Prevention of mother to child transmission a panacea for an hiv free generation
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PREVENTION OF MOTHER TO CHILD TRANSMISSION: A PANACEA FOR AN HIV – FREE GENERATION. INCREASING PREVENTION OF MOTHER TO CHILD TRANSMISSION SERVICE UPTAKE THROUGH INTEGRATED HEALTH CARE DELIVERY SYSTEM -Dr. Adeyanju A. O. Global impact of the HIV epidemic on children.

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PREVENTION OF MOTHER TO CHILD TRANSMISSION: A PANACEA FOR AN HIV – FREE GENERATION

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Prevention of mother to child transmission a panacea for an hiv free generation

PREVENTION OF MOTHER TO CHILD TRANSMISSION: A PANACEA FOR AN HIV – FREE GENERATION


Prevention of mother to child transmission a panacea for an hiv free generation

INCREASING PREVENTION OF MOTHER TO CHILD TRANSMISSION SERVICE UPTAKE THROUGH INTEGRATED HEALTH CARE DELIVERY SYSTEM

-Dr. Adeyanju A. O


Global impact of the hiv epidemic on children

Global impact of the HIV epidemicon children

  • 14 percent (370,000 of 2.7 million) of new global HIV/AIDS infections

  • 14 percent (270,000 of 2.0 million) of HIV/AIDS deaths annually

  • 6 percent (2.0 million of 33.0 million) of the persons living with HIV

    Over 90% of children acquire HIV through mother-to-child transmission (MTCT)

Source: UNAIDS/WHO/UNICEF – Towards Universal Access 2008


National hiv prevalence trend 1991 2010

NATIONAL HIV PREVALENCE TREND 1991 – 2010


Hiv estimates by end of 2010

No requiring ART- 1,512,720

- Adult-1,300,000

- Children-212,720

New infections - 281,180

-Adult-126,260

-Children-154,920

Total AIDS orphans - 2,229,883

HIV ESTIMATES BY END OF 2010


Nigeria and global hiv burden

Nigeria and Global HIV Burden

Nigeria now has the second highest number of people living with HIV in the world after South Africa.

Nigeria, with about 2.98million PLWHIV, accounts for about 9% of the global HIV burden.

Home to 30% of the global PMTCT Gap burden


The global pmtct gap

The Global PMTCT Gap

UNICEF Mid-Year Review Meeting July, 2011


Mother to child transmission of hiv can occur

Mother To Child Transmission of HIV can occur

  • In-utero [5-10%]

  • Postpartum [5-20%]

  • Labour/delivery [10-20%]


Background

Background

HIV prevalence (ANC): 4.1%

HIV positive persons: 3.15million (1.83m female)

HIV+ pregnant women(annual): 229,480

Children <15 years living with HIV: 331,150

  • Transmission rates (at 6 weeks): from 2.34% (HAART) to 15.6% (no intervention)*

  • 58% of pregnant women attend ANC at least once; 45% attend at least 4 times

  • 35% of births occur in health facilities, 62% occur at home.


National pmtct programme

National PMTCT Programme

Goal

  • To contribute to improved maternal health and child survival through accelerated provision of comprehensive PMTCT services

    Targets

  • At least 50% reduction in HIV incidence among 15-49yr old women by 2015

  • At least 90% of all pregnant women have access to quality HIV counseling and testing by 2015

  • At least 90% reduction in unmet need for Family Planning among women with HIV by 2015


National pmtct targets

National PMTCT Targets

  • At least 90% of all HIV positive pregnant women and their breastfeeding babies access more efficacious ARV prophylaxis by 2015

  • At least 90% of HIV exposed infants have access to early infant diagnosis services by 2015

  • At least 90% of pregnant women requiring ART for their own health receive life long ART by 2015


  • Score board after nearly one decade of implementation

    Score Board after nearly One Decade of Implementation

    UNICEF Mid-Year Review Meeting July, 2011

    NigeriaSouth Africa

    HIV+ pregnant women:210,000210,000

    Coverage of ARV/ART for PMTCT:22%88%

    Estimated HIV incidence (modelled):0.39%1.68%

    Contraceptive prevalence:20%62%

    Unmet need for FP:20%14%

    ANC at least 1 visit:58%92%

    Median duration of BF:19 m16 m

    MTCT rate in 2009:32%19%

    New child infections 2009:64,70040,500

    Sources: WHO Universal access report 2010, Nigeria DHS 2008, South Africa DHS 2003, UNAIDS analysis


    Problems peculiar to developing countries

    Problems peculiar to Developing Countries

    High fertility rate

    Lack of access to good antenatal and delivery care and support

    Absence of antiretroviral drugs/therapy


    Historical background

    Historical Background

    Over the years prolongation of life with availability of better treatment options among HIV patients have been achieved.

