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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

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
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%)
slide10

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)
slide12

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%)
slide18

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 !

slide19

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

slide20

National HIV and Syphilis

Prevalence Survey 2006

30.2

29.5

29.1

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%”
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
slide27

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!

slide28

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

slide30

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

slide31

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 ?

slide32

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
slide36

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

slide37

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
slide43

What are we aiming for ?

95 % HIV Negative Babies

5%

Infected

slide44

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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