 Mae gallwn i am ddeudydd Coryllaid Y Polnayon, gallwn i'r falch gyda'r Llyfrgell Traffico'r Meddhalin Antwerp. Mae cwestiynau gyda Helen ac Katy oherwydd. Mae ydy yw dweud. Rydyn ni'n ymweld i'w ddataeth o'r dweud hyn o 말씀 iysgrin Llyfrgell Rymd i'r MSF. Rydyn ni'n sylfa MSF oedd oedd oedd hynny i MOH sian yn yng Nghymru? Roedd ni. Yn gyffredin ni, mae MSF yn yn mynd fort o'n dweud i MSF-i setyn. mae'n amlwg yn ddweud o'i cynhyrch ar gyflodau gwaith. Mae'r cwestiynau, mae'r cwestiynau yw'r rai gwasanaeth, ydych chi'n ymwyaf o unig o'i cynu paediatrig o'r MSF i'r Cyflawn i'r cymdeithas ym MhW, rwy'n dechrau i chi'n gweithio'r llyfr yw ddweud o'i cymdeithas oherwydd mae'n cymdeithas ymweliadau. Rydyn ni'n fwyaf iawn di oes ridei'r cymdeithas oedd ymwyaf o'i cymdeithio'u cymdeithio, roedd mae'r labai arall wedi'u hayfawr i'n dweud ymgyrchu'r holl hwnnw, oherwydd, ei hunain ystod dyma'r genêmach, a rydyn ni wedi'i gweld i ddim yn dda i, mae'r cyfiniad gydarif wedi'i dod yn fy fhyddoedd yn cynwedig ni'n ddweud â'r parteidwyr o'r hyn ar gyfer eu hunain i'r unrhyw Llywodraeth wedi bod, ydych yn fawr, felly rydych gaf y pwysig yn LLMOSF a LLMA? Oni'n mod i sylwedd yn ymgyrchudd mewn beth. Mae hyn oed ymgwrdd yn bryd wedi'i fighwyddiadau tynnu'r fawr hwnnw, ysgol yn fawr feel ymgyrchweithio enhygoelol yn yr LLMA, ac mae'n rhoi'r peth yn ei rhaid i'u gyd, yn y pethau pediatru, ond hyn yn ymgyrchwyno ar gyfnod LLMA ac ymgyrchweithio wedi'u bwysig. chased it out. You were very lucky. You say that there is often a setting to be able to do it. But the reality is that that's not happening in many many of the places we're working and I know with our paediatric working group colleagues. Yes, there's there's a great degree of frustration there. That isn't still happening. I think MOHS has limitations. We have limitations. We have work together to see whether that's us putting in one or two умtig gweithio rhaglennwyr o'r cyfnod, ond byddwn i'n ei wneud fel hynny'r cyffredinon that there are a lot of children who are malnourished who are not getting better because they have HIV or TB. Mae chaibu'r T conclusions if you can take the online question please. Yr wyf. Yngyrch, dw i ddiddur i dwell shedigig ddim bod ati'r ymwyaf, wrth gwrs, yma yna yma yw dr Cmelu Cymru, yr Ethyffor i'r ydym niwn ndigid yma ymlaen i'r cyflewchol, gallwn y cyflwyfod mdrTB wedi'i hynny'n gwneud o ddwybu newydd, ond yn ystafell yn fynd i'r effordebol ac wedi'i cyflwyfod â'r cyflwyfiadau ymddangos. Rwy'n gallu cael ei ddechrau y cwestiynau. Rydyn ni'n meddwl. Rydyn ni'n meddwl y gallu'r cyflwyfiadau fel y cyflwyfiadau a'r cyflwyfiadau yn yr unig, yn y cyflwyfiadauau yn dweud. Rydyn ni'n meddwl bod wirwyr drwsio gyrfaith i'r ddrago a'r Lobi a rhoi ychydig oedd y ddrago wedi ymddangos i'r ddrago, a lle rydyn ni'n rhanogu bod yn ymdangos i'r ddrago i'r ddrago a'r ddrago a'r ddrago i'r ddrago i'r ddrago i'r ddrago, rydyn ni'n rhanogu bod dyna'r ddrago sydd wedi amdano i'r ddrago. Yr wych yn ymwybodol yw ymdangos i'r parodydd yng nghyrchol. yna'r panel yw'r cyllid yn ymdweud ymdweud ymdweud ymdweud ymdweud ymdweud ymdweud ymdweud ymdweud ymdweud? A cymryd o'r stifol ymdweud ymdweud ymdweud ymdweud ymdweud ymdweud? Helin, rydyn ni'n gobeithio i'r cwestiynau. Rydyn ni'n eisiau gwneud, so diwrnodd a mi ddim yn ddarparadau chi sydd yn ei ddweud. Rydyn ni'n cyfrifio i'r cyflwyno a i'r cyflwyno hwnnw i'r cyflwyno i'r cyflwyno i'r cyflwyno, ac mae hynny, nad yna ymrwynych yn ddefnyddio chi bobl yn defnyddio ymdweudol yn amlwyfio'r cyflwyno i'r cyflwyno i'r cyflwyno i'r cyflwyno i'r cyflwyno, a rydyn ni'n gobeithio i hyffordiaeth gyflym ymddweud maen nhw lle,ろうfaint yn y gyfer o'r gweithio'r cyfnadiad, ond dweud yw'r corll iawn i, mewn cyfnodol yn y gyflotech o'r swydd, gwahanol yn y rhaglun i ac mae'n ymdaith, mae'n dweud ymddangos i yw cyfnodol yn ei ddweud yn y cyfnodol, ychydigon yn cyfnodol. Mae cyfnodol yn y cyfnodol, nad ydym ni wedi bod yn angen yr arnyn. Yna ydi'r yr ysgrifennu, nesaf? Berdie Sqaia, gyda'r ysgolhaeth yn Ylifythbol. Felly, dyna'n gwneud am fy Hygwun Llywodraeth fel gyfweliadau deallol y Dynut Hygwun Cymru, a r evenolwyr maen nhw'n ddod y ffigurain mewn Mhysbethysdann. Mae'r ddaddfod i'n gwirio diddorol 299 perreu cyfle, dydyn nhw'n ddod 299 fydd yn rhan o gwybod. Rydw i ddim yn ei wneud sefydlu i dda i'r rhannueg a ddim yn rhan o gwybod. Fy hoffi, go ahead i'r dd varsion ddod o ddysgu'r honnol, rydw i ddiddorol cyfle flasgol a gyd-ddill. o'r maternig o'r meddwl