    PMTCT has become an effective part of Obstetric practice in HIV/AIDS care

    Emerging issues then include:

    Integration of HIV prevention and care into other RH programmes

    Contraception, Fertility desires, options and management is an important component.


    Previous policy

    Previous Policy

    Initially, the Centers for Disease Control and Prevention (CDC - 1985) encouraged HIV-infected women to defer pregnancy because of poor prognoses associated with HIV infection and the risk of perinatal transmission


    Previous policy1

    Previous Policy

    In 1987, the American College of Obstetrics and Gynecology (ACOG) advised physicians to encourage women infected with HIV NOT to become pregnant, and to inform pregnant HIV-infected women of termination options.

    The Ethics Committee of the American Society for Reproductive Medicine suggested in 1994 that physicians “counsel couples about the consequences of using potentially infected sperm and discuss the options of donor sperm, adoption, or not having children.


    A ray of hope

    A ray of HOPE

    The introduction of potent ARV (HAART) in the last decades has changed both the decisions & discussions about HIV infection generally.

    People infected with human immunodeficiency virus (HIV) are living longer and experiencing improved health.

    Also, physicians now view HIV infection as a manageable chronic illness and encourage patients to maintain normal lives


    Current situation

    Current Situation

    In 2001, the CDCamended its previous recommendations, stating that HIV-infected pregnant women should receive information about all reproductive options and that reproductive counseling should be nondirective and supportive of the patient’s decision.

    Currently ACOG now states that “assisted reproductive technologies should not be denied to HIV-infected couples solely on the basis of their positive HIV serostatus.”


    Conception issues

    Conception issues

    Women with HIV are similar to non-HIV infected women in what influences their desire to get pregnant

    Among those desiring children,

    69% of women

    59% of men

    Desired to have children in the future

    Women’s desire for children is more affected by personal health status vs. men’s

    Sowell RL et al. AIDS Care. 2002;14(2):181-191


    Importance of getting pregnant

    Importance of getting pregnant

    83.2% (74.7% M; 90.7% F) believed it is very important to have own biological child.

    Reasons:

    Low parity (57.5% parity ≤ 2)

    To continue family name

    Availability of better treatment

    Having a HIV negative baby from previous pregnancy

    Less stigmatisation


    Preconception care

    PRECONCEPTION CARE

    A specialized form of care for women of reproductive age group before the onset of pregnancy, to detect ,treat or counsel them about preexisting medical and social conditions that may militate against safe motherhood and the delivery of a healthy offspring.

    It is a component of comprehensive maternity care– PrCC, ANC, IntraPC, and PNC

    AIM: TO IMPROVE THE PROSPECT OF SAFE MOTHERHOOD


    Objectives of preconception care

    Objectives of Preconception Care

    • Avoidance of maternal exposure to teratogens during fetal organogenesis

    • Checking basic measurements e.g BP, Weight before conception

    • Introduction of intending mothers to social and medical interventions at a time they can have maximal effect on the outcome of pregnancy


    National pmtct programme1

    National PMTCT Programme

    Goal

    • To contribute to improved maternal health and child survival through accelerated provision of comprehensive PMTCT services

      Targets

    • At least 50% reduction in HIV incidence among 15-49yr old women by 2015

    • At least 90% of all pregnant women have access to quality HIV counseling and testing by 2015

    • At least 90% reduction in unmet need for Family Planning among women with HIV by 2015


    General principles

    General Principles

    • Combination regimens are more effective than single or double drug regimens.

    • Combination Highly Active Antiretroviral Therapy is standard of care for treatment of maternal HIV infection and prevention of mother to child transmission of HIV.

    • Pregnancy in the HIV positive woman is an indication for prophylactic ART irrespective of CD4 count, viral load or clinical stage of the disease.

    • All efforts should be made to ensure that all HIV positive pregnant women have access to ART.


    General principles ii

    General Principles (II)

    • All patients placed on ART should be monitored clinically, biochemically and immunologically.

    • Pre-treatment evaluation should include:

      • Complete history and physical examination.

      • Checking laboratory parameters (FBC/ESR, FBS, LFT, E&U, Serum lipids, CD4 count and viral load).

