Download Power Point Presentation

Programmatic issues around
PMTCT Ruth Nduati
Senior Lecturer
Department of Pediatrics
University of Nairobi
Urban antenatal HIV prevalence in sub
Sahara Africa
S Africa
E Africa
C Africa
W Africa
5
10
15
20
%
0
25
30
35
40
Infant mortality rates by maternal HIV
status (Coulter 1993, Boerma 1998)
HIV exposed
HIV unexposed
40
35
30
25
20
15
10
5
0
Kinshasa
Kigali
Brazzaville
Malawi
Kampala
Magnitude of MTCT
transmission of HIV
During pregnancy
Transmission
rate
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 1824mths
30-45%
Mortality among HIV-1 seropositive
breastfeeding and formula-feeding women(Nduati
et al. Lancet 2001)
12
10
8
Breastfeeders
Formula-feeders
6
4
2
0
6wks
6mths
12mths 18mths 24mths
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)
35
30
25
20
ZDV
placebo
15
10
5
0
2 wks
6 mths
24 mths
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 Busia
N=3754
N=3597
Karatina
N = 5316
Homa Bay
N=4169
% tested
40%
46%
86%
18%
% RPR
+ve
4.8%
3.4%
1.6%
9%
Proportion 98%
treated
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
600
500
400
HIV+
Collect results
Take ARV Px
300
200
100
0
KTN
HBY
Busia
Kakamega
Content of Health education & counseling before
and 9 months after a PMTCT program in Karatina
30
25
20
% 15
Before PMTCT
After PMTCT
10
5
0
Maternal
nutrition
Infant
nutrition
MTCT
HIV risk
reduction
Content of Health education & counseling before
and 9 months after a PMTCT program in Homa Bay
30
25
20
% 15
Before PMTCT
After PMTCT
10
5
0
Maternal
Infant
nutrition nutrition
MTCT
HIV risk
reduction
Quality of HIV testing in Homa
Bay District Hospital
6%
Correctly classified
Wrongfully classified
94%
Quality of HIV testing in
Karatina District Hospital
1%
Correctly classified
Wrongly classified
99%
Counseling Environment
Baseline
100
100
Follow-up
64
80
56
60
40
47
22
11
20
0
Privacy
No
interuptions
No barriers
Communication Skills in HIV
counseling sessions (1)
Baseline
Follow-up
97
100
88
86
75
80
60
44
40
44
33
33
20
0
Rapport
Confid
Listen
Explore
Communication Skills in HIV
counseling sessions (2)
Baseline
91
38
80
77
33
29
85
79
33
11
Clarify
Open-end
Non-
verbal
silence
Feedback
100
90
80
70
60
50
40
30
20
10
0
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 MboriNgacha
• J Ndinya Acholla
• J Bwayo
• Anthony Mwatha
• James Ochieng