AIHA’s Pilot Project in Odessa: A Comprehensive
MTCT Prevention and Intervention Program
Zoya [email protected]
James SmithAmerican International Health Alliance
Educational Objectives Understand the main components of comprehensive
mother-to-child HIV transmission prevention (pMTCT) program
Learn about the implementation of effective comprehensive pMTCT program in the health care setting with limited resources in the region with concentrated stage of HIV/AIDS epidemic (Ukraine)
Understand how to apply “hospital twinning” and “medical volunteer” methodology to pMTCT project
Learn about a pilot project that can be used as a teaching laboratory to implement systemic change
Strategic Framework to Prevent HIV in Infants and Young Children
All women prevent HIV infection (level 1)
HIV+ women prevent unintended pregnancy (level 2)
HIV+ women prevent MTCT (level 3)
HIV+ women, their infant and family provide care and support (level 4)
Source: Prevention of HIV in infants and young children. Review of evidence and WHO’s activities. WHO/HIV/2002/08
Odessa Strategic Framework to Prevent HIV in Infants and Young Children
“+pMTCT+”
First “Plus”: prevention of HIV among women of reproductive age
pMTCT: Prevention of mother-to-child transmission of HIV
End “Plus”: Follow up care and support for families
Timing and Risk of Transmission*Tr. Rate
During pregnancy 5-10%
During labor and delivery 10-20%
During breastfeeding 5-20%
Overall without breastfeeding 15-30%
Overall with breastfeeding till 6 months 25-35%
Overall with breastfeeding till 18 to 24 months 30-45%
*Source: de Cock, JAMA (2000)
Main Components of pMTCT (Level 3)
Prenatal voluntary counseling and testing (VCT)
Prophylactic antiretroviral (ARV) regimens
Safer delivery practices
Infant feeding counseling and support
Prenatal Voluntary Counseling and Testing
VCT – the entry point for HIV prevention and care
HIV testing must be done with informed consent of the woman, using reliable laboratory tests and ensuring confidentiality (basic requirements)
Availability of efficient referral system to other services (Family planning, STI treatment, MCH, MTCT, etc.)
Choice of most appropriate and feasible model of VCT (individual, group)
Coordination of USAID Donor and Inter-Donor Efforts in Odessa
USAID Donors JHPIEGO Family Planning Trainings including
counseling component 1997-8, Odessa Oblast Hospital AIHA Consultation Training and Pre- and Post HIV
Testing Counseling workshop, May 2002, Kiev. Attended by all AIHA WWCs and PHCs including OOH
PATH VCT training, June 2002, OdessaInter-Donor MSF: Provide Nevirapine, infant formula, C-section
delivery kits for OOH and develop laboratory capacity UNICEF: Developed training materials on pMTCT in
collaboration with OSMU and OOH
Prophylactic Antiretroviral Regimen
Ante- and intra-partum regimen: reduce viral load in mothers’ blood and genital fluids during pregnancy, labor and delivery
Post-partum regimen: act as post-exposure prophylaxis (viral particles eventually transmitted during birth are eliminated)
Main regimens (see handout “Use of antiretroviral regimens for MTCT prevention”)
Safer Delivery Practices
Planned, hemostatic C-section
Avoidance of unnecessary invasive procedures (episiotomy, rupture of membranes, forceps, etc.): reduce infant contact with mothers infected blood and genital fluids.
Birth canal cleansing with chlorhexidine
Infant Feeding: the Ukrainian Context
Avoidance of breastfeeding eliminates HIV transmission through breast milk, but carries other risks (infections other than HIV, malnutrition)
Counseling: information about the risks and benefits of various infant feeding options, guidance in selecting the most suitable option for their situation.
