 Mae'r berthynas gweithio ymlaen, Kate Whitehouse. Mae'n gweithio'r cysyllt y cymdeithas ac mae'n gobeithio ymlaen eich ydyn nhw'n gyffredigau o gyfrifio'r pethau o'r higion HIV yn y cyfnod Film TCT mae'n cyfnod o'r ddysgu'r cynghwladol a'r bwysig o gyfrifio ymlaen i gyfrifio ar gyfer hynny. Dwy ddod am yr hyn i'n gweithio, mae'n gweithio i'r gweithio. So, is to give you some context on why we conducted this systematic review. We know that globally, the number of children living with HIV under the age of 15 years is approximately 3.2 million. 90 per cent of those live in sub-Saharan Africa and reducing mortality of infants infected at or around birth is achieved with early treatment initiation. Felly, ydych chi'n eu cyfleidio i'ch trafnod o ddwylliant. Mae'n rhoi'r dda i ymddangos yn y cyfleidio ar gyfer mae'r dda, ond thysgu'r digon ar gyfer pwysigol. Mae'r gael ffôl â'r target a ffordd o'r ffawr o'r mhwy o'r ffiarogau i'r kitai ar gyfer a'r brydging yma. a ydych chi'n gweld i'w ddweud o'r nifer o'r cyflwyng? Y dyfodol yn ei ddweud i fynd i'r rhaid i'r adnoddau a'r uchyr, y FWHO's global guidance, o'r cyffredin iawn i'r strategii a'r ffindio'n hiv positif ar gyfer hynny. Rwy'n rhaid i'r cwestiynau diogel yng Nghymru, sy'n ymgyrch beth hynny o'r llythdoedd a ddyn nhw'n yn fawr am gyfarfod ymgyrch, Does HIV screening in four key contexts enable a higher yield of HIV diagnosis when compared with screening in prevention of mother-to-child transmission settings? So those four key contexts are paediatric inpatient, paediatric outpatient, nutrition centres and essential programs for immunisation. So on methods, we limited to 2014 studies published in English or in French in the four key context mentioned and we looked at under 12 HIV prevalence. We included either serological or molecular testing and either universal or triggered screening protocols and needed an HIV positivity of those tested included in the studies. We excluded anything outside of those four key contexts. We excluded diagnostic testing and we excluded studies where testing criteria was not stated. We also didn't include studies that had highly specialised or specific out or inpatient care, so for example TB. We searched the databases using a highly sensitive search strategy, extracted titles in duplicate and reviewed everything in duplicate and had a third party tiebreaker and we aged disaggregated outcomes and pulled the data using random effects meta-analysis. So a review, we found 2,890 studies after de-duplication of the main databases, identified 38 studies with HIV prevalence data and of those 25 with specific under five HIV prevalence and those are the results that I'm going to present today. So an overview, as I said, 25 studies with primary outcome, so that's under five HIV diagnosis, with 15 reporting secondary outcomes, so we also extracted data around acceptance rates by caregivers for HIV testing. We looked at retention in care and we also looked at feasibility or acceptability and uptake by healthcare workers. I'm not going to present secondary results today but you can ask me about them. Geographically, 23 studies were in sub-Saharan Africa, one was from India and one was from Papua New Guinea and the majority of studies came from pediatric inpatient settings with 16 studies reporting those outcomes. So to have a look at our results, there's a fair degree of heterogeneity in these results, but what we can see when we look at pediatric inpatient settings, which is the top section of this virus plot, we can see that the pool proportion was 25.3% for HIV positivity in under five. If we look at nutrition settings, which is the second section down, that reduces to about 13.1% and in EPI settings, again, reduces to 4.9%, without patients the lowest HIV positivity rate at 1.62%. What we can say is that these results offer us a certain amount of direction whereby to investigate new settings to try and find HIV positivity in pediatric patients. To give you some context for why this is relevant to MSF, we did a very quick extraction of one operational centre, one section offering of HIV testing to pediatrics in projects where there's an HIV focus within the country. So to have a look at those results, again, this is just one section. Many thanks to Helen for helping us out and pulling this data together for us. We can see that broadly HIV testing for pediatrics is available, but primarily if symptomatic. Where it is available, there are a number of barriers that healthcare workers noted as to why it's difficult to offer HIV testing. Those include availability of trained counsellors, consent for testing, and the confidence to provide testing and to disclose results. So no testing is available in EPI settings, and I think that's worthy of note. In terms of a breakdown as to the number of projects, as compared where HIV prevalence is greater than 1% within the country that the projects are operating, we see that the number of projects actually offering testing is substantially different from that number. So if we look at inpatient departments, we see 18 projects operating in countries with the prevalence greater than 1%, but only four are actually offering HIV testing to those pediatric patients. So there needs to be some work done as to how we improve the situation within MSF itself. And so some of the recommendations that we've pulled together are that we need a bigger emphasis on postpartum retesting of mothers in EPI contexts, which would be much easier than actually testing the pediatric patients. There's an ongoing lobby, the HIV working group and the pediatric working group, both proponents within MSF to integrate HIV testing into pediatric projects. And there is guideline training and support materials available, which have also been developed intersectionally, so there are no excuses. So