, continuity of care, and treatment optimization. In response, the United States President's Emergency Plan for AIDS Relief created the Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response (FASTER). Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response addressed gaps in countries with the highest unmet need by working with government to operationalize innovative interventions and ensure alignment with national priorities and with communities living with HIV to ensure the change was community-led. Between 2019 and 2021, FASTER's interventions were incorporated into national policies, absorbed by Ministries of Health, and taken up in subsequent awards and country operating plans. Continued effort is needed to sustain gains made during the FASTER initiative and to continue scaling evidence-based interventions to ensure that children and adolescents are not left behind in the global HIV response.

Background

The number of children newly infected with HIV globally dropped by 52% from 320 000 in 2010 to 160 000 in 2021, in part due to the significant gains made in preventing vertical transmission of HIV. ¹ Similar progress was made in pediatric HIV treatment, with the number of children on antiretroviral therapy (ART) more than doubling from 440 000 in 2010 to almost 900 000 in 2021. ² Despite this remarkable progress, ongoing gaps in pediatric HIV diagnosis, continuity of care, and treatment optimization hinder progress for children against UNAIDS 95-95-95 targets, defined as 95% of people living with HIV (PLHIV) are diagnosed, 95% of those diagnosed are on ART, and 95% on ART are virally suppressed by 2025. ³

Every day of 2021, there were an estimated 440 new pediatric infections worldwide, ¹ and less than two-thirds (62%) of babies born to mothers living with HIV in 2021 had access to requisite early infant diagnosis (EID) by 2 months of age. ⁴ Among the estimated 1.7 million children living with HIV (CLHIV) ≤14 years in 2021, 59% were aware of their status compared to 86% of adults living with HIV, and only 52% were on ART compared to 76% of adults living with HIV. ¹ Adolescents aged 10 to 19 also represent a growing share of PLHIV; approximately 160 000 adolescents were newly infected in 2021, three-quarters of which were adolescent girls. ⁵ However, according to nationally representative surveys, only 39% of girls 15% to 19% and 29% of boys 15 to 19 in Eastern and Southern Africa have ever been HIV tested, with numbers even lower in other global regions. ⁵ To achieve the UNAIDS 95-95-95 targets for children and adolescents, strategies to accelerate the identification of undiagnosed children and adolescents living with HIV (C/ALHIV), linking them to treatment and retaining them in care need to be improved to reach and maintain virologic suppression in this population.

The Faster Initiative

In November 2017, the High-Level Dialogue on Scaling Up Early Diagnosis and Treatment of Children and Adolescents held in Vatican City brought together leaders of faith-based organizations (FBOs), pharmaceutical and diagnostics companies, international organizations, donors, governments, and regulatory agencies to commit to an action plan to address gaps in pediatric HIV. Key stakeholders included Catholic Relief Services (CRS), the Clinton Health Access Initiative (CHAI), the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), the World Health Organization (WHO), the United States President's Emergency Plan for AIDS Relief (PEPFAR), and the Joint United Nations Programme on HIV/AIDS (UNAIDS). The High-Level Dialogue identified priorities and actions urgently needed to accelerate pediatric and adolescent HIV treatment to improve outcomes for infants, children, and adolescents living with HIV, now referred to as the Rome Action Plan. ⁶

Building on these priorities, CRS and CHAI proposed the Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response (FASTER) Initiative to address key gaps in the pediatric and adolescent HIV testing and treatment cascade and reignite advancement toward the 95-95-95 targets. In response, PEPFAR allocated funding to an existing US Centers for Disease Control and Prevention (CDC) agreement with CRS and CHAI to address these gaps in countries with the highest unmet needs in the pediatric cascade.