pMTCT+: Follow-up Care of Women and Infants
Comprehensive care for women: Primary and HIV specialty care OB/GYN and family planning services Mental health and substance abuse treatment as needed Coordination of care for entire family Support services
Follow-up for Infants: HIV diagnostic testing to determine HIV status Referral to an HIV specialist PCP prophylaxis initiated at 6 weeks of age Long term follow-up of HIV-exposed infants Support services for entire family
Ukraine HIV Profile
Ukraine – epicenter of the HIV/AIDS epidemic in Eastern Europe and Central Asia. In Eastern Europe and Eurasia HIV is growing faster than anywhere else in the world (UNAIDS, 2002)
Concentrated stage of HIV/AIDS epidemic (USAID, UNAIDS, WHO classification, 2000) – HIV prevalence rate: adults -1% (2001); male STI patients – 13.3% (1996); IDUs – 8.6% (1998)*, pregnant women – 0.22% (2001)**
*Report on the Global HIV/AIDS Epidemic, July 2002, UNAIDS** Ukrainian AIDS Prevention Center
Ukrainian Context for MTCT Strategy
Prenatal HIV screening is widely available Prenatal, perinatal and postnatal coverage is almost
universal High percentage of HIV+ women are IDUs; high
percentage of infants are born addicted to drugs Replacement feeding can be carried out by HIV infected
mothers without major risks and obstacles Because numbers of identified HIV infected women is
still limited, it is still affordable to provide pMTCT interventions
The current, relatively low number of MTCT cases provides a window of opportunity to prepare the health care system to cope with the emerging problem
AIHA MTCT Pilot Project Goals Reduce the incidence of HIV in women of reproductive age
(+pMTCT)
Prevention of MTCT during pregnancy, delivery and postpartum (pMTCT)
Provide follow up care and support to infants, mothers and families to ensure that children born to HIV+ mothers grow up in a sustainable, nurturing environment (pMTCT+)
Prevent occupational exposure to HIV among healthcare workers
Create a model that is adaptable to other cities and a teaching laboratory to facilitate dissemination and replication (scaling up)
Project History Pre-project background: Active AIHA partnerships in Odessa (IC, WWC,
NRP, PHC) developing long-term relationship with Odessa Oblast Hospital (OOH) and Odessa State Medical University (OSMU)
Fall 2000: Identification of Odessa, Ukraine as MTCT project site (hot spot for region) to be a replicable model for change in Ukraine
February 2001: Key Ukrainian participants attend 8th Conference on Retroviruses and Opportunistic Infections in Chicago
Spring 2001: Collaboration scheme developed with Medicins sans Frontieres (MSF)
Spring 2001: Development of workplan, training needs identified (role of AIHA partnership)
March - August 2001: Cooperation with Cook County Hospital, Chicago September 2001 – present: Collaboration with Denver Health Medical
Center, University of Colorado Health Sciences Center, Children’s Hospital of Denver, Boulder Community Hospital (“hospital twinning” and “medical volunteer”)
August 2001 to present: AIHA project team collects data, performs monitoring, develops materials for dissemination, conducts clinical training
Main Components of AIHA’s Odessa Pilot Project
Develop a comprehensive strategy and establish widespread community support for key components
Creation of a “center of excellence” at a designated healthcare facility (OOH)
Restructuring of health care delivery system: effective communication and referral system between health institutions, effective allocation of limited resources
Development and implementation of relevant, evidence-based protocols, practical guides, informational brochures, and patient charts among others
Training of healthcare professionals Assure high quality of care at designated health care facility (OOH) Provision (including substantial donations) of essential medical
equipment and supplies Coordination of activities with other donor organizations (MSF,
UNICEF, PATH) and NGOs
Project Milestones A catalogue of reference documents was developed (practical guides for
healthcare workers, patient’s charts, and patient education materials). A clinical training program was initiated in Denver in April 2002. MTCT supplies and equipment were delivered to the Odessa Oblast
Hospital. A Monitoring and Evaluation database was developed, data entry is in
progress; preliminary results are available. A MTCT training course curriculum was developed and approved by the
Odessa Oblast Health Administration. Odessa Oblast Health Administration issued an order requesting HCWs
from all women's consultations in Odessa to participate in the MTCT training course. Developed a patient flowchart and redesigned the referral system for MTCT.
Odessa Oblast Health Administration issued an order in May 2002 that all HIV-positive pregnant women be referred for prenatal care to the Odessa WWC and for delivery to OOH
Five abstracts based on project results were published in the XIV International AIDS Conference abstract book, six articles were published in the special volume containing the extended versions of the conference abstracts and five posters were presented at the conference.
