 So, our next speaker is Helen Bygrave. So, she's going to continue with a slightly older age group. And these are children which have already been diagnosed and it is looking at the Kailicha project and how to deal with adolescents who are on treatment but seem to fail. Okay, good morning, everybody. First of all, I'm not Jonathan Bernheimer. So, I'm very much here on behalf of the Kailicha team this morning so I guess they're watching online so they can tweet and do whatever they're doing online if I say something wrong or to add things to this presentation. So, Jonathan is one of the most kind of enthusiastic pediatricians I've worked with or met in the last few years and I'm sure he and I are both delighted that we've got not just one but two pediatric HIV presentations this morning. Because certainly it's an area I think that we haven't paid enough attention to in our programs. So, I'm going to follow on from what Katie said. Why is this so important? Of the 35 million people living with HIV, 3.2 million of them are children less than 15. All the children, less than five, most countries have followed the WHO guidelines so they're all eligible for arts, they're put onto treatment straight away and in fact a number of countries are now putting all children less than 10 on art. But still after kind of 15 years of kind of more of HIV programming, I think there is still a real bottleneck around putting kids on treatment and the challenge of pediatric adherence still is really massive and when you chat to our counsellors and our clinicians, it's a real challenge that they face. And what's interesting in the last two, three years as we've scaled up routine viral load in the projects is that we've started to get a feeling of how big a problem this adherence challenge is. So, what do we already know from the literature? So, from the idea cohorts, there's around about 20% of kids failing by three years and another South African study, even worse rates of failure, up to 38% of children failing. So, not great, okay? If we look at our, these are OCB cohorts where we started to roll out routine viral load in the last couple of years and you see similarly not great outcomes and really quite consistently children having kind of two to three times the rates of virological failure compared with adults. So, this pilot project was started in Kailitsa. It's one of our oldest HIV projects within MSF. It's an urban township just outside Cape Town. And really what happened in kind of in the analysis of the viral load data, the team really started to see and flag up, you know, 30% of our kids are failing, what are we going to do about it? So, they actually set up a specific pediatric risk of treatment failure project. It's in a separate building, it's very child friendly, it's got dedicated staff, the program is nurse led, but there is a doctor, a pediatrician involved. And basically they enrolled in the program all kids from infants up to the age of 19. So, basically any kid, so child or adolescent who had a high viral load was enrolled into the program and they received some specific adherence interventions. And that really was a combination of kind of one-on-one counseling with some, you know, pediatric friendly tools and combined with, and I think this is the really important thing, it's not just about sitting for a longer period of time with a doctor, but very much combined with peer support. So they had family clubs for the younger ones, where the caretakers also kind of brought together, and then kind of team clubs for the older adolescents. So very much kind of learning from each other, finding out about their disease from each other. And the other really important thing, I think Jonathan wanted to bring out, is just having the luxury of spending more time with that child. And I just want to link back with Emily's presentation yesterday. If we can employ strategies to decongest the clinics and get the stable patients kind of out of the queue, maybe our healthcare workers will be able to spend more time with the kids and also the adults that are failing and need more kind of clinical input and attention. So, after getting that adherence intervention, they get a repeat viral load. If the viral load is still high, then the clinicians are deciding to do any switch the regimen. Or actually, if the viral loads kind of come down a bit, will we go on and do a further adherence intervention? So if we just look at the kind of demographics of the kids who went into this program, so up to the time of analysis, 133 kids had been enrolled in this project. The median age when they started their ART was three, which is quite late. And the median age at time in enrollment in this failure program was 10 years. Mediantime on ART was four years and the viral load at enrollment, 14,500. Four of the kids actually, on questioning once they got into this clinic, weren't actually taking their drugs at all. But the majority were failing a protease inhibitor based regimen. In South Africa, it's really the only country in the region at the minute that is using a protease inhibitor based first line. Although it's recommended other countries haven't quite got there yet because of the difficulties around the formulation still. Three children, only 2% actually had to concurrent TB at time of enrollment. But 15% did have other comorbidities. So they were sick with their failure. So ranging from nasty skin infections, tinnier capitals to pneumonia. So these kids were actually sick with their failure. And then I think some interesting stuff around this kind of the social situation. The majority, 68% did come with their parent. But clearly what came from the team is that these kids are swapping caretakers. So they might come with the parent, but you know, they're kind of past pillar to post in terms of who might be giving their drugs. The other interesting thing I think is 71% of those caretakers were HIV positive themselves and I'm going to get the team to look at, I'm quite interested in this, are they