 Thanks to the organizers for allowing me to share this experience as my last experience as HIV TV advisor. I'm here to share with you our experience implementing systematic HIV testing in a nutritional program in Niger. So, as you might know, there are different projects in Niger currently tackling different situations from conflict in DFA, but mostly malnutrition and malaria, who are the main killers in this area. Sorry. So, about this project, which is Madawa Project, some particularities it is rural area with a Muslim population and the reason why I mentioned this is because this population has been almost non-exposed to any HIV information so for us was quite tricky to decide to start these activities. The main killers, as I mentioned before, where malaria and malnutrition, this is why we decided in 2005 to open a nutritional project including inpatient therapeutic feeding center, ambulatory therapeutic feeding center and hospitalized management for kids under five years old. Just for you to give you an idea of the volume of patients in the ITFC, more than 2,200 kids are admitted per year, which is an average of 400 kids per month and this is a lot. So, just for you to keep in mind for the following slides. And regarding hospitalization, there are more than 1,500 kids admitted per month. Regarding HIV, as you may know, Niger is one of the lowest HIV prevalent countries in the Western Central African region, however, with a very low ART coverage as well. So the other population is estimated to be 0.5, but the ART coverage in the country is below 9%. However, we find out in our blood bank that the rate of HIV prevalence among blood donors was 8% and the rate of 12% of hepatitis B prevalence. This plus some publications where there are not many reported articles about it, but there were two of them that really pushed us to move forward on this regard. One from Niger that find out an HIV prevalence among malnourished kids of 9% in the capital. And systematic review of Saharan African countries where they find out HIV prevalence between 8% to 30% among malnourished kids. This is a reason why in 2014 from the AIDS Working Group and the Pediatric Working Group, we recommend to start systematic HIV testing in nutritional centers. However, we know that pediatric access to HIV is a challenge even in those high settings where we have the beautiful HIV projects. So we thought that in these particular settings where we are only treating malnutrition and malaria, it would be even more difficult. Particularly in Niger, there was lack of access to early infant diagnosis, trained staff in existence, also due to the low HIV prevalence, people has never been exposed to clinical management of HIV. There is poor or almost inexistent supply of ARBs, pediatric formulation. And it was a difficult programmatic decision to tackle only children. It was a difficult programmatic decision to include HIV. There was quite some reluctance from the team due to the stigma, to the unknown situation of this community, the perception, and only the question of what do we do with the rest of the family? What do we do with mothers and fathers? Fortunately, there is an MOH program in the same hospital. Although quality is questionable, at least there is a place where to refer the family. And there was a strong fear of jeopardizing the nutritional activities. I think the stigma and the unknown situation of this community was the main barriers to start this activity and the team fear that by starting HIV testing, mothers will not bring their sick kids to the hospital. So the objective of this study is to describe the implementation model and also to assess the HIV prevalence among this particular population. So it has been a polypoly slow process to do it. The first thing we did was to send what we call a flying HIV TV doctor who was a person that will be only focused on HIV TV, mostly training MSF and MOH staff, training community health workers, training health promoters, and starting talking in the community with community leaders and with the religious leader about their perception of MSF starting HIV activities. Slowly the team felt much more confident and in 2014 they started targeting HIV testing. So they were only doing HIV testing in those kids who were suspicious of having HIV positive. So they were not doing systematic HIV testing. The reason why is because they wanted to gain confidence. They wanted to be sure that mothers and kids will not be stigmatizing the community. By December 2014, among the children tested, which were more than 100, only 3% of the total admissions, 7% were found out to be HIV positive. So by June 2015, the team felt confident enough and they launched the systematic HIV testing. And when I say launching systematic, I'm talking again about testing more than 400 kids per month in an intensive, in patient therapeutic feeding center where kids are very, very sick. So by December 2016, more than 7,400 children had been tested. And I add here this information about 2017 starting reproductive health activities because what we find out is that most of the mothers who are coming with the kids to the nutritional project, they've never been tested for HIV. So during the period of implementation of systematic HIV testing, 98% of mothers or kids accepted to be tested, the kids be tested, and due to the difficult access to the NAPCR, all these kids were tested with rapid diagnostic tests. Among the more than 7,400 kids tested, 0.7 were found out to be HIV positive. Among those, only 25 were older than 18 months, so the diagnosis was confirmed. For the rest, samples were sent to NMA for the NAPCR and 13 were found out to be HIV positive. So in total, during all this period and with too much effort, 38 kids were found out to be positive, which is a prevalence of 0.5. 