yn ysgrifennu i'r meddwl, a'r costau yn gyfawr o'r gwrthoedd yn ysgrifennu o'r gwrthoedd yn gweithio'r gwaith yn fawr oedd yn gweithio'r regimus yn ystod. Mae'r ddweud o'r cwestiynau, Gaeliau, a rydyn ni gallu bod yn gweithio'r defnyddio Gaeliau. Rydyn ni'n adrofiadau i'r ddweud o Philip Ducros, i gael'r ddweud i'r ddweud, ond rydyn ni'n ddweud o'r ddweud i'r ddweud, ar eich prynsibol yng Nghymru? Mae'n ddweud i'r ddweud? Mae'n ddweud i'r ddweud. Dwi'n ddweud am y cwestiynau. Mae'n ddweud i'r ddweud i'r ddweud. One is when we started the study, we weren't sure whether this would work for all patients and we were particularly concerned with the initial results from the Bangladesh paper around failures in patients with oafloxus and resistance. Given high rates of second line drug use in Uzbekistan and in the region, we had quite restrictive exclusion criteria and therefore I think we were a bit too limited and cautious. I think the second thing we learnt is when we started and when we counselled patients for consent to go into this study or to take the regular international recognised treatment, there were many patients who actually said well actually I don't want an experimental regimen, I want to at least take something that I know that works and people who chose that it changed over time but I think that shows that we at least addressed an issue that comes up in many trials around proper informed consent and that's something we're still learning how to do well to counselled about the risks for new treatments. I think the other thing to say is that while this regimen, the interim results look promising, I don't think this is the answer for all MDRTB, there's still a lot of cases where this is not going to work and we also need to be looking for the new drugs and other solutions. For the patient costs, that's a long discussion and maybe I can throw to Shona who's done some separate research on adherence in MDR in Uzbekistan. Shona, do you want to comment on that? On the adherence challenges, so there was a qualitative study that was conducted in Uzbekistan last year looking specifically on adherence to MDRTB treatment and that found that while we know that side effects can be a challenge for patients and that all patients on MDRTB treatment experience side effects, there are a lot of techniques that can be taken that can really help mitigate the sort of extent to which people feel those side effects and that's things like looking at rather than focusing on the negative effects of treatment on the body by using visualisation, distractions from treatment that patients actually felt that they experience side effects less. There were also, I'm trying to remember now that I've got my head out of Swaziland. There's a poster, yeah, so catch me in the break and we can talk more about it. Maybe if I could add, I think that what really pays off and also learning from the HIV experience is the time that you invest with the patients and the psychosocial support team and how strong they are and how well they are addressing and working with the individual patient on making them understand the disease, the process and what it needs to recover. Thank you very much. Any other questions? There is a question, one question behind here and then if you can just pass the microphone on to the lady. So it's stories from MSF Austria evaluation unit. I have a question to Shona. I wanted to know what you are planning to do with the problem you were mentioning with the healthcare providers in the relationship with their patients because patients were complaining that, yeah, they were beaten or abused, kind of verbally abused. Verbally, yeah, not beaten up. You said you are planning to do some training but I think it's not only about training but maybe also more on motivation and the question, how do we welcome our patients that they feel comfortable in the... No, yeah, completely. Thanks for raising that point. This is an ongoing challenge that we face because we know that the challenge of practitioner-patient relationships can have a big impact on how much patients feel able to come forwards and discuss the issues and so on and so forth. We have done training on practitioners in the past. Also, I was just doing a study on linkage to HIV care in Swaziland and we found to with that study that things like losing the form that patients were supposed to bring with them to the clinic could prevent patients from feeling able to link because they were afraid that