FY03 Workplan Improve the system of follow up care for women with HIV
and babies born to HIV infected women in cooperation with UNICEF/Kiev and MSF/Kiev
Enhance the HIV ELIZA testing capabilities at OOH lab to provide primary HIV testing for pregnant women
Strengthen the nursing component of healthcare delivery to HIV+ pregnant women, their infants and families
Develop consecutive and interactive pMTCT management model of primary prevention, prenatal, delivery, postnatal care, infant preventive care and monitoring, including follow up care for families with HIV
Improve the health care of HIV infected women who are IDUs and their babies
Initiate cross-border collaboration on pMTCT (Constanta, Romania)
Incidence of Babies Born to HIV+ Mothers at Odessa Oblast Hospital
0
20
40
60
80
100
120
140
1998 1999 2000 2001 2002* 2002**
# of Women whoGive Birth to HIV+Babies
*represents first nine months of 2002
** represents projection for 2002 (Jan-Dec)
Preliminary Project Results
HIV test
result availa-
ble before
delivery
ARV therapy (mother
and baby)
C-section
Episiotomy (vag. del.)
Birth canal
cleansing
Formula feeding
MTCT Rate*
Baseline group
(1997-99)
56% 2% 10% 20% 75% 97% 24%
MTCT group (2001-
present)
100% 100% 50% 10% 95% 100% 12%
*HIV status of all babies are verified by HIV PCR tests/ELISA and WB tests
MTCT Practical GuidesPurpose: Provide improved practice guidelines for OB/GYNS, neonatalogists, pediatricians, family physicians, nurses, midwives, social workers, microbiologists and lab technicians on various aspects of treating HIV+ patients.
Prevention and Treatment of STIs Treatment of STIs in HIV+ Pregnant Women Infection Control Practices Voluntary Counseling and Testing Lab Testing Prenatal Care for HIV+ Women Prevention of MTCT During Delivery Pediatric Care for Infants Born to HIV+ Mothers Primary Health Care for HIV+ Patients Family Planning Infant Feeding
Other MTCT Products for Dissemination
1. QuestionnairesPurpose: Assess knowledge of HIV/AIDS and MTCT of healthcare workers in maternity houses and pediatric settings. Questionnaires have also been developed for parents and guardians of children born to HIV infected Mothers and for HIV+ pregnant women
2. Information PackagesPurpose: Disseminate information among women of reproductive age and HIV+ women on HIV prevention, pregnancy and HIV testing, HIV, newborn and infant care
3. Patient ChartsPurpose: Collect and maintain information about HIV infected women and infants
Integration of pMTCT into the MCH System
HIV testing of babyReferral for pediatric care if baby is HIV+
HIV screening schedule
Growth and development monitoringNutritional and infant feeding counselingInfections prevention/treatmentPossible vaccination
Infant follow up
ARV treatment for infant (if needed)Support for infant feedingFamily planning counselingReferral to support groups
Postpartum
Intrapartum ARV componentAvoidance of unnecessary invasive proceduresUniversal precautions
Labor/Delivery
Initiation of ARV treatmentIndividual counseling
Prenatal visit 3
Confirmation of HIV+, post-test counselingSTI treatmentARV treatment counselingInfant feeding counseling
Prenatal visit 2
HIV/STD counselingHIV testing, STI screeningAnemia prevention
Prenatal visit 1PMTCT interventionsMCH schedule
National and Regional Support for pMTCT Activities
Ministry of Health: Support for project activities and possibility of implementing pilot project in other sites across the country
Odessa Oblast Health Administration: Support for restructuring the referral system, facilitating communication between healthcare institutions that provide care to HIV+ patients, healthcare worker training and allocation of limited resources
Applying AIHA Partnership Methodology to the pMTCT Project
Partnering/Hospital Twinning: Long term commitment that brings people, institutions and communities together to achieve common goals through sharing of ideas, labor and even risks.
Volunteering: The project is founded on a community-based approach and volunteerism to create effective sustainable change in health care.
Project Buy-in: Instill a strong sense of ownership within the partner communities by focusing on appropriate and sustainable solutions to healthcare problems.