84% start ARTs during admission, still until now, 88% are under care, three kids die before ART initiation, and there has been only one kid lost a follow-up. Fortunately, unfortunately, I'm sorry for my English, there's no date on biological situation because there is no access to viral load in Niger. So about the challenges, as I mentioned before, I think the poor awareness about HIV in this population was one of the main barriers or fears, the lack of trained staff, the lack of access to early infant diagnosis in this population. Nutritional malaria being the main priorities was a barrier in the sense that the team did not feel comfortable starting HIV activities. Monitoring and evaluation tools were not available, so the data for HIV was paper-based data, basically data reported in the Ministry of Health books. About limitations, as I mentioned before, this is a retrospective review, so there is limited data, we would like to have more data on these kids. HIV kids, there is no segregation per age, either they were older or about 18 months old, and there is no date on biological outcomes. As a conclusion, we can say that implementing HIV testing in nutritional settings is feasible, with some little extra support, which is highly recommended. However, we find out a lower HIV prevalence than what has been reported in the same region, and this is why we think that in settings with low HIV prevalence, it might be worth to start by offering HIV tests to the mothers and only to test those kids whose mothers are positive, and this has been a matter of discussion for a long time, even among ourselves in the AIDS working group as well. When it is a new activity, we strongly recommend that you reassess HIV situation in a short time to redefine your strategy, and it's urgent to advocate to have early infant diagnosis at the point of care in these settings. It's totally unacceptable to wait three, four months to have the results for these babies. So what's next? We are going to review the data from all our nutritional projects provided in HIV care right now. In particular, in Niger, we are going to change the strategy, and we are going to offer HIV tests first to the mothers, and we are going to test those kids whose mothers are positive. We would like to share this experience and more similar projects for a wider rollout. We have still quite a number of nutritional projects without access to HIV care, and we would like to simplify the package of HIV care, pediatric HIV care for these settings. One thing that I didn't mention in the slides is that all this fear and concern about stigma and jeopardizing the nutritional activities were a myth, but this took us some time, it took us some time for this flying HIV TV doctor to sit with the mothers, to sit with the community leaders, to sit with the religious leader, and be listened by themselves that they really wanted to have this service in the area. So finally, what we thought would be a blockage has been quite encouraging for the team to move forward with this activity. So I would like to thank mostly all the staff and the patients from Madawa Hospital, and the AIDS Working Group and the Pediatrics Working Group for really pushing very hard this and the agenda and keep fighting HIV. Thank you very much. Excellent work in one of the most challenging and poorest parts of the world. Questions for clarification or technical questions? Right. So we have one, two, three. Yes. So we'll start with the person at the back there, and then we'll move to the person in the middle, and then we'll go to that end of the room. If you can speak clearly into the microphone, please, and introduce yourself. Estrella Lasry, MSF. Thank you for an excellent presentation and for excellent work. Do you have an idea of what the, if the reaction to testing for HIV is going to be different when you start testing the mothers, and what are you going to do if the mother refuses to be tested? Is there a plan to still test the child? Okay. Can I go question by question? Okay, sure. Because I don't have that memory. That's allowed. Go ahead. Let's wait. So the reason why we will offer HIV testing to the mothers first is to avoid testing 400 kids to find out very low number of children. So that's the main reason regarding the second question. If mothers refuse to be tested, there is nothing we can do apart from counseling and explaining again the situation. Right. Thank you. Should we move on to our next question? Hi. Can you hear me? Yes. Sorry. I'm Hannah, an ID doctor from North Manchester Hospital. I was just wondering about the follow up for these patients. So I worked in a similar setting in Sierra Leone, and at that time we weren't offering HIV treatment because the program with the MOH was so poor. I just wondered, has MSF made a long term commitment to following up these patients or was an agreement made with the MOH? And if so, what challenges did you face in sort of making that agreement? That's a great question. It's a great question because it was an initial discussion we have with within ourselves internal discussions. I was pushing forward for a longer follow up of these patients, and there were some reluctances, again, the fear of finishing with a huge cohort of HIV patients. Finally, the realities that we are doing the follow up of these kids, together with their mothers. We are lucky because in the same compound there is the MOH HIV clinic. With a questionable quality of care, but still we managed to do what we call family approach, so mother and child are being seen by MSF in a pediatric consultation with an MOH staff for on the job training. Thank you for that. There was one more question at this end of the room. Hi, I'm Madhu from MSF. What explanations or ideas do you have to explain the differences in HIV prevalences that you found? So your data and malnutrition in your malnourished children corresponded with the national data on HIV prevalence, but contradicted your own data and your own blood donors and other publications. So any ideas about that? Yeah. The first assumption that we have, this is why we want to review again all this data and we want to see what is going on in the following years. Regarding the HIV prevalence in the blood donors, you have to keep in mind that MSF protocol says that is the first we do only one test in the in the back. If the bug is positive, this is disposed. We've changed in either that by sending the blood donors who are positive in one test to be to the voluntary counseling and testing. This is the real prevalence that we have in the blood bank with one test, which means that if we go further, this prevalence might be lower than that. The second reason is that in the in the same study done by Saltis in EMA in the capital, they they they themselves they explain that there is difference in prevalence between urban and rural areas. And this is a really rural area with a particular population. So we believe that in fact, this prevalence might be lower. We will have more data once the antenatal care clinic and maternity activities start because HIV testing is going to be offered to the mothers. But we believe that this is the prevalence. And this is why we want to review all the data from all projects. Thank you. So we're doing so well with time that I'm going to ask one question. You alluded to the MOH clinic being next door to you. And you're changing your program to testing the mothers first. What is the sort of coverage within antenatal care if any exists? So before the babies are born in terms of HIV testing, it's below 9%. Right. Okay. So it seems to me that there's a big reason why we want to get involved into SRA activities. Right. Okay.