PMTCT: Achievement, Challenges and the Way Forward in
Namibia
August 16, 2019
Ms. Francina Rusberg
Senior Programme Officer
PHC Directorate
MOHSS
Andrew Agabu MBBS, MPH, MSc
SRMCH – TA
PHC Directorate
MOHSS
Outline
• Background
• EMTCT Targets
• Achievements in PMTCT
• Challenges
• The way forward/Priorities
Background to PMTCT Programme in Namibia
• PMTCT services introduced in 2002 and integrated into MCH settings (ANC, Delivery and
postnatal care)
• Early infant diagnosis (EID) for HIV exposed infants (HEIs) introduced in 2005, also integrated into the MCH service.
• PMTCT and EID services are in almost all public health facilities providing ANC/Maternity/PNC services
• Implementation of Lifelong ART for PMTCT (OPTION B+) for all HIV positive pregnant and breastfeeding women started in 2014/2015.
• Treat ALL ART guidelines rolled out in 2016
• 2019 revisions of ART guidelines including regimens for PMTCT and EID to be completed soon
Goal of EMTCT in Namibia
To eliminate new pediatric HIV infections and improve the survival of children and their mothers within the context of HIV infection
Expected EMTCT Outcome Results Include:
1. The pregnant women who know their HIV status increased to >95%
2. The HIV positive pregnant women receiving effective ARVs increased to >95%
3. Early infant diagnosis (EID) of HIV exposed infants increased to 95%
4. All HIV infected children to be initiated on ART
5. Reduce unmet need for family planning among HIV positive women to Zero
Pathway to achieving elimination of MTCT by 2023 (final draft )
Achievements
PMTCT services in almost all health facilities in Namibia April 2018- March 2019
100% 100% 100% 100% 100% 94%
85%
100% 100% 100% 100% 96%
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
10
20
30
40
50
60
Number of Public Health Facilities, PMTCT sites by Region Apr 2018-Mar 2019
Number of Health Facilities PMTCT Sites % PMTCT sites
372 363
0
50
100
150
200
250
300
350
400
Namibia
Number of Public Health Facilities & PMTCT Sites in Namibia
98%
Source: Programme data 2014-2019
78911 79919 84237 86125 86953
0
20000
40000
60000
80000
100000
Apr 2014 to Mar2015
Apr 2015 to Mar2016
Apr 2016 to Mar2017
Apr 2017 to Mar2018
Apr 2018 to Mar2019
Total number of pregnant women attending ANC
NDHS 2013: 97% of Pregnant women attend at least 1 ANC visit in Namibia
Source: Programme data 2014-2019
PMTCT Cascade at ANC by year 2014-2019
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Apr 2014to Mar2015
Apr 2015to Mar2016
Apr 2016to Mar2017
Apr 2017to Mar2018
Apr 2018to Mar2019
Pregnant women who know their HIV status
Total HIV Positive pregnant women
Total HIV Positive pregnant receiving ART
0100002000030000400005000060000700008000090000
100000
Apr 2014 toMar 2015
Apr 2015 toMar 2016
Apr 2016 toMar 2017
Apr 2017 toMar 2018
Apr 2018 toMar 2019
Pregnant women 1st ANC Pregnant women who know their HIV status
Total HIV Positive pregnant women Total HIV Positive pregnant receiving ART
High uptake of PMTCT services at ANC settings
Source: Programme data 2014-2019
Majority of HIV Positive pregnant women already know their HIV positive status before 1st ANC
69% 73% 73%
78% 83%
31% 27% 27% 22% 17%
0%
20%
40%
60%
80%
100%
120%
Apr 2014 toMar 2015
Apr 2015 toMar 2016
Apr 2016 toMar 2017
Apr 2017 toMar 2018
Apr 2018 toMar 2019
Known Positives and Tested Positive at ANC
% PMTCT/ANC Clients NEW HIV positive
% Pregnant women known HIV positive (KP)
93
%
93
%
APR17-MAR18 APR18-MAR19
% ALREADY ON ART OF KNOWN POSITIVE AT 1ST ANC
Source: DHIS2 database 2014-2019
PMTCT Cascade at Maternity
0
20000
40000
60000
80000
100000
Apr 2014to Mar2015
Apr 2015to Mar2016
Apr 2016to Mar2017
Apr 2017to Mar2018
Apr 2018to Mar2019
PMTCT Cascade at Maternity over 5 years
Total deliveries Know HIV status
Total HIV positive at Maternity Total receiving ART at Maternity
0%
20%
40%
60%
80%
100%
120%
Apr 2014to Mar2015
Apr 2015to Mar2016
Apr 2016to Mar2017
Apr 2017to Mar2018
Apr 2018to Mar2019
Trends in PMTCT Cascade at Maternity over 5 years
Know HIV status Total HIV positive at Maternity
Total receiving ART at MaternityHigh uptake of PMTCT services at labour and delivery settings
Source: DHIS2 database 2014-2019
Progress in Early Infant Diagnosis
Apr 2016 to Mar 2017
Apr 2017 to Mar 2018
Apr 2018 to Mar 2019