The FASTER initiative aimed to facilitate a unique partnership between government, civil society organizations (CSOs), private sector, and FBOs to address systemic barriers to pediatric testing and treatment, expand access to innovative diagnostics, and scale up evidence-based interventions. FASTER also aimed to advance operational guidance, disseminate training materials, and provide clinical mentorship for facilities and providers to quickly expand HIV testing and pediatric/adolescent-friendly treatment, care, and support for C/ALHIV. To address these challenges, the partnership between CRS and CHAI strategically paired CRS's extensive network and engagement of FBOs and CSOs with CHAI's trusted partnership with government and long history of accelerated HIV product access and introduction.

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response activities began in April 2019 in close partnership with Ministries of Health (MOH), country offices of CDC, CRS, CHAI, and PEPFAR implementing partners (IPs) to provide technical assistance to strengthen the national HIV responses. In 2019, Nigeria, Uganda, Tanzania, and Zambia comprised approximately 21% of the unmet need for pediatric ART globally. ⁷ As a result, these 4 countries were selected for FASTER activities between August 2019 and December 2021. In-country staff from each organization focused on management and operations, health workforce mentorship, and monitoring and evaluation. Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response embedded activities within existing national structures, such as MOH National AIDS Control Programs or Pediatric HIV Technical Working Groups, to ensure collaboration and sustainability of progress.

Key components of the FASTER model (Figure 1) included:

• Priority Site Selection: FASTER worked with PEPFAR IPs and other civil society and faith-based partners to identify 245 health facilities that supported 35 000 CLHIV and 17 000 ALHIV on ART in Nigeria (58 sites), Tanzania (48 sites), Uganda (89 sites), and Zambia (50 sites). The selected sites were referred to as “FASTER Priority Sites” and formed the foundation of activities linking national-level strategies with frontline health service delivery to ensure the implementation of national guidelines at the facility level.

• Mentorship, Tools, and Service Quality Improvement: Embedded within existing national structures, FASTER provided technical assistance through clinical mentors using quality improvement approaches and training-of-trainers models and conducted service quality assessments.

• Human-Centered Design: FASTER engaged with youth participants to understand how HIV testing and treatment services could better meet their needs and to encourage peer-support models to promote access to HIV testing and treatment services. Using human-centered design, tailored job aids were created to meet the needs of various health care roles.

• Data Use Dashboards: FASTER employed a range of quantitative metrics to monitor implementation, including customized performance indicators, quality improvement standards, and selected PEPFAR monitoring, evaluation, and reporting indicator data. A FASTER dashboard was developed using PEPFER data to provide quarterly summaries and visualizations for key pediatric/adolescent outcomes, allowing teams to rapidly adjust activities at the facility level.

• Strengthening Coordination: FASTER supported MOHs to strengthen the coordination of pediatric and adolescent HIV services at national and regional levels in collaboration with PEPFAR IPs and FBOs. This included the addition of FBO representatives to national HIV technical working groups. Catholic Relief Services collaborated with MOHs to chair pediatric HIV technical working groups, which increased visibility and oversight of IP activities and facilitated changes in national guidelines.

• Innovation: FASTER supported innovative interventions for collecting data and reducing turnaround times. These included but were not limited to data dashboards across 4 countries to enhance data visibility and evidence-based decision-making, novel technique for identification of adolescents living with HIV, novel quality improvement techniques, digital mother–infant-pair tracking systems to improve retention through the period of vertical transmission risk, and accelerating access to innovations in pediatric treatment and diagnostic products.

• Continuous Learning and Research: FASTER created multiple forums to share lessons learned and effective strategies to improve practice across countries. These included routine technical presentations with project staff and CDC technical experts. FASTER hosted a monthly webinar series featuring deep dives on technical aspects of care for C/ALHIV. These sessions facilitated cross-country sharing, highlighting feasible and achievable interventions. FASTER teams also facilitated one-to-one consultations between country teams, as needed.

Figure 1.

Key components of the Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response (FASTER) model.

Faster Priority Action Areas

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response implemented 6 Priority Actions (PAs) to accelerate pediatric and adolescent HIV diagnosis and treatment (Table 1).

Table 1.

FASTER Priority Actions.