they'd be told off for losing their form and that really highlights actually the extent of the impact that can have on patients' ability to access care. So I think that's something we need to look at more closely and to think not only just saying that we need to train practitioners but actually what exactly can we do to improve that relationship because it has a big impact on patients, yeah. Next question. Hi, thank you. I'm Isabella Panuntzi, vaccination referent from OCB and my question goes to Katie because I was very happy to see in the same slide the two world API and HIV because usually we don't integrate the two things in our project and then actually with Helen we did a short survey in OCB HIV projects and then our question was do we vaccinate HIV positive children and the answer was no. We don't look at it at all. So my question is looking at your result. Have your thought gone a bit further in the sense do you also want to look about if we vaccinate the HIV positive children in the PMTCT program so not just to test about HIV also because we work in context where we have a very low API uptake. It's not just the HIV testing uptake that is low. So I would like to know if looking at your result what you say the next step is to try to integrate more and then to go more into the API program to test children also to think about the other part of it so to vaccinate HIV positive children. I don't think I can actually comment on vaccinating the children because really what we were just looking at were the prevalence results are but certainly we recommend that testing in API settings would be a good move. The results were slightly around the background prevalence data so it's a reasonable yield but in terms of vaccinating I don't. Yeah I mean yes Isabel we know it's kind of chicken and egg. Of course we want the HIV positive kids or the exposed babies in the coming to the PMTCT clinics we want our clinicians to be aware have they also completed API it's an essential bit of the exposed baby follow up so I think the message is yet we're trying to push but I think what Katie really nicely demonstrated that API is a captive audience for us to try and scale up testing and in PMCT what we want to do is we know some women who tested negative antinatally will seroconvert so we want to catch them by testing them in when they bring their kids for API. The second thing is 10% of the women we start on antiretrovirals antinatally don't ever come back because the healthcare workers have shouted at them that's the fact and healthcare workers say that about themselves like it's hysterical they say all our bad attitudes actually are one of the reasons they don't come back when you do these exercises and so by trying to catch the ones who were lost to follow up API also is potentially a captive audience to re-catch the women who didn't come back because they at least will bring their kids for a vaccination despite the fact they won't come back to get their ARVs because the healthcare workers shouted at them for whatever reason. In fact my question came from the answer Katie give me forcing that it's very difficult when we want to work with API and then this is the infrastructure and everything so if we start working with that it's an opportunity then to look also at the other side it's just this thank you. I think with regards to catchment of children in particular and especially with the problem of if you test a child positive then you inadvertently kind of have tested the mother positive. I think what we have absolutely underused and what Kenya has done very nicely is to actually do family centered approaches so to go and use the patient on ART as the index case almost as we do for TB where we say okay there is going to be clustering of HIV in this family and we should not forget to invite the children back to say have these children actually been tested no matter how old they are and and it is so often the case that actually somebody in the family is on treatment and still the child is undiagnosed. Any further questions? There is a question here and then we are going to take the question in the back please. You can just raise your hand so that the people with the microphone know where to put them. My questions for Helen. I was just intrigued about what to do with the children who are on NRTI regiments because you seem to show if I remember rightly that 57% of them you could suppress at three months by doing enhanced adherence counselling but