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Integration of Reproductive Health into VCT Centers: A Strategic Intervention for HIV Prevention

Integration of Reproductive Health into VCT Centers: A Strategic Intervention for HIV Prevention. A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004 Marie Marcelle Deschamps, MD. Background.

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Integration of Reproductive Health into VCT Centers: A Strategic Intervention for HIV Prevention

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  1. Integration of Reproductive Health into VCT Centers: A Strategic Intervention for HIV Prevention A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004 Marie Marcelle Deschamps, MD

  2. Background • Haiti is the most affected country by HIV after those in Sub-Saharan Africa. • Heterosexual contact is the major mode of transmission with a male to female ratio of 1:1. • It is estimated that there are up to 235,000 adults between the ages of 15-49 and as many as 11,800 children are living with HIV/AIDS. • Approximately 3% of the women visiting prenatal clinics are HIV (+) and as much as 6% are HIV (+) in the northern region of the country.

  3. Background (continue) • Maternal mortality rate: 457/100,000 • Infant mortality rate: 74/1,000 • 20% infant mortality caused by AIDS • Majority (80%) of women deliver outside a health care setting • HIV vertical transmission rate estimate at 30% in Haiti

  4. Before 1996 Counseling unit HIV unit STD unit TB unit Pediatric unit Laboratory Data Management After 1996 IEC FP methods Prenatal care/Rapid testing Women’s clinic (HIV+ mother/rape victims) GHESKIO Centers have developed a comprehensive model of integrated care for VCT and services (HIV/STI/TB/RH).

  5. Integration of Reproductive Health at GHESKIO CentersCharacteristics

  6. Objectives: • To integrate RH services and family planning methods (FP) into the existing health facilities (STI/HIV/TB clinic). • To reinforce knowledge and encourage behavior change among HIV/STI infected individuals and those at risk. • To provide adequate VCT services to individuals of reproductive age, using rapid testing for pregnant women. • To offer care and anti-retroviral therapy to HIV/STI infected pregnant women.

  7. Strategy Information/Education/Communication (IEC) and Counseling • Waiting room using educational and audio visual materials • Information sessions and discussions with social workers on HIV/AIDS/TB/STI/FP adressed to all patients • Group counseling targeting HIV(+) individuals • Focus group targeting HIV(+) pregnant women • Face to face counseling with HIV (+) and partners • Focus group targeting HIV(+) mother/parents

  8. Strategy (continued) • Family Planning Program addressing HIV infected individuals and partners • Information on vertical transmission • Information on FP methods • Condom distribution • Availability of FP methods

  9. HIV status of family planning users at GHESKIO

  10. FP Methods Available at GHESKIO • Condom • Depo-provera • Eugynon • Lo-femenal • Noristerat • Ovrette • Vaginal Tab

  11. ResultsFP Methods Available at GHESKIO Most commonly used methods • Condom : 70% • Depo Provera (injection) : 23% • Other : 7% Dual protection is recommended to all HIV infected individuals or HIV (-) individuals at risk or discordant couples

  12. Contraceptive prevalenceJanuary 1996 – December 2003 Number of users

  13. New individuals of childbearing age (15 – 50 years old) referred to GHESKIO for VCT

  14. ResultsPopulation referred for HIV testingMarch 1999 – December 2003

  15. New pregnant women tested at GHESKIO for HIV

  16. Characteristics of Pregnant Women Referred for VCT

  17. Antenatal Clinic at GHESKIO • Enroll HIV (+) pregnant women in the MTCT prevention program after post-test counseling • Use standardized protocol with a specific team approach (psycholoigist, physician, social worker, nurse) • Provide routine check-ups for prenatal care every month including immunization, iron and vitamins • Prevent and treat specific HIV-related infections • Provide routine laboratory testing • AZT or Nevirapine for women with CD4 cell count >200 • HAART to women with CD4 cell count <200

  18. Psychosocial care objective • Same day pre and post test counseling • Offer emotional support to the HIV (+) women • Maintain adherence to AZT/ARV • Offer the choice for infant feeding (breast vs artificial milk) • Encourage special precautions regarding preparation of milk • Propose Family Planning methods to the mothers • Face to face counseling and support group meeting • Consent form

  19. Mother Prenatal follow-up AZT: 300 mg bid at 8th month (36th week) AZT: 300 mg every 3 hrs during labor Infant AZT: 2 mg/kg q 6 hrs during 1 week Mixed diet not advisable* PCIME** during the 24 months of follow-up Protocol *The mother may breastfeed or give artificial milk, a mixed diet is not advised. Early warning (at least 6 months after birth) is recommended ** Prise en charge intégrée des maladies de l’enfant

  20. Regimen Protocol Prevention of HIV Transmission from Mother to Infantwith Nevirapine Monotherapy N.B: The mother may choose between breastfeeding or artificial milk, a mixed diet is not advised

  21. Women with 2nd Episode of PregnancyN= 23 Number (%) 4 (17) : New partner 10 (43) : Not on Family Planning 2 (9) : Was using Family Planning irregularly 7 (30) : Child died

  22. Rate of Mother to Child TransmissionMarch 1999 – December 2002 There were 190 children born in the program • Confirmed rate by NASBA 10/132 children with results: 7.5% • Assumed rate and clinical signs 28/190 (14.7%) • Estimated range of vertical transmission 7.5% - 14.7%

  23. Summary • Increase in the contraceptive prevalence rate at GHESKIO from 4% to 21% • Increase number of pregnant women using VCT services, from 51 (1999) to 1,800 (2003) • Reduction of the (MTCT) rate from 30% to 10% • Majority (64%) of HIV(+) mothers from MTCT program adopted a FP method to prevent subsequent unwanted pregnancies • This model of integration (VCT/MTCT) is being replicated nationwide involving public and private sectors

  24. Conclusion • Reproductive health service is critical entry point for HIV prevention and diagnosis and treatment of HIV-infected individuals • Family planning methods are essential components of services at VCT as individuals who receive information, counseling and treatment are more likely to avoid unwanted pregnancies, and HIV transmission. • Dual FP method is strongly recommended as it can reduce heterosexual transmission and MTCT. • VCT/MTCT integration has resulted in a dramatic increase in the number of self-referred pregnant women coming for services.

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