Total number of HIV exposed infants 11939 12733 12607 MBF HIV exposed children aged 6-8 weeks who received daily NVP prophylaxis from birth 11102 12087 12200
Total tested for EID 10184 10794 10736
MBF HIV exposed children confirmed negative for HIV 5191 5377 4127
Total Infants confirmed HIV positive 268 264 221
Infants with final outcomes 5459 5641 4348
Apr 2016 to Mar 2017
Apr 2017 to Mar 2018
Apr 2018 to Mar 2019
HEI receiving ARV prophylaxis 93% 95% 97%
Total tested for EID 85% 85% 85%
Infants Confirmed HIV positive 2.63% 2.45% 2.06%
Source: DHIS2 database 2017-2019
Challenges
Unit 1: Slide 13
HIV Prevalence Rate of Pregnant Women, Biannual
Surveys 1992-2016
Source: MOHSS National HIV Sentinel Survey Report , November 2016
High HIV
prevalenc
e among
Pregnant
women
0% 1% 0% 1% 0% 0%
16
%
15
%
15
%
15
%
15
%
15
%
29
%
28
%
28
%
27
%
26
%
27
%
23
%
24
%
24
%
24
%
25
%
24
%
17
%
18
%
18
%
18
%
18
%
18
%
14
%
14
%
15
%
16
%
16
%
15
%
0%
5%
10%
15%
20%
25%
30%
35%
Apr 2014 to Mar 2015 Apr 2015 to Mar 2016 Apr 2016 to Mar 2017 Apr 2017 to Mar 2018 Apr 2018 to Mar 2019 Average
Pregnant Women by Age Range Apr2015 - Mar 2019
ANC Antenatal 1st visit - Under 15 years ANC Antenatal 1st visit - 15-19 years ANC Antenatal 1st visit - 20-24 yearsANC Antenatal 1st visit - 25-29 years ANC Antenatal 1st visit - 30-34 years ANC Antenatal 1st visit - 35+ years
Source: DHIS2 database 2014-2019
21% 22% 22% 23% 24% 23%
64% 63% 63% 62% 62% 63%
15% 15% 15% 14% 14% 15%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr 2014 to Mar2015
Apr 2015 to Mar2016
Apr 2016 to Mar2017
Apr 2017 to Mar2018
Apr 2018 to Mar2019
Average
First ANC attendance by trimester Apr 2014- Mar 2019
ANC Antenatal 1st visit in 1st trimester ANC Antenatal 1st visit in 2nd trimester ANC Antenatal 1st visit in 3rd trimester
Less than a quarter of pregnant women start ANC during 1st trimester.
Close to two-thirds start ANC during 2nd trimester 15% start ANC in 3rd trimester The trend has not changed over the last 5 years
Less than a quarter of pregnant women start ANC during 1st trimester.
Source: DHIS2
database 2014-2019
Identification of new HIV positives during pregnancy and labour/delivery
4% of pregnant women re-tested by 36 weeks tested HIV positive
6% of those having 1st HIV test at L&D
were HIV positive
4%
6%
0%
2%
4%
6%
8%
0
2000
4000
6000
8000
ANC 36 week Retest Newly Tested L&D
New HIV infections among pregnant women attending ANC and Newly identified HIV positive
women during delivery Apr 2018 - Mar 2019
Tested Positive Yield
Source: DHIS2 database 2018-2019
Loss to follow up for EID and not all HEIs have final outcomes
Apr 2016
to Mar
2017
Apr 2017
to Mar
2018
Apr 2018
to Mar
2019
MBF HIV exposed children aged 6-8 weeks who received daily NVP
prophylaxis from birth 11102 12087 12200
MBF HIV exposed children confirmed negative for HIV 5191 5377 4127
MBF Children diagnosed confirmed HIV positive 6-8 weeks 89 102 118
MBF Children diagnosed confirmed HIV positive 9 weeks - 8 months 58 55 28
MBF Children diagnosed confirmed HIV positive greater than 9 months 121 107 75
Infants with final outcomes 5459 5641 4348
% infants with final outcomes 49% 47% 36%
Source: DHIS2 database 2016-2019
Namibia MTCT During ANC and Breastfeeding Periods Oct 2017 – Sept 2018
Started ART before pregnancy, nonsuppression 1.5%
Started ART during pregnancy, nonsuppresion 1%
Dropped off ART in pregnancy 4%
Started ART in late pregnancy 1.5%
Did not receive ART during pregnancy; 16% [CATEGORY NAME], 2%
Started ART before pregnancy, nonsupression 3%
Started ART during pregnancy, nonsuppresion 4%
Started ART in late pregnancy 2%
Did not receive ART during breastfeeding 21%
[CATEGORY NAME] 15%
Mother dropped off ART during breastfeeding 29%
Source: CDC – Namibia presentation
Child infected during breastfeeding:74%
Child infected during pregnancy: 26%
Special attention needed during breastfeeding period to stop new
pediatric HIV infections
Challenges • Shortage and rotations of trained staff
• Poor maternal VL monitoring, no documentation in patient cards/registers
• Inadequate maternal retesting at 36 weeks and recommended intervals during breastfeeding
• Delayed 1st EID for HEIs & many not re-tested at recommended intervals
• Inadequate cohort monitoring and analysis to measure retention and final outcomes.