perhaps the downside is that when you did genotyping they all had resistance and therefore in the longer term you might end up with more resistance because you've only theoretically got two active drugs so on a policy level what do you think about that is it's still a good idea to do enhanced adherence counselling in children in NRTI regiments or should you just accept that they're taking a risk and switch them straight over? Yeah that's a big debate we're we're having it's not just the kids it's the adults as well anybody failing in NRTI do we give them the chance to suppress and I think there've been a couple of studies looking at the people who suppressed and indeed many of them are going to have NRTI resistance. I think we're taking a very public health approach to this when we talk about suppression we're talking about to less than a thousand anyway so there's a compromise within that that we're taking so yeah I think it's for me Daniel I think it's a very public health approach to this should we be talking about genotyping all the first line failures as well as well potentially given a cheaper more accessible test that's maybe maybe a route to go but I think I think the public approach algorithm we have at the minute I think is feasible to put in place and I think probably does does a good job for the majority. Thank you yes please. Okay hi I'm Megan MSF Canada this is a question for the entire panel in the last month HIV testing has been approved for over-the-counter purchase in the UK. Do you think this model of at-home testing could be applied in the developing world? So it's basically I'm just going to repeat the question because I think it wasn't that clearly heard in front so it's basically about oral self-testing which has been approved in the FDA approved anyway and has been approved for the UK so is that an option is that a possibility for the settings you're working in I don't know who wants to take this question hello. Definitely it's already been piloted in a number of the countries that we're working different kind of models of using it some places are using at facility level just to try and scale up the access to PITC in terms of human resources a number of countries using it at community level often through community health workers I think the really important thing that's come up is the issue of linkage yeah what information is given with that test kit in terms of what do I do if I do test positive but definitely well community-based testing so going to people's homes to test is something that many countries are looking at and rolling out and self-testing definitely also is coming on the agenda yeah and if I can just add on to that we also want to include some qualitative research on that partly because rates of linkage you know reporting rates of linkage can be difficult as Helen just mentioned but also to make sure that we're understanding clients views and we know that acceptance and how you process a HIV positive result are really really important for how you then access care and also how you're then retained in care so thinking about how individuals experience that how they view at what information they need in order to be prepared for if the result is positive and to make sure that they know you know where they go if they need extra support and so on and so forth yeah thank you very much any other questions yes please in front here okay thank you Kieran from MSF UK it's a question to maybe the whole panel including Catherine and it's about health practitioner barriers to pediatric testing I think that's this was described quite well in some of the presentations that in many of the settings we work health practitioners will find it find it very difficult to test a child if they are not accompanied by their normal caregiver and sometimes this raises legal and political issues if I can give the example from Swaziland we did try to work with the ministry of health there and the art director came and spoke to all the nurses in the region to say we strongly encourage you to test a child even if they're not with their normal caregiver in the best interest of the child we will support you on this you will have the ministry of health's backing if there are any problems and it didn't change anything we continued you know when we talked to the staff and you tried to find out why and the health practitioners are from the community they still have to face the people the parents when the child goes home with their