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AIHA’s Pilot Project in Odessa: A Comprehensive MTCT Prevention and Intervention Program Zoya Shabarova zoya@dds.nl James Smith American International Health Alliance jim@aiha.com. Understand the main components of comprehensive mother-to-child HIV transmission prevention (pMTCT) program

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AIHA’s Pilot Project in Odessa: A Comprehensive MTCT Prevention and Intervention ProgramZoya Shabarovazoya@dds.nlJames SmithAmerican International Health Alliancejim@aiha.com

educational objectives
Understand the main components of comprehensive mother-to-child HIV transmission prevention (pMTCT) program

Learn about the implementation of effective comprehensive pMTCT program in the health care setting with limited resources in the region with concentrated stage of HIV/AIDS epidemic (Ukraine)

Understand how to apply “hospital twinning” and “medical volunteer” methodology to pMTCT project

Learn about a pilot project that can be used as a teaching laboratory to implement systemic change

Educational Objectives
strategic framework to prevent hiv in infants and young children
All women  prevent HIV infection (level 1)

HIV+ women  prevent unintended pregnancy (level 2)

HIV+ women  prevent MTCT (level 3)

HIV+ women, their infant and family  provide care and support (level 4)

Source: Prevention of HIV in infants and young children. Review of evidence and

WHO’s activities. WHO/HIV/2002/08

Strategic Framework to Prevent HIV in Infants and Young Children
odessa strategic framework to prevent hiv in infants and young children
“+pMTCT+”

First “Plus”: prevention of HIV among women of reproductive age

pMTCT: Prevention of mother-to-child transmission of HIV

End “Plus”: Follow up care and support for families

Odessa Strategic Framework to Prevent HIV in Infants and Young Children
timing and risk of transmission
Tr. Rate

During pregnancy 5-10%

During labor and delivery 10-20%

During breastfeeding 5-20%

Overall without breastfeeding 15-30%

Overall with breastfeeding till 6 months 25-35%

Overall with breastfeeding till 18 to 24 months 30-45%

*Source: de Cock, JAMA (2000)

Timing and Risk of Transmission*
main components of pmtct level 3
Prenatal voluntary counseling and testing (VCT)

Prophylactic antiretroviral (ARV) regimens

Safer delivery practices

Infant feeding counseling and support

Main Components of pMTCT (Level 3)
prenatal voluntary counseling and testing
VCT – the entry point for HIV prevention and care

HIV testing must be done with informed consent of the woman, using reliable laboratory tests and ensuring confidentiality (basic requirements)

Availability of efficient referral system to other services (Family planning, STI treatment, MCH, MTCT, etc.)

Choice of most appropriate and feasible model of VCT (individual, group)

Prenatal Voluntary Counseling and Testing
coordination of usaid donor and inter donor efforts in odessa
USAID Donors

JHPIEGO Family Planning Trainings including counseling component 1997-8, Odessa Oblast Hospital

AIHA Consultation Training and Pre- and Post HIV Testing Counseling workshop, May 2002, Kiev. Attended by all AIHA WWCs and PHCs including OOH

PATH VCT training, June 2002, Odessa

Inter-Donor

MSF: Provide Nevirapine, infant formula, C-section delivery kits for OOH and develop laboratory capacity

UNICEF: Developed training materials on pMTCT in collaboration with OSMU and OOH

Coordination of USAID Donor and Inter-Donor Efforts in Odessa
prophylactic antiretroviral regimen
Ante- and intra-partum regimen: reduce viral load in mothers’ blood and genital fluids during pregnancy, labor and delivery

Post-partum regimen: act as post-exposure prophylaxis (viral particles eventually transmitted during birth are eliminated)

Main regimens (see handout “Use of antiretroviral regimens for MTCT prevention”)

Prophylactic Antiretroviral Regimen
safer delivery practices
Planned, hemostatic C-section

Avoidance of unnecessary invasive procedures (episiotomy, rupture of membranes, forceps, etc.): reduce infant contact with mothers infected blood and genital fluids.

Birth canal cleansing with chlorhexidine

Safer Delivery Practices
infant feeding the ukrainian context
Avoidance of breastfeeding eliminates HIV transmission through breast milk, but carries other risks (infections other than HIV, malnutrition)

Counseling: information about the risks and benefits of various infant feeding options, guidance in selecting the most suitable option for their situation.

