The new doh pmtct policy challenges and opportunities
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The New DOH PMTCT Policy Challenges and Opportunities. A H Coovadia ECHO Enhancing Childhood HIV Outcomes Department of Paediatrics and Child Health Coronation Women and Children Hospital University of The Witwatersrand. Overview. PMTCT - Background The Old PMTCT Policy

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The New DOH PMTCT Policy Challenges and Opportunities

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The new doh pmtct policy challenges and opportunities

The New DOH PMTCTPolicyChallenges and Opportunities

A H Coovadia

ECHO

Enhancing Childhood HIV Outcomes

Department of Paediatrics and Child Health

Coronation Women and Children Hospital

University of The Witwatersrand


Overview

Overview

  • PMTCT - Background

  • The Old PMTCT Policy

  • Where are we with PMTCT today ?

  • The NSP (2007-2011)

  • The New Revised PMTCT Policy

  • PMTCT – The ‘Gateway Programme’

  • Challenges and Opportunities


Background

Background

  • 55% of all HIV-1 positive adults are women of child bearing age.

  • Seroprevalence rates among pregnant women exceeds 30% in many urban populations in sub-Saharan Africa


Mtct rates

MTCT Rates

  • ~10 - 30% in non-breastfeeding population of HIV-1 positive women in more developed countries

  • 25 -45% in breast-feeding populations in Africa


The new doh pmtct policy challenges and opportunities

Timing of transmission in Non breast-feeding


The new doh pmtct policy challenges and opportunities

Timing of transmission Breastfeeding


Risk factors for mother to child transmission

Risk Factors for Mother-to-child-transmission

  • High maternal viral load

  • Low maternal CD4 count

  • Vaginal delivery

  • Premature rupture of membranes

  • Breast milk


Risk factors for mother to child transmission1

Risk Factors for Mother-to-child-transmission

  • chorioamnionitis

  • low birth weight of the baby

  • the first twin born

  • unprotected intercourse with an HIV-infected partner

  • IV drug abuse

  • STI’s


History of pmtct and arv interventions

History of PMTCT and ARV interventions

  • ACTG 076

    • 1994, AZT to mother from 2nd trimester, IV during labour and delivery, 6 weeks to infant; transmission reduced from 25%-8%

  • Shorter course therapies sought

    • Thai regimen

    • PETRA

  • HIVNET 012

    • Nevirapine one dose to mother and one dose to baby (transmission reduced to 13%)


  • The new doh pmtct policy challenges and opportunities

    PACTG 076

    USPHS AZT

    Recommendations

    80% decline

    Number of cases


    What did we know and when did we know it perinatal hiv clinical trial results

    What did we know and when did we know it? Perinatal HIV Clinical Trial Results

    1994

    2004

    • 1994 U.S. AZT Trial ACTG 076

    • 67% reduction in transmission

    • 2004 ThailandPHPT

    • 1.9% AZT + NVP

    • 1998 Thai Bangkok short AP/IP AZT trial

    • 50% reduction in transmission

    • 2003 DITRAME + 1201.1

    • 4.7% TR with AZT/3TC & IP/PP NVP

    • 1998 Cote d‘Ivoire short AP/IP AZT trials

    • 37% reduction in transmission (breastfeeding)

    • 2002 Cote d’Ivoire DITRAME +

    • 6.2% TR with AZT & IP/PP NVP

    • 2000 ThailandLong vs short AZT regimens

    • 4% TR in LL (non BF)

    • 1999 PETRA AZT/3TC trial (6 wk results)

    • 50% reduction with longest arm.

    • 38% reduction with the IP/PP arm

    • 1999 Uganda 2-dose IP/PP NVP trial (HIVNET 012)

    • 47% reduction in transmission (breastfeeding)


    The new doh pmtct policy challenges and opportunities

    PMTCT: The four-pronged strategy

    • Primary prevention of HIV in parents-to-be

    • Prevention of unwanted pregnancies

    • Prevention of transmission from HIV-infected mother to infant

    • Appropriate treatment and care


    Sa pmtct programme 2001 2007

    SA pMTCT Programme2001 - 2007

    • Nevirapine as single dose (sd) administration

    • Dose= 1 tablet to mum at onset of labour and a dose to baby within 72 hours after birth

    • Provision of infant formula for six months to mothers choosing this option.

    • NVP prevents MTCT by ~50% (Transmission Rates of approximately 10%)


    The new doh pmtct policy challenges and opportunities

    Non-pregnancy related infections mainly

    HIV, TB and Pneumonia were the leading

    cause of death in 38% of women

    However probably an underestimate as

    only 46% of women who died were

    tested for HIV, and 78% of those tested

    were HIV positive

    PMTCT is an opportunity to save the

    lives of mothers

    and not only babies !