	PA 1: Streamline Regulatory Approvals	Support governments and regulators to streamline processes for approvals of new HIV diagnostics and drugs for children and adolescents.
	PA 2: Integrate Public Sector & FBO Service Delivery	Facilitate interoperability of government-based and faith-based processes for healthcare delivery, commodity procurement, record keeping, and results reporting to enhance efforts and resources for pediatric and adolescent HIV testing and treatment outcomes.
	PA 3: Expand Diagnostic Platforms	Strengthen and expand the rational uptake of point of care (POC) and other diagnostic platforms that improve outcomes for timely HIV and TB diagnoses, especially in infants and children, and use standardized comprehensive pricing and strong service agreements.
	PA 4: Evaluate Novel HIV Testing Approaches	Implement and evaluate novel HIV testing approaches, such as oral mucosa testing of children by parents/caretakers, to improve pediatric case-finding, especially linked to index testing services for adults living with HIV, faith-based programs supporting orphans and vulnerable children (OVC), and other community settings.
	PA 5: Implement Validated HIV Risk Screening Tools	Develop, validate, operationalize, and evaluate HIV risk screening tools to strategically identify children and adolescents in need of HIV testing in outpatient departments, faith-based OVC programs, and other community settings.
	PA 6: Optimize pediatric ART Regimens	Accelerate scale-up and transition to optimal pediatric and adolescent antiretroviral treatment (ART) regimens, working with communities to guide HIV response through generating demand and improving HIV literacy, monitoring the introduction of optimal treatment, and training frontline healthcare workers on the use of optimized HIV treatment regimens for C/ALHIV.

PA 1—Streamline Regulatory Approvals

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response supported MOHs to streamline regulatory review and approval pathways for new diagnostics and drugs to accelerate the uptake of WHO prequalified pharmaceuticals and products. For instance, Nigeria and Zambia institutionalized standard operating procedures to enhance regulatory agency coordination and streamline their approval processes. ⁸ The Tanzania Medicine and Medical Device Authority revised the Client Service Charter, fast-tracking registration of WHO prequalified products, and expedited clearances for pediatric HIV testing and treatment commodities. ⁹ Through these interventions, point-of-care (POC) EID/viral load (VL) and HIV self-testing (HIVST) products were registered and approved, leading to their use in Nigeria, Tanzania, Uganda, and Zambia. In collaboration with the African Society for Laboratory Medicine and WHO, FASTER developed a public, online Diagnostic Evidence Hub to enable stakeholders to access critical technical performance data on HIV diagnostic products to inform regulatory and programmatic uptake decisions. ¹⁰

PA 2—Integrate Public and Faith-Based Service Delivery

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response strengthened partnership between MOHs, faith-based and CSOs, and networks of PLHIV to catalyze rapid change and champion country-specific opportunities to close gaps in pediatric and adolescent HIV care. Linkages between FBO networks and national program strategy, planning, and monitoring were improved. Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response strengthened the continuity of treatment for youth by setting up appointment systems, mobilized community resources to enhance tracking, and ensured that adolescents effectively participated in HIV activities through youth-friendly, peer-centered support services, such as Operation Triple Zero in Nigeria and the Young People and Adolescent Peer Support in Uganda to ensure continuity on ART and high rates of viral suppression.

PA 3—Expand Diagnostic Platforms

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response supported the scale-up of POC EID by improving strategic device placement based on geographic coverage and laboratory readiness, procurement of commodities, assessment, and utilization of spare capacity on existing GeneXpert devices, developing comprehensive mentorship packages, and demand generation. In Tanzania in particular, FASTER supported the MOH rollout plan for whole blood use in POC EID to address challenges with sample rejection. Infant HIV exposure screening in diverse entry points (eg, nutrition clinics, immunizations, inpatient services) served to increase the identification of infants that may not present during the prevention of mother-to-child transmission (PMTCT) visits. Interventions to support mother–infant-pair tracking through introducing new digital solutions and strengthening paper-based reporting enhanced follow-up of exposed infants and their mothers through cessation of breastfeeding, which increased EID/HIV testing uptake at appropriate time points in FASTER-supported countries. Further, pediatric and adolescent HIV Community Advisory Boards (CABs) were established, comprised of adolescents and caregivers of CLHIV, to increase demand generation and literacy around better diagnostics for POC EID and VL and demand for optimal ARVs in communities, ensuring community-led changes to HIV service delivery.

