Programmatic issues around PMTCT -

Ruth Nduati

Senior Lecturer

Department of Pediatrics

University of Nairobi

Urban antenatal HIV prevalence in sub

Sahara Africa

0 5 10 15 20 25 30 35 40%

W Africa

C Africa

E Africa

S Africa

Infant mortality rates by maternal HIV status (Coulter 1993, Boerma 1998)

0

5

10

15

20

25

30

35

40

Kinshasa Kigali Brazzaville Malawi Kampala

HIV exposed HIV unexposed

Magnitude of MTCT transmission of HIV

Transmission rate

During pregnancy 5-19%

During labour and delivery 10-20%

During breastfeeding 5-20%

Overall without breastfeeding 15-30%

Overall with breastfeeding <6mths 25-25%

Overall with breastfeeding 18-24mths

30-45%

Mortality among HIV-1 seropositive breastfeeding and formula-feeding women(Nduati

et al. Lancet 2001)

0

2

4

6

8

10

12

6wks 6mths 12mths 18mths 24mths

BreastfeedersFormula-feeders

Effect of mother’s death on infant survival

“Independent of infection status HIV exposed infants were at an 8 fold increased risk of death following their mother’s death

Nduati et al., Lancet 2001;357:1651

Efficacy of short course AZT in a breastfeeding population (Leroy AIDS 2002;16:631-641)

0

5

10

15

20

25

30

35

2 wks 6 mths 24 mths

ZDVplacebo

Cumulative mortality at 24 months

Breastfed Formula Hazard ratio (95% CI)

Overall 24.4% 20% 1.1 (0.7-1.7)

Uninfected 8.1% 10% 1.3 (0.6-8.0)

Infected 46% 40.2% 0.9 (0.5-1.8)

HIV AND INFANT FEEDING: THE DILEMMA

Strategic approaches to prevention of HIV related morbidity and mortality in children

• Prevention of HIV in young women

• Prevention of unintended pregnancies in HIV infected individuals

• Prevention of MTCT transmission of HIV

• Provision of c are to HIV infected women and their families.

Steps in implementing a PMTCT

• Program level– Advocacy with District Health Management

Teams and other important stake holders– Consensus building on the package of services– Development of guidelines– Development of IEC materials– Development of monitoring and evaluation

tools

The PMTCT package

• Quality antenatal care• Universal HIV counseling and voluntary testing • Partner involvement in counseling• Provision of anti-retroviral prophylaxis • Counseling on replacement feeding and safer

breastfeeding practices • Safe delivery• Post-natal care for the infant

Provision of quality antenatal care

• Health education• Screening and treatment of STD’s• Screening for anaemia• Micronutrient supplementation• Malaria chemoprophylaxis• Immunization against tetanus• Screening for other pregnancy related

complications eg. Diabetes or eclampsia• Family planning counseling

Screening for syphilis with RPR

Kakamega

N=3754

Busia

N=3597

Karatina

N = 5316

Homa Bay

N=4169

% tested 40% 46% 86% 18%

% RPR +ve

4.8% 3.4% 1.6% 9%

Proportion treated

98% 59% 82% 82%

Guidelines to support PMTCT

• National Infant feeding policy

• Guidelines for the care of HIV infected women

• Guidelines on the use of anti-retroviral drugs

IEC materials to support PMTCT

• Posters to be used within the health facility and at community level

• Take home brochures to help women initiate discussion on PMTCT

• Flip charts with detailed information to help the health worker provide accurate information

• Badges for counselors to help clients identify who they can approach for information

• Video to be used in antenatal clinic • Counseling cards on infant feeding

Tools for monitoring PMTCT at health facility level

• Modified antenatal card• Modified institutional registers

– Antenatal register– Laboratory register– Delivery register– Bin cards– Drug registers (maternity, MCH, pharmacy)

• New register– Counselors register

• Weekly summary sheets

Steps in implementing PMTCT at facility level

• Advocacy with the staff• Needs assessment to

– Determine the existing resources and gaps

– existing package of services being provided

• Development of training materials• Training of health workers• Establishment of appropriate client flow• Carrying out monitoring and evaluation

Factors affecting uptake of testing

• Counseling case load • Prevalence of HIV• Counseling strategy –

– Group versus one-one counseling– Opt-in versus opt-out approach to testing

• Client flow– one-stop service provision versus production

line approach

Uptake of HIV-test results and ARV’s

0

100

200

300

400

500

600

KTN HBY Busia Kakamega

HIV+Collect resultsTake ARV Px

Content of Health education & counseling before and 9 months after a PMTCT program in Karatina

0

5

10

15

20

25

30

%

Maternalnutrition

Infantnutrition

MTCT HIV riskreduction

Before PMTCTAfter PMTCT

Content of Health education & counseling before and 9 months after a PMTCT program in Homa Bay

0

5

10

15

20

25

30

%

Maternalnutrition

Infantnutrition

MTCT HIV riskreduction

Before PMTCTAfter PMTCT

Quality of HIV testing in Homa Bay District Hospital

94%

6%

Correctly classifiedWrongfully classified

Quality of HIV testing in Karatina District Hospital

99%

1%

Correctly classifiedWrongly classified

Counseling Environment

22

100

11

5647

64

0

20

40

60

80

100

Privacy No

interuptions

No barriers

Baseline Follow-up

Communication Skills in HIV counseling sessions (1)

44

97

33

88

33

86

44

75

0

20

40

60

80

100

Rapport Confid Listen Explore

Baseline Follow-up

Communication Skills in HIV counseling sessions (2)

38

91

29

80

11

77

33

79

33

85

0102030405060708090

100

Fe

ed

ba

ck

sile

nc

e

No

n-

ve

rba

l

Op

en

-en

d

Cla

rify

Baseline Follow-up

CHALLENGES

• Sustaining the consumables – HIV Test kits, IEC Materials

• Providing essential package of services such as syphilis screening, and antenatal multivitamin supplements

• Improving uptake of test results and intervention among HIV infected women..

• Providing standardized messages and ensuring quality of counseling.

Partnerships

• Joan Kreiss

• Grace John

• Barbrar Richardson

• Julie Overbaug

• Dana Pantaleef

• Christine Rousseau

• Population Council

• Family Health International

• Ruth Nduati• Dorothy Mbori-

Ngacha• J Ndinya Acholla• J Bwayo• Anthony Mwatha• James Ochieng