    The new doh pmtct policy challenges and opportunities

    National Antenatal Testing Rate was 75%

    compared with 45% (2005/6)

    HIV prevalence rate amongst ANC attendees = 29%

    Compared with 30.2% (2005/6)

    Percentage of Women receiving Nevirapine was 61%

    Compared with 52% (2005/6)

    Percentage of Babies receiving Nevirapine was 45%

    Lower than 2005/6 BUT more likely reflecting better quality data


    The new doh pmtct policy challenges and opportunities

    National HIV and Syphilis

    Prevalence Survey 2006

    30.2

    29.5

    29.1


    The national strategic plan 2007 2011

    The National Strategic Plan2007 - 2011


    Nsp goals

    NSP Goals

    KEY Priority Area 1 – PREVENTION

    Reduce the rate of new infections by 50% by 2011

    • Section 3 of the Key Priority area 1

    • 3.1 Broaden existing mother to child transmission services to include other related services and target groups

      • 3.2 Scale up coverage and improve quality of PMTCT to reduce MTCT to less than 5%”


    Nsp targets

    NSP Targets


    The new revised pmtct policy 2008

    The New Revised PMTCT Policy2008

    • ‘Routine offer of VCT’ (Provider Initiated)

    • Addition of AZT (Dual Therapy)

    • Emphasis on getting CD4 counts on all pregnant women to start HAART in pregnancy (CD4 < 200 OR WHO stage 4)

    • Infant Feeding Options – better guidance

    • Emphasis on infant diagnosis at 6 weeks


    Sa pmtct programme 2008 dual therapy

    SA pMTCT Programme2008 DUAL THERAPY

    • Women who need ARVs – get put onto this ASAP (CD4 count less than 200)

      FOR WOMEN WITH CD4 COUNTS ABOVE 200 OR IF NOT YET ON ARVs (I.E ALL WOMEN)

    • Mother - AZT during pregnancy from 28 weeks gestation + single tablet Nevirapine in Labour

    • Baby – Single dose Nevirapine + AZT for 7 days (and in some cases upto 28 days)

    • Able to reduce MTCT to 5% with new policy !


    Azt to baby for 4 weeks if

    AZT TO BABY FOR 4 WEEKS IF:

    • Mother received no PMTCT

    • Mother received only nevirapine for PMTCT

    • Less than 4 weeks of AZT/HAART taken by mother

    • Mother diagnosed for the first time in labour or postpartum – AZT to baby best given within 12 hours of birth


    The new doh pmtct policy challenges and opportunities

    Mother to Child Transmission

    One out of four babies (25%) born to all HIV positive mothers will acquire HIV from their mother ( if no intervention is offered )

    That means at least 75% of babies are uninfected at birth!


    The new doh pmtct policy challenges and opportunities

    PMTCT RATES

    Of all HIV Infected Women

    95 % HIV Negative Babies !

    75 % HIV Negative Babies

    25 % HIV Infected Babies

    Where no intervention

    Old policy

    Sd NVP

    10% Infected

    5%

    Infected

    New policy

    AZT +

    Sd NVP


    First step testing

    First StepTesting

    Testing


    The new doh pmtct policy challenges and opportunities

    SCREENING HIV TEST

    SCREENING

    POSITIVE

    SCREENING

    NEGATIVE

    CONFIRMATORY HIV TEST

    NEGATIVE

    CONFIRMATORY

    POSITIVE

    CONFIRMATORY

    NEGATIVE

    REPEAT TEST AT AROUND

    34 WEEKS

    FINAL RESULT

    POSITIVE

    INDETERMINATE

    SEND FOR HIV ELISA

    INDETERMINATE ELISA

    SEND FOR HIV DNA PCR (diagnostic PCR)

    POSITIVE / NEGATIVE ELISA

    FINAL RESULT


    The new doh pmtct policy challenges and opportunities

    Management of HIV infected Pregnant Woman

    First Visit (WHO stage I-III)

    If 28 wks or more

    Hb ≥8g/dl

    StartAZT

    300mg BD

    If < 28 weeks

    Or

    Hb <8g/dl

    Do NOT Start AZT

    Hb

    CD4

    Gestation

    Week ?


    The new doh pmtct policy challenges and opportunities

    Assessment of HIV infected Pregnant Woman

    Second Visit

    CD4 < 200

    OR

    WHO Stage IV

    CD4

    WHO

    Stage

    CD4 > 200

    OR

    WHO Stage I-III

    HAART

    If previously on AZT

    Switch to 3TC/d4T/NVP

    PMTCT Regimen

    If ≥ 28weeks

    AZT until Delivery


    Labour and delivery

    LABOUR AND DELIVERY

    • At onset of labour, woman to take 600mg AZT (2 tablets) stat plus 200mg sd (1 tablet) nevirapine.

    • If Nevirapine already taken previously with false labour, do not repeat nevirapine dose and neonate receives standard post exposure prophylaxis.

    • Continue AZT 300mg 12 hourly at the usual times until the neonate is delivered.

    • Mother on HAART, continue treatment as usual during labour.