PA 4—Evaluate Novel HIV Testing Approaches

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response supported testing approaches to close the HIV testing gap, including studies to evaluate the acceptability, feasibility, and effectiveness of caregiver-assisted oral HIVST for children in Uganda and Zambia. FASTER supported the programmatic rollout of oral HIVST for children and adolescents in 2 countries, expanding HIV testing options during the COVID-19 pandemic. In Uganda, FASTER worked with adolescents 15 to 17 years to demonstrate the use of peer-supported oral HIVST to inform policy changes to reduce the age limit for HIVST from 18 years to 15 years. In Nigeria, FASTER supported the MOH to roll out 100 000 oral HIVST kits to caregivers of children over 2 years old. In Zambia, FASTER supported school coordinators, supervisors, childcare workers, and school nurses to find adolescents at risk of HIV and link them to adolescent-friendly HIV services.

PA 5—Implement Validated HIV Risk Screening Tools

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response expanded the use of HIV risk screening tools for children, adolescents, and pregnant and breastfeeding women. Case-finding efforts for children and adolescents were scaled up through the promotion of differentiated service delivery models across FASTER priority sites to meet the testing and treatment needs of CLHIV. In Tanzania, healthcare workers were trained to increase client awareness of the need for maternal retesting, and maternal retesting in the demonstration sites increased from 12% to 68% during this time. In Uganda, the MOH rolled out the validated pediatric and adolescent HIV Risk Assessment Tool (HRAT) ¹¹ to all health facilities with support from IPs, including all 89 FASTER-supported health facilities, FBOs/CSOs, networks of PLHIV, and youth groups. In Zambia, FASTER supported the validation of the HRAT, programmatic screening was rolled-out in 50 supported sites, and HIV screening services extended to 6 residential care facilities and one juvenile reformatory school. In Tanzania, FASTER focused on enhancing index testing and supported the creation, review, and dissemination of age-appropriate eligibility screening tools and screening job aids for national dissemination. Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response also conducted a continuous review of the absolute number of children identified and testing yields to inform ongoing program adjustments.

PA 6—Optimization of Pediatric ART Regimens

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response deployed high-impact interventions that included but were not limited to accelerating uptake of optimal pediatric ARV formulations, updating pediatric HIV treatment guidelines and operational tools, building healthcare worker capacity for pediatric care and treatment, rolling out the quality of care standard packages and dashboards on key quality pediatric indicators, and engaging communities. Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response supported countries to accelerate transition to dolutegravir, improved monitoring and visibility of pediatric ART by weight band based on WHO recommendations, and supported national ARV stock monitoring and distribution. Working with EGPAF, FASTER supported the introduction of optimal ART for newborns diagnosed at birth. Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response helped establish Pediatric and Adolescent CABs in Tanzania, Uganda, and Zambia to improve demand generation, literacy for optimal treatment and quality of care, host community dialogues, and develop a comprehensive multimedia package and advocacy materials for pediatric dolutegravir.

In Tanzania, FASTER supported the rollout of optimal pediatric ARVs, disseminated patient literacy materials, supported upgrades to the national HIV data system to incorporate key pediatric and adolescent quality indicators, and revised the national comprehensive health care worker (HCW) mentorship package for pediatric and adolescent ART management. In Uganda, FASTER developed and disseminated a comprehensive case-based modular toolkit for HCWs focused on treatment optimization, psychosocial support, and treatment failure management. In Zambia, FASTER strengthened the implementation of the National Pediatric Change Package and Pediatric Surge and institutionalized quality improvement through data-use practices to guide facility-level quality improvement projects.