      • WHO clinical and immunological staging of the client.

      • Ensuring availability of supportive measures (nutritional and psychosocial).

      • Patient-specific adherence strategy

    • If facility for CD4count is not available, the client should be referred or client’s specimen sent to the nearest centre with such facility.

    • Where the patient is on AZT only for prophylaxis, the minimum tests to be done will include HB /PCV, CD4 count and urinalysis.


    Prevention of mother to child transmission a panacea for an hiv free generation

    Specific PMTCT Interventions

    •HCT- HIV Counseling and Testing

    •Modification of Obstetrics practices

    •Administration of ARV prophylaxis to mother-child pair

    •HIV and Infant Feeding Counselling

    •Care and Support for HIV positive women and their families (PMTCT plus).


    Pmtct strategies

    PMTCT Strategies

    Primary prevention of HIV infection in women of reproductive age group and their partners.

    Prevention of unintended pregnancies among HIV positive women.

    Prevention of HIV transmission from HIV infected mothers to their unborn babies and infants.

    Care and support for HIV infected women, their infants and family members.


    Integrated health care delivery system

    INTEGRATED HEALTH CARE DELIVERY SYSTEM

    Integration-stems from the Latin verb integer i.e to complete

    Integrated-=organic part of a whole or reunited part of a whole

    Used to express the bringing together or merging of elements or components that were formerly separate

    It is a desire to understand the relationship of elements that constitute the entirety


    Integrated service delivery

    INTEGRATED SERVICE DELIVERY

    “The management and delivery of health services so that clients receive a continuum of preventive and curative services , according to their needs over time and across different levels of the health system.”

    Referrals and Linkages


    Prevention of mother to child transmission a panacea for an hiv free generation

    We need a comprehensive , integrated approach to service delivery. We need to fight fragmentation—

    Dr Margaret Chan

    WHO Director General (2007)


    Integrated health services

    INTEGRATED HEALTH SERVICES:

    A package of preventive and curative health interventions for a particular population group.

    Refers to multi-purpose service delivery points i.e a range of services for a catchment population is provided at one location.

    Achieving continuity of care over time i.e a life long care for chronic condition or a continuum of care between more specific stages in a person’s life cycle e.g ANC,PNC, Newborn and child care.

    Refer to the vertical integration of different levels of services. There is a well functioning procedures for referrals up and down the levels of the system, and between public and private providers.

    Refer to integrated policy- making and management which is organized to bring decisions and support functions across different parts of the health service.

    Mean working across sectors. It occurs when there are institutionalized mechanisms to enable cross-sectional funding, regulation and service delivery. E.g working with education services to develop effective school health promotion campaigns

    --NB: identify the most appropriate sector(s) to deal with a particular health issue and establish linkages with them.


    Comprehensive hiv aids service

    Comprehensive HIV/AIDS Service

    Provision of HIV prevention, treatment, care and support services through

    • VCCT--HCT

    • PMTCT

    • HOME BASED CARE

    • CLINICAL CARE

    • LABORATORY SUPPORT

    • SUPPORT GROUP

    • OVC


    Prevention of mother to child transmission a panacea for an hiv free generation

    Specific PMTCT Interventions

    •HCT- HIV Counseling and Testing

    •HIV and Infant Feeding Counselling

    •Modification of Obstetrics practices

    •Administration of ARV prophylaxis to mother-child pair

    •Care and Support for HIV positive women and their families (PMTCT plus).


    Essential commodites for pmtct programme

    Essential commodites for PMTCT Programme

    HIV test Kits/reagents

    IEC materials

    Consumables

    Antiretroviral drugs

    Drugs for opportunistic infections

    Starter packs for PEP

    Family planning commodities

    National PMTCT Guidelines


    Essential commodities for pmtct programme continue

    Essential commodities for PMTCT Programme-- continue

    Registers and forms for Monitoring and Evaluation

    Items for Universal precautions

    Supplies for cervical screening


    Oyo state

    OYO STATE

    • 5 State Hospitals

    • 27 General Hospitals

    • 351 Primary Health Centers

    • 166 Primary Health Clinics

    • 113 Rural Health Centers or Posts

      Most of the PLWHA can be reached if all these are involved in their treatment, care and support


    Prevention of mother to child transmission a panacea for an hiv free generation

    Meeting the needs of growing number of PLWHA, their care givers and their family members requires the collective effort of many facilities and organizations

    It also requires appropriate policies, supportive social attitude and community support system


    Number of service delivery points offering pmtct services

    Number of Service Delivery Points Offering PMTCT Services


    Community based pmtct

    COMMUNITY BASED PMTCT

    • Definition:

      Is the provision of PMTCT services by formal or informal caregivers outside the hospital or facility settings

      What is the need:

    • Most deliveries in Nigeria and sub-Saharan Africa occur in homes, churches etc; and attended by mothers, family relatives, TBA.