    Postnatal care

    POSTNATAL CARE

    Baby: Nevirapine 0.6 ml as soon as possible after delivery (under 2.5kg give 0.2ml/kg),

    plus

    AZT 4mg/kg 12 hourly for 7 days or 28 days

    (premature <35 weeks 2mg/kg)

    • Above the same for women on AZT or on HAART

    • Enquire about feeding options from the mother


    Babies requiring 28 days of azt

    Babies Requiring 28 days ofAZT

    • Where mother had no ARVS at all during antenatal period or labour i.e unbooked

    • Mother had < 4 weeks of AZT or

    • Mother had < 4 weeks of HAART

    • Mother received only sd NVP


    The new doh pmtct policy challenges and opportunities

    What about the women testing Negative ?

    Repeat HIV testing at or around 34 weeks of gestation

    About 5% of women will seroconvert during pregnancy

    HIV NEG ----------------- HIV POS


    The new doh pmtct policy challenges and opportunities

    What about the women who haven’t been tested ?

    Postnatal Ward

    Labour Ward

    No women should leave a healthcare facility without being

    offered an HIV test.

    Not doing so is tantamount to being negligent

    Remember too our responsibility to both mother and the child


    Challenges to success of the programme

    Challenges to Success of the Programme

    • Political leadership

    • Testing rates below target

    • Adequacy of human resources (e.g trained counsellors)

    • Information transfer between facilities.

    • Stigma

    • Drug supply – NVP + AZT (no stock outs)

    • No widespread campaign explaining benefits of programme

    • Lack of integration with other services such as family planning/CCMT/EPI

    • Community and NGO involvement largely lacking

    • Not seen as priority programme by healthcare facilities that have other competing demands

    • Public sector focussed rather than larger public health concern, where only addressing attendees to the public health service


    Which services need integration

    Which Services need integration ?

    • VCT – Family Planning

    • VCT – PMTCT

    • PMTCT – CCMT (ARV sites)

    • PMTCT – Infant Diagnosis and Follow up (IDFU)

    • Infant Diagnosis and Paediatric ARV site

    • EPI – IDFU

    • TB - CCMT

    • STI - CCMT


    Meeting the challenges

    Meeting the challenges

    • Political Commitment

    • Increase effective coverage - PMTCT programme in 100% of healthcare facilities providing ANC

    • Testing strategy needs revisiting – Provider initiated TC

    • Adequate staffing with role clarification and systems improvement to enable better coverage of all women.

    • Prioritization of programme within healthcare facility. All staff at facilities must understand importance of the programme.

    • Programme leadership with dedicated and responsible team who monitor progress in on-going manner i.e M&E at local level.

    • Integration of PMTCT with CCMT services to enable smooth transfer of patients needing treatment

    • Community education and involvement in getting testing rates up.

    • Mass media and educational campaigns to raise awareness of the programme and it’s benefits.

    • INFANTS - Need to ensure that ALL HIV exposed infants reap the benefits of an enhanced PMTCT programme, which would include

      • Abandoned infants (upto 50% have been noted to have had HIV exposure)

      • Infants whose mothers are indisposed – death, coma, serious post-partum illness, mental confusion

      • Infants whose mothers refuse testing -

      • Infants whose mothers refuse any intervention despite knowing their status


    Opportunities

    Opportunities

    • Improve overall maternal antenatal care and outcomes

      • Through training on basic ANC

      • Reduction in maternal mortality (NCCEMD)

      • Improvement in basic infrastructure/equipment

    • Improve HIV testing rates amongst adults (women and men)

    • Expedited entry onto ARVs for women with low CD4 counts

    • Increasing access points for ARVs for patients

    • Drastically reducing numbers of infected infants

    • Establishing follow up for infants with early diagnosis and treatment if needed

    • Decreasing orphanhood


    Pmtct the gateway programme

    PMTCT‘The Gateway Programme’

    • Thesaurus

      • Entry

      • Opening

      • Access

      • First step

      • Opportunity

      • Chance

    • Longman Dictionary

      • An opening in a fence or way etc, across which a gate may be put

      • A way of finding e.g Hardwork is the gateway to success


    The new doh pmtct policy challenges and opportunities

    What are we aiming for ?

    95 % HIV Negative Babies

    5%

    Infected


    The new doh pmtct policy challenges and opportunities

    Decrease number of infected Women

    In SA

    Early Identification

    Of Sick Women

    Decrease

    number

    of infected

    Children

    In SA

    PMTCT

    95% HIV negatives

    Decrease morbidity

    And mortality in HIV

    infected Women in

    SA

    +ves

    Early Identification

    Of all infected infants

    Decrease morbidity

    And mortality in HIV

    infected Children in

    SA

    Early initiation of HAART

    in infants


    References

    References

    • SA National DOH PMTCT Policy (2008)

    • District Health Barometer (HST 2006/7)

    • Every Death Counts Report

    • Lancet – Every Death Counts

      Would like to thank Prof James McIntyre for use of some slides.

      [email protected]


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