Quality Improvement

To support quality improvement efforts across all 6 PAs, FASTER provided mentorship and strengthened accountability mechanisms at the 245 priority pediatric sites supported by IPs. Across the 4 countries, FASTER supported several technical assistance models tailored to each country's needs. These included the use of clinical mentors in Zambia and Nigeria, quality improvement initiatives in Uganda, and training of trainers in Tanzania to disseminate guidelines and tools to frontline HCWs.

Faster Performance Indicators

In an effort to use data to drive implementation, make midcourse corrections, and improve outcomes, the FASTER team developed and tracked 17 performance indicators, nested under the 6 PAs (Table 2).

Table 2.

FASTER Performance Indicators.

Indicator ID	Indicator definition
PA 1: Streamline Regulatory Approvals
1.1	Proportion of target diagnostics registered or approved in program countries
1.2	Increased information transparency through establishment of global database of technical performance data on WHO-prequalified or Stringent Regulatory Authority approved diagnostics products
PA 2: Integrate MOH-FBO Service Delivery
2.1	Number of priority sites with adopted standardized referral/linkages procedures
2.2	Number of active national and sub-national community-facility committees developed/ strengthened to enhance pediatric and adolescent HIV services
2.3	Proportion of priority sites implementing Differentiated Service Delivery models
2.4	Proportion of priority sites integrating community reporting systems into facility-level National HMIS systems
PA 3: Expand Diagnostic Platforms
3.1	Proportion of the total early infant diagnosis volume performed on point-of-care platforms
3.2	Proportion of priority sites conducting infant exposure screening in non-PMTCT entry points
3.3	Proportion of priority sites tracking retention/testing along the EID/PMTCT cascade, including the end of breastfeeding outcomes of mother-infant pairs in PMTCT
PA 4: Evaluate Novel HIV Testing Approaches
4.1	Proportion of priority sites that scaled up pediatric and adolescent HIV testing models
4.2	Proportion of priority sites routinely conducting provider-initiated testing and counseling (PITC) for eligible children and adolescents in priority entry points
4.3	Proportion of priority sites completing family trees for index clients (ie, PLHIV)
PA 5: Implement Validated HIV Risk Screening Tools
5.1	Proportion of priority facility sites routinely using age-specific screening tools, in high-volume entry points
5.2	Proportion of community sites routinely using age-specific screening tools
PA 6: Optimize Pediatric ART Regimens
6.1	Proportion of eligible children and adolescents on target optimal ARV formulations at priority sites
6.2	Proportion of priority sites implementing comprehensive quality of care standard package for children and adolescents
6.3	Proportion of priority sites providing standard-of-care viral load monitoring for children and adolescents

Beginning in July 2020 and concluding in March 2022, performance indicator data were collected from each of the 4 FASTER countries: Within each country, a project-based Monitoring & Evaluation (M&E) Officer supported FASTER IPs to collect aggregated data. Implementing partners, in turn, worked with facilities to collect aggregated performance data aligned to the indicators noted in Table 2. The M&E Officers were responsible for managing this process.

Data were abstracted from IP databases as well as secondary data sources, including, but not limited to the following sources: national HIV program reports, national health management information systems (HMIS) reports, National HMIS/District Health Information System 2 (DHIS2), national data repositories, national laboratory information management systems, PEPFAR monitoring, evaluation, and reporting data, POC dashboards, POC stock management systems, POC instruments, site records, facility-level HIV Testing Services registers, national/facility-level integrated maternal child health or mother–infant-pair registers, and/or site-level data capture forms for countries where data at the national level was not disaggregated according to entry points. These data were captured using a cloud-based data collection platform and entered using password-protected mobile devices. Designated FASTER staff entered the data directly into the devices, which were then stored on an encrypted server. As some data sources were from national HMIS, such as DHIS2 and other databases in the HIV/AIDS response, data abstraction and reporting coincided with the national system to ensure data completeness and to build the capacity of national systems, especially as it concerns data-driven decision-making.