to have a look back at the review, I just want to note a couple of main limitations of our systematic research. Studies were limited by language, so that may have an indicator for other studies that are available, not published in English or French. We're limited by date and to lower and middle income country contexts. The data that's primarily available is only really for under fives. It's very difficult for us to have disaggregated the data for the five to 12-year-olds, and that would be interesting, and that's something that we're continuing to try and work on. And the data is only really from sub-Saharan Africa and in in-patient settings. Not all of the studies provided comparable background prevalence data, so they're either inadequate or indirectly comparable. And PMTCT coverage changes have occurred since some of the studies were published. So to look briefly at our recommendations, we have one main policy recommendation, which is that testing pediatric populations in some key contexts may well offer high-yield opportunities to identify HIV-infected children, and notably pediatric in-patient settings would appear to be the most pragmatic approach. And our research recommendation is that we definitely need more studies from other settings, including nutrition, outpatient and EPI, with only three studies apiece in their systematic reviews. It's quite difficult to really draw strong conclusions on that. And we definitely need studies outside of sub-Saharan African contexts. And in order to address the barriers that were raised notably within the MSF projects that I mentioned, whilst HIV testing is already recommended, the uptake is low, and we need to consider how to address training needs, what to do about the availability of testing and counselling, and the legal barriers, so age of consent to test must all be addressed in order to improve the situation. So many thanks to the brilliant collaborators and colleagues that I've had the pleasure to work with on this. Thank you very much. Thank you very much for an excellent talk and for a very important, to cover a very important topic. Again, it's just technical questions we are going to take, and then hopefully we will touch on that subject again in the discussion round. Any questions? Thanks, Katie. That's a very interesting talk. I mean, as you say, the recommendation for testing kids has been around for a long time now, and I guess I was very surprised to see how low the rates of testing are. Has somebody looked at what the actual reasons are? Do we have any data on why? I know there are possible theories, but has someone actually collected reasons for why we're not testing? I'm not actually sure, but there are a few people notably in the front row who probably have an idea as to why. I don't know if Helen, you want to...? I think you might need one. So, as you know, Daniel, a long debate within MSF, some sections are better at it than others. Still, the question comes back to, are we going to test who's going to treat them, believe it or not? Still in 2015, that discussion goes on. So it's something we're still really pushing the nutrition projects and paediatric projects towards that it should just be a normal part of the care we're providing, but we're not quite there yet. Thank you. Any other questions? So there are questions from the online audience. I have a question from MSF India who are asking, is there a reason why we're not testing at present, and is there a qualitative research study plan? I've got no plans for a qualitative analysis as yet, but reasons for not testing I think are probably covered mostly by the challenges and the barriers. It's very difficult to address age of consent issues. I think a number of healthcare workers feel quite uncomfortable with providing testing for paediatrics when either the paediatric is a little bit older and there's that blurred line between a minor and an adult. I think also disclosure is another aspect within age of consent. Disclosing an HIV positive result when the parent or the caregiver hasn't actually initiated the test is probably problematic. Then in terms of availability of staff, the MSF projects all noted that it's very difficult to have staff available ready to give train counselling. Then within EPI context it's quite a quick turnaround of paediatrics, so you're seeing them very briefly. We probably need to look at a different strategy, i.e. testing mothers or caregivers rather than the paediatric themselves. If I can just add to that, even so it's not an MSF project but it's from Zimbabwe, so I have been working with Rashida Ferrand on adolescent testing. We actually had six primary care clinics where we had provider initiated testing and only 70% of the children got the test offered by the healthcare providers because the healthcare providers weren't very comfortable. We did a qualitative piece around that and asked why are you not testing the children even so we have trained you for doing that. Really the main barriers were A, running out of test kits because PMTCT is prioritised. The second bit was not really being sure if a guardian who is not the mother or the father is going to be allowed to consent, age of consent and how to actually do the test in the context of a young person. Following that we did a big kind of stakeholder and training campaign and that brought the offering of testing up to 95%. It is achievable but you really need to bring your healthcare providers on board and I think we have to think about moving from something which we call provider initiated testing but a provider still says what is the risk I'm going to do it on a symptom basis because I'm more comfortable with that that patient probably has HIV and that one doesn't to a real routine opt out testing for children and adolescents. Thank you very much.