Roll Out of More Efficacious PMTCT Regimens

Lesotho’s National Approach

Mpolai M. Moteetee B.Sc, MB.ChB, MPH

Director-General of Health ServicesMinistry of Health and Social Welfare

Kingdom of Lesotho

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Kingdom of Lesotho

Kingdom of Lesotho

Health Care Pyramid

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Demographic Information

• Maternal Mortality Ratio: 762/100,000 LB (2004:LDHS, higher 2009 DHS)

• Infant Mortality Rate: 91/1000LB (2009:LDHS)

• Child Mortality Rate: 28/1000LB (2009 LDHS)

• Under Five Mortality Rate: 117/1000LB (2009 LDHS)

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Impact of HIV in Lesotho 2008

HIV Prevalence Rate: 23.6% 270,000 adults & children

living with HIV in 2009

Population: 1,880,661 (Census 2006)

Children (<18): 800,000Orphans: 110,000

Estimated 21,000 new infections & 11,000 deaths

in 2009>57% eligible patients

(CD4 <350) on ART in 2009

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Population Impact continued

• Life expectancy at birth: Men - 39 yearsAnd Women – 44 years

• Little population growth in 10 yrs (0.08% 2006 census)

• Most affected are young adults of child bearing age

• Women affected more than men

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Government Response

• 2003 – Launch of PMTCT initiatives• 2004 – Care and treatment for adults

– Government procurement of antiretrovirals for every citizen

• 2005-7 - Know Your Status campaign for 12yrs and above

• 2008- Free health center services • Mitigation efforts for OVCs: school fees

and welfare; cash grant 2009

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PMTCT Services

• Lesotho’s adult HIV prevalence is 23.6 %, one of the highest in the world. The prevalence among pregnant women attending ANC is 27% (MOHSW 2010)

• The rate of ANC care by a health professional is high (91.8%), but only 58.7% of deliveries take place in health facilities (LDHS 2009)

• It is estimated that there are 50,000 annual births in the country, out of which approximately 12,855 infants are born to HIV infected women each year. In the absence of any intervention to prevent vertical transmission of HIV, this would result in approximately 5,142 new paediatric HIV infections per year. (PMTCT Guidelines)

• A national PMTCT scale-up plan was developed in 2007, with the goal of reaching 100% facility coverage by 2011

PMTCT Services cont’d

• PMTCT coverage increased gradually from:• 16.5% - 31% in 2006 • 31% - 56% in 2008• 56% - 71% to date

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Health Facilities and PMTCT

PMTCT Services, continued

• PMTCT services were made possible through expanded training & decentralization of PMTCT interventions to the H/Cs

• PMTCT services are largely provided by nurses, who have been trained in Integrated Management of Adult and Adolescent Illnesses (IMAI) and are able to assess pregnant mothers and initiate prophylaxis regimens based on HIV tests

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PMTCT Services, continued

• 71% of facilities were providing PMTCT by the end of 2009

• PMTCT uptake for women is at 90% (AJR 2009) at clinics and 34% for infants, but under-reporting is suspected

• The USAID-funded CTA project began in 2005 and went through March 2010. EGPAF supported PMTCT and care and treatment services in 6 of the 10 districts.

PMTCT Services, continued

• Lesotho’s initial PMTCT guidelines (developed in 2004) recommended the use of single-dose NVP given to HIV-positive mothers and infants

• The revised PMTCT guidelines in 2007 introduced WHO-recommended regimen of:o AZT 300mg 12 hourly for mothers from 28 weekso AZT 600 mg and 3TC 300mg and NVP 200mg

during labour o AZT 300mg and 3TC 150mg 12 hourly for one

week post-partum

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PMTCT Services, continued

PMTCT Prophylaxis for the Baby

• Plus single-dose NVP of 2mg/kg to infants

• AZT 4mg/kg for one week after birth (or 4 weeks if the mother received less than 4 weeks of AZT prior to delivery)

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The Mother/Baby Package

• Introduced in 2007

• Service to the remote and not easily accessible as well as to the 30% (48%) of the women that deliver at home

• Contents of the Mother Baby Package (MBP) are:- AZT from 28 weeks in 1st pill bag - AZT/3TC/NVP in labour 2nd pill bag- AZT/3TC for 1 week post-partum 3rd pill bag

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Mother/Baby Package, continued