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response used these 17 performance indicators to monitor the implementation of each PA intervention. Project staff had access to real-time data visualizations, allowing close monitoring of performance data. Data were reported to CDC on a quarterly basis but were most commonly analyzed weekly, depending on programmatic needs. In cases where data suggested an intervention was not performing as expected, FASTER would convene internal dialogues among its technical staff, as well as external meetings with CDC, Ministerial staff, and IPs. This allowed the initiative to be both nimble and responsive to the needs of those providing and receiving services. Data analyses supported the timely identification of focus areas to improve the quality of HIV clinical care. Implementing partners were able to act on these data to inform nurses, physicians, and other cadres’ decisions with respect to improving, advancing, or modifying service offerings. The information gathered is fundamental to the implementation of HIV treatment initiatives related to PMTCT and pediatric and adolescent HIV care at these sites, describing in detail the local capacity of healthcare providers to deliver important HIV services to mothers and their children and guiding continuous data use for quality improvement for sustainable change.

Limitations

The FASTER initiative faced several challenges over the course of implementation. While the data FASTER used to monitor performance helped to document trends over time in key clinical indicators, improvements in various HIV indicators cannot be attributed directly to the FASTER program due to a lack of individual-level data and the existence of multiple concurrent campaigns and interventions over the course of implementation. These included but were not limited to the global scale-up of multi-month dispensing, WHO approval for 10 mg DTG in children <20 kg, other national efforts to optimize treatment regimens in children, and the presence of other established organizations working across priority sites.

Furthermore, in-country monitoring teams overcame multiple challenges to complete data collection, particularly COVID-19 travel restrictions and lockdowns. Preparation for data collection activities was conducted virtually, with various rounds of tool development review and testing. Follow-up trainings for the data collectors were often completed virtually. The high turnover of data collectors resulted in the need for frequent refresher training to ensure high data quality. While the intention was for direct data entry into a mobile data collection platform, some sites did not have mobile devices with the platform and others experienced turnover among staff trained in the use of the technology. This resulted in manual data entry and transmission, thus requiring extensive time to be spent on data entry, data cleaning, and verification.

Conclusion and Next Steps

The FASTER initiative was designed to accelerate progress in the pediatric HIV response in a select set of countries facing the greatest needs, gaps, and barriers to reaching C/ALHIV. It focused on bringing together public and civil society partners to tackle 6 PAs that, when operationalized at a national level, could demonstrably ensure that C/ALHIV are identified, receive treatment, and attain VL suppression. It sought to demonstrate strategies to find C/ALHIV more effectively through innovative HIV diagnostic strategies and ensure access to and retention of optimal ART regimens to achieve viral suppression. Its partnership model built on existing structures, capitalized on the strengths of different stakeholders and created sustainable platforms for continuing critical interventions and monitoring results.

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response devoted significant time and attention to strengthening district and national-level coordination mechanisms, policies, and regulations, modeling critical interventions at priority sites, monitoring impact through continuous performance reviews, and crucially supporting cross-country sharing of lessons learned and best practices. The initiative supported a robust learning agenda, with cross-country learning sessions and monthly technical “deep-dives,” combining global updates on key topics with in-country implementation experiences, and concluding with 3 global webinars presenting FASTER's achievements and results.

Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response's contribution can be seen in the extent to which the interventions it promoted have been incorporated into national policies and strategies, adopted by MOH and National AIDS Control Programs, and taken up in subsequent awards and country operating plans seeking to ensure optimal outcomes for C/ALHIV. Future publications will also continue to detail specific achievements by subject matter area. Moving forward, continued effort is needed to sustain gains made during the FASTER initiative and to continue to scale up interventions to accelerate HIV testing and treatment at the national level and in other high-burden countries to ensure the global HIV response delivers equitable health outcomes for children and adolescents.