    • Studies in Nigeria have shown that home deliveries account for about 80% of deliveries in Nigeria. Although about 60-80% attend at least one ANC visit; only approximately 20-30% deliver in Hospitals.


    Community based pmtct1

    Community based PMTCT

    • There are low number of hospitals and maternity homes

    • Low coverage of PMTCT services (10%). Mostly in urban areas.

    • Predictors of home deliveries

      • Poor maternal education, multiparity, low socioeconomic status, distance from health facility, political instability, industrial strikes, poor attention at facilities etc


    Components of a community based pmtct

    Components of a community based PMTCT

    A strong facility based PMTCT

    Cultural accepted health based education programs

    Strong support group ( facility & community)

    Lay counselors ( Peer)

    Incorporation and training of retired midwives/nurses

    Incorporation and training of TBA

    Involvement of District , local government health Authorities

    CT as an important entry point for PMTCT

    Encourage the involvement of CBO, FBO, Traditional healers and Leaders


    Models for implementation

    Models for implementation

    • PMTCT facility networking to lower cadres of care (Network model)

    • Community programs using retired midwives, TBA

    • Community referral programs using Lay counselors, Chews,

    • PMTCT mobilization with retired midwives, TBA, Lay counselors, Chews,

      Potential areas for linkages

    • Health sector: Family planning; Safe motherhood, child survival, TB, Malaria

    • Other developmental linkages: education, food and nutrition, economic strengthening.


    Prevention of mother to child transmission a panacea for an hiv free generation

    ART

    PMTCT

    HCT

    Labs – CD4, FBC, Chemistry

    FP

    QC/QI

    HUB & SPOKE MODEL

    PHC

    PHC

    PHC

    Secondary

    Facility

    eg

    Onikan Health centre

    • Community

    • Prev. message

    • Treatment literacy

    • Treatment support

    • Adherence

    • Patient tracking

    • Comm. Based services

    • IEC

    • FP

    • BCK

    • Condoms

    • DOTS

    • Out reaches

    • BCC

    • Treatment message

    • HCT

    • Advocacy

    HCT

    PMTCT

    STI

    CXT

    BCK

    DOTS

    ?ART refills

    FP

    Multivitamins

    PHC

    PHC eg Irru


    Prevention of mother to child transmission a panacea for an hiv free generation

    ART

    PMTCT

    HCT

    Labs – CD4, FBC, Chemistry

    FP

    QC/QI

    HUB & SPOKE MODEL

    Molete, Mapo

    Ayeye

    Orieru, Ayeye

    Adeoyo Maternity

    Hospital, yemetu

    • Community

    • Prev. message

    • Treatment literacy

    • Treatment support

    • Adherence

    • Patient tracking

    • Comm. Based services

    • IEC

    • FP

    • BCK

    • Condoms

    • DOTS

    • Out reaches

    • BCC

    • Treatment message

    • HCT

    • Advocacy

    HCT

    PMTCT

    STI

    CXT

    BCK

    DOTS

    ?ART refills

    FP

    Multivitamins

    Oniyanrin

    Odo-ona


    Conclusion

    CONCLUSION

    Integrated health care service delivery will enhance and promote decentralization of HIV care, support and services .

    Comprehensive HIV/AIDS services at PHC level will bring services to where people live and enhance their ability to access services and adhere to care and treatment

    It is a key to the successful expansion of HIV services(PMTCT inclusive) for people living in the rural areas

    It will assist in decongesting hospitals where such services are typically delivered

    However, training and mentoring of health care providers with recruitment of staff are important in conjunction with a good referral systems and linkages

    Strong political support at all levels with appropriate policies is of paramount importance for the overall success of this laudable approach


    Conclusion1

    There is therefore the need for all stake holders in the country and at all level of government to maintain the earlier momentum of interventions so as to sustain the decline in prevalence earlier observed

    CONCLUSION


    Thank you

    THANK YOU………

    ………..WITH LOVE, FROM MOTHER TO CHILD.


    Prevention of mother to child transmission a panacea for an hiv free generation

    Thank you


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