suppressed? Is the parent taking their drug or not? But I don't have that data yet. And ignore that slide because what we did actually, we've actually looked at disclosure rates according to age. And 83% of the children, more than 10, who should have been disclosed, were disclosed. But that still means one in five didn't know they had HIV. Yeah. And when we talk about disclosure, does the child know they've got HIV? But it's also about disclosure within the family. And often another story that came out was, often if a lady gets a new partner, she's not then telling that partner she's got HIV. Therefore, she's not telling that part of the child's also got HIV, hence the drug stop. Disclosure is a bit of a hot topic for us. So just to also say, a colleague of mine looked at this across our projects. And again, despite the fact we've been trying to do this for 10 years, we're not doing that well. So most projects hovering around 50% of the kids who should have been disclosed to getting to that point. So we look at suppression of these kids. Having gone into this program, having had those adherence interventions, left-hand side kids failing on a protease inhibitor, right-hand side kids failing on a navirapine-based regime. 67% of the kids on a PI suppressed after around about three months, 53% on an NNRTI. And if we look at those kids who suppressed, the majority, 85, 87% say it stayed suppressed. For those that didn't initially suppress, we're giving them a bit more time, giving them a bit more support. A further nine, so 60%, went on to suppress on a PI. This side of the chart, the kids were actually switched so they would change their regimen to a protease inhibitor. And again, a third of them went on to suppress their viral load. So overall, of the kids who'd been in the program for, let's say, nine months plus, and had three viral load follow-ups, 84% of them had managed to be suppressed through basically good adherence support. They also, in Kaliica, they managed, they genotyped 34 of these children. 100% of the kids failing an NNRTI regime were resistant, kind of supporting the public health principle of switching from directly from NNRTI to a PI. And 43% of them showed resistance to the protease inhibitor. So in conclusions, some of the points Jonathan wanted to make, the median age of starting ART was very late. We need to be better, we need to be testing those kids earlier and getting them onto treatment. Disclosure rates weren't good enough, although they were better in Kaliica than some other places. This is something we really, really need to do better in our projects. Most of the children on NNRTI showed resistance, kind of as we suspected, with lower rates of resistance in those on the protease inhibitors. Basically, Shane, we need to push towards a PI-based first line. We need to get a formulation that's accessible in our settings. And this was a pilot project. It was quite resource intensive, say, specific HR, specific building, but I think there are some really important pieces of this implementation that we can take to other settings. So I'm gonna say again, disclosure counseling, with the tools available, we need to be supporting our staff to do this better. And actually, it's not just about MSF projects. I don't see any Ministry of Health that's providing these tools, providing counsellors, somebody even to do the job. And this is something I think at national level really needs to be addressed. Really simple, just book your kids on the same day. Automatic kind of peer support for the caretakers, peer support for the teens, on the same day that they're picking up the drugs, and preferably after school. Can we organize that in our clinics? And also just thinking about is a home visit possible? Because I think seeing that social situation and understanding that better is kind of a really important piece of the puzzle. And as I said before, just having the luxury of spending a bit more time with these vulnerable kids, with these vulnerable caretakers, yeah? And to do that, if we're gonna put another 15 million people on treatment to add to the 15 million already on treatment, we're gonna have to revisit how we're delivering the services in the clinic. Okay, so thank you very much. Thank you very much to the Kailita team, the patients there, and yeah, to you for all listening. Thank you very much again. Anybody, any technical questions? Otherwise, we will move on swiftly and leave it to the discussion round. Thank you very much. I think it was an excellent presentation and goes back to all the great work the Kailita project has been doing. It links to both of your presentations from the previous speaker as well. Helen, can you tell a little bit more what this project is also doing with regard to the identification of the children because your presentation, of course, is very focused on the children under care. What are the strategies in the project for creating access for the ones not yet being diagnosed? Identified, that's a really good question. I really think it's an area we haven't worked hard on because I think the issue of testing kids where they're coming to EPI, to the under five clinic, it's still not a routine thing that's in those caretakers' minds. We see time and time again, kids are coming with diarrhea, diarrhea, diarrhea, and they're still not getting a test. So I mean, certainly, I think now we're starting to have a bigger push about trying to normalise testing within the EPI. And trying again to work around some of the barriers around healthcare workers, the issue of mature minor, the issue of healthcare workers, the best interest of the child principle is a lot of quasi-legal issues that we have to take on board with the ministries of health at country level because healthcare workers often just don't feel comfortable to test a child without that guardian consent. And it's a very fine line for them. I don't blame them. But there are some training issues, but there's also some kind of political issues around it. Thank you very much.