• Pack for the baby is:– A capped syringe of 6mg (0.6ml) of NVP for the

baby– AZT syrup 12 mg BID for seven days

• Instructions are given to the mother on when and how to take them in case she delivers at home, but ideally all mothers are encouraged to deliver at the health facilities

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Challenges Based on Evidence, 2009

• Rotation of nurses from the health facilities affects the provision of PMTCT services

• Concentration only on HIV + mothers and those HIV negative not attended to

• Though mothers given PMTCT MBP, its difficult to monitor whether the mother has taken drugs or not

• There sometimes are drugs stock outs experienced at H/Cs; some of the mothers are not given MBP

• Wastage of AZT syrup as a baby has to be given 240 ml in seven days and the remaining syrup is discarded

• Some mothers get confused learning of their HIV status for the 1st time & being given instructions on how to take the drugs.

• Will the mothers remember the instructions especially if they deliver at home

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Partners for PMTCT Interventions

UNICEF EGPAF UNFPA ICAP WHO PIH PEPFAR Clinton Foundation CIDA MSF UNITAID Baylor GFATM

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Results of MBP

• By September 2008, all 138 health facilities providing PMTCT used the MBP

• UNICEF assisted in the assessment of the Lesotho minimum package in 2009 and the findings informed the development of UNICEF/SD MBP and the decision for Lesotho as one of the pilot sites for the MBP

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Findings of the Mother Baby Pack Assessment, 2009

• Strong Partnerships: Health partners have formed a solid relationship with the MOHSW to implement the key elements of the PMTCT program in the country

• Coverage of PMTCT: There was general confidence that targets set by the MOHSW, to reach PMTCT coverage of 80% by end of 2010 and 100% by end of 2011, was achievable

• Integrated Programs: PMTCT is well integrated with other MCH services. There is a degree of continuity of services and support during ANC and after through education and enrolment into support groups for HIV-positive women

• Satisfied Users: Over 80% of women indicated general satisfaction with the packaging and physical appearance of the MBP

• Quick Preparation Time: Facility supervisors estimated that staff spend a relatively short time preparing the MBP (46%). Nearly 70% of service providers said they spend less than 10 minutes putting together one package. 83% of supervisors indicated that they pack it when it is prescribed rather than in advance

• Storage Location: The most frequently cited places for storing the MBP by women were handbags and cupboards in the kitchen or bedroom

• Use of Medications: The actual use of the MBP during delivery outside the health facility environment is not yet know and calls for further investigation

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Recommendations• Improve systems to deal prevent and to deal with stock outs of

medications.

• Community awareness campaigns need to encourage women to deliver in facilities and to address stigma and discrimination.

• Need more male support groups so that men can talk about issues relating to HIV.

• PMTCT training among service providers was indicated to be high, though there is about 20% of service providers who may require in-service or refresher training.

• Clear written instructions are required for the use of the MBP.

• Need to train community support structures so as to be able to help in providing services when users cannot access the facilities. This is especially with regards to home deliveries and adhering to proper use of the Minimum Package.

• Patients recommend that the MBP should have a strong “container” for medications which would withstand wear and tear.

• Syrups should be packed in smaller bottles for AZT for infants and it should be packed in containers suitable for the period prescribed.

Way Forward

• The MOHSW has again reviewed the PMTCT guidelines and has incorporated the WHO recommended regimen of starting PMTCT prophylaxis at 14 weeks for mothers & at birth until the babies stop breastfeeding

• Sensitization and empowerment campaigns will be continued to encouraging women (husbands and mothers-in-law) to deliver at health facilities

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Way Forward, Continued

• The MOHSW has to again orientate the health professionals on the new WHO Recommendations on PMTCT regimen

• The MOHSW will disseminate the latest revised PMTCT guidelines

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Conclusion• The strong political will, and Government support, for HIV and

AIDS including PMTCT facilitates innovations and fast roll out of interventions.

• Lesotho will reach 100% PMTCT coverage with the support from the partners.

• The Ministry will continue to develop strategies for ensuring that mothers deliver in the health facilities and delivering HIV negative babies.

• The MOHSW (and GOL) appreciates and is immensely grateful for the support by its partners.

• We look forward to even closer and improved efforts towards attaining the goal of 100% PMTCT

• We acknowledge and register the support by EGPAF (positive experience) and are looking forward to the national coverage (from 6 to 10 districts) for not only PMTCT but to the broad HIV and AIDS control

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THANK YOU