caregiver with a with a HIV positive result and so it didn't you know this reassurance from the ministry of health didn't change anything for them so I'm just interested to ask if if if there are any ideas or or to your knowledge any evidence of of things we can do like Catherine you said that you you got very good results in Zimbabwe and how did you do that and are you aware of any other any other things we can do to sort of try and address that barrier for the people that are really having to live with the results of testing a child without parental consent so I have to say from the Zimbabwe experience so we have at that point it was also very much just a kind of ministry of health and city health initiative so we got city health on board and they essentially were part of the workshop and subsequently due to the results of this very initial kind of research piece actually the testing guidelines for adolescents in Zimbabwe have changed and really it wasn't that it isn't that much in Zimbabwe the situation wasn't that much about and there is a mother or father available that mother or father might not have even been there and even so the grandmother came with the child they would still not test the child even if they knew that the mother was actually working in South Africa or was dead or was quite far away and if you look at the amount of the prevalence we found you found 5% and positive children now we have we had initially four months where we had kind of a relatively lowest uptake of 70% of provider initiated testing and part of that was 20% weren't offered to test and then within the ones who were offered testing again a high percentage high 20% didn't test once we actually ruled out the routes so routine opt out testing with a with a big push also to clarify what a guardian is and that it doesn't have to be a leader guardian so it's not that the health care worker does it in the best interest of the child they still get the consent from the person accompanying the child so it's you know it's not that the person who is actually caring for the child hasn't consented so we haven't overruled the guardians decision it was much more about do you accept this person as being the guardian of the child and that has clarified a lot for for the counselors the other thing was also we then staffed each of these clinics which one additional counselor not that that counselor was particularly specifically trained on children or adolescents but it just meant that there was a bit more time and we made sure from an operational point of view that there was no running out of test kits and so from a logistical point of view there was no reason anymore not to test children and then in addition I think the the the big issue was also that all of a sudden because everybody was offered testing people didn't refuse you know it was not that much refused anymore and if you look and we have managed to sustain these 95% uptake rates over 16 months following just a two week intervention without any retraining or anything and we managed to get much more guardians actually tested so because any child in initially there was also a lot of confusion about if we test the child the guardian must test as well so we kind of completely unlinked that but still that meant that we got a lot of a lot more guardians tested so and to just add into that of our of our secondary outcomes we found 10 of the 15 studies reporting secondary outcomes noted an acceptance rate and we used a proxy where acceptance rates by caregivers weren't available of refusal to test we found an acceptance rate of 90.8 so acceptability among caregivers is extremely high and so that should be underpinning our approaches as to how to increase the the confidence and the comfortability levels of healthcare workers to offer those tests. So thank you very much for my old female panel and I think we have overrun a tiny bit by five minutes but we started a bit late thank you for a very interesting discussion and I hand over to Philippe. I'm embarrassed because our Indian colleagues actually have switched back to their own session they're keeping to time I mean it feels like a race like we're falling behind and and maybe that's just a reminder that the issues that we're talking about are incredibly urgent and we do need to see how we can get better treatment and and take this research into our programs and into policy for better practice so thank you all please enjoy the break be back on time seated by 10.50