• Lack of standardized maternal postnatal care approach to facilitate postnatal HIV related service delivery – no standardized PNC register
• Data recording and reporting issues- missing data in registers and delayed reports
• Low partner testing in eMTCT
• EMTCT/EID not included in facility quality improvement activities
• PMTCT data from Private Sector not integrated into national HIS systems
The Way Forward for EMTCT
3. Viral suppression prior to and during
pregnancy and breastfeeding
What will it take? effectively no risk of MTCT when…
1. Identification and ART initiation prior to
conception
2. Family and pregnancy planning
for HIV-positive women
3 pillars for ‘U=U for MTCT’
What is the VL threshold for MTCT?
0-0.25% MTCT <40 copies/ml- TND
40-400 copies/ml 0.5%-1.1% MTCT
400-1000 copies/ml 1.1%-3.6% MTCT
1000-9999 copies/ml 6.8% - 14% MTCT
>10,000 copies/ml 14%-30% MTCT
0% transmission if women is TND before conception
Ernest Nkhoma, “Maternal Viral Load Suppression and it’s Impact on Infant HIV Transmission in Malawi’s Option B+ PMTCT Program”, CROI 2018 Mandelbrot, L., Tubiana, R., Le Chenadec, J., Dollfus, C., Faye, A., Pannier, E., ... & Devidas, A. (2015). No perinatal HIV-1 transmission from women with effective antiretroviral therapy starting before conception. Clinical Infectious Diseases, 61(11), 1715-1725. Myer, L., Phillips, T. K., McIntyre, J. A., Hsiao, N. Y., Petro, G., Zerbe, A., ... & Abrams, E. J. (2017). HIV viraemia and mother‐to‐child transmission risk after antiretroviral therapy initiation in pregnancy in Cape Town, South Africa. HIV medicine, 18(2), 80-88.
Recommendations and PMTCT priorities Health worker training, mentorship and supportive
supervisory activities for eMTCT/EID • Strengthen collaboration between mentors and PMTCT programme for onsite training and mentorship of
health workers in PMTCT/EID and Ptracker and use ECHO platform for PMTCT
• Strengthening national/regional/district supportive teams
Intensify maternal case identification and prevention –PITC including retesting during pregnancy and breastfeeding in MCH settings
• Same day ART initiation
• Maternal viral load monitoring (including POC VL)
• Prevention of new infections among pregnant and breastfeeding women e.g. PrEP
• Strengthen partner testing
• Integration of FP and HIV services
Recommendations and PMTCT priorities
EID at recommended intervals for HEIs. • Higher risk categorisation and birth testing of higher risk HEIs
• Strengthen EID services (including POC PCR for EID)
• Strengthening mother baby follow- up care and tracking initiatives including facility and community linkages.
Increase awareness on the importance of eMTCT for both maternal and infants to enhance service uptake, adherence and retention
Recommendations and PMTCT Priorities Strengthening M&E of eMTCT/EID:
• Facilitate use of updated registers and monthly reporting forms
• Rollout implementation of electronic system (Ptracker) - data recording and reporting & cohort monitoring
• Regular programme and data reviews
Integration of eMTCT/EID into quality improvement approaches
Strengthen PNC approaches including development of standardized postnatal care register aligned to current PMTCT/HIV interventions for both mothers and their infants
Strengthen strategic partnerships for PMTCT at all levels of health system including Private Sector.
Thank You