Infant Feeding: the Ukrainian Context
pmtct follow up care of women and infants
Comprehensive care for women:

Primary and HIV specialty care

OB/GYN and family planning services

Mental health and substance abuse treatment as needed

Coordination of care for entire family

Support services

Follow-up for Infants:

HIV diagnostic testing to determine HIV status

Referral to an HIV specialist

PCP prophylaxis initiated at 6 weeks of age

Long term follow-up of HIV-exposed infants

Support services for entire family

pMTCT+: Follow-up Care of Women and Infants
ukraine hiv profile
Ukraine – epicenter of the HIV/AIDS epidemic in Eastern Europe and Central Asia. In Eastern Europe and Eurasia HIV is growing faster than anywhere else in the world (UNAIDS, 2002)

Concentrated stage of HIV/AIDS epidemic (USAID, UNAIDS, WHO classification, 2000) – HIV prevalence rate: adults -1% (2001); male STI patients – 13.3% (1996); IDUs – 8.6% (1998)*, pregnant women – 0.22% (2001)**

*Report on the Global HIV/AIDS Epidemic, July 2002, UNAIDS

** Ukrainian AIDS Prevention Center

Ukraine HIV Profile
ukrainian context for mtct strategy
Prenatal HIV screening is widely available

Prenatal, perinatal and postnatal coverage is almost universal

High percentage of HIV+ women are IDUs; high percentage of infants are born addicted to drugs

Replacement feeding can be carried out by HIV infected mothers without major risks and obstacles

Because numbers of identified HIV infected women is still limited, it is still affordable to provide pMTCT interventions

The current, relatively low number of MTCT cases provides a window of opportunity to prepare the health care system to cope with the emerging problem

Ukrainian Context for MTCT Strategy
aiha mtct pilot project goals
Reduce the incidence of HIV in women of reproductive age (+pMTCT)

Prevention of MTCT during pregnancy, delivery and postpartum (pMTCT)

Provide follow up care and support to infants, mothers and families to ensure that children born to HIV+ mothers grow up in a sustainable, nurturing environment (pMTCT+)

Prevent occupational exposure to HIV among healthcare workers

Create a model that is adaptable to other cities and a teaching laboratory to facilitate dissemination and replication (scaling up)

AIHA MTCT Pilot Project Goals
project history
Pre-project background: Active AIHA partnerships in Odessa (IC, WWC, NRP, PHC) developing long-term relationship with Odessa Oblast Hospital (OOH) and Odessa State Medical University (OSMU)

Fall 2000: Identification of Odessa, Ukraine as MTCT project site (hot spot for region) to be a replicable model for change in Ukraine

February 2001: Key Ukrainian participants attend 8th Conference on Retroviruses and Opportunistic Infections in Chicago

Spring 2001: Collaboration scheme developed with Medicins sans Frontieres (MSF)

Spring 2001: Development of workplan, training needs identified (role of AIHA partnership)

March - August 2001: Cooperation with Cook County Hospital, Chicago

September 2001 – present: Collaboration with Denver Health Medical Center,University of Colorado Health Sciences Center, Children’s Hospital of Denver, Boulder Community Hospital (“hospital twinning” and “medical volunteer”)

August 2001 to present: AIHA project team collects data, performs monitoring, develops materials for dissemination, conducts clinical training

Project History
main components of aiha s odessa pilot project
Develop a comprehensive strategy and establish widespread community support for key components

Creation of a “center of excellence” at a designated healthcare facility (OOH)

Restructuring of health care delivery system: effective communication and referral system between health institutions, effective allocation of limited resources

Development and implementation ofrelevant, evidence-based protocols, practical guides, informational brochures, and patient charts among others

Training of healthcare professionals

Assure high quality of care at designated health care facility (OOH)

Provision (including substantial donations) of essential medical equipment and supplies

Coordination of activities with other donor organizations (MSF, UNICEF, PATH) and NGOs

Main Components of AIHA’s Odessa Pilot Project
project milestones
A catalogue of reference documents was developed (practical guides for healthcare workers, patient’s charts, and patient education materials).

A clinical training program was initiated in Denver in April 2002.

MTCT supplies and equipment were delivered to the Odessa Oblast Hospital.

A Monitoring and Evaluation database was developed, data entry is in progress; preliminary results are available.

A MTCT training course curriculum was developed and approved by the Odessa Oblast Health Administration.

Odessa Oblast Health Administration issued an order requesting HCWs from all women's consultations in Odessa to participate in the MTCT training course. Developed a patient flowchart and redesigned the referral system for MTCT.

Odessa Oblast Health Administration issued an order in May 2002 that all HIV-positive pregnant women be referred for prenatal care to the Odessa WWC and for delivery to OOH

Five abstracts based on project results were published in the XIV International AIDS Conference abstract book, six articles were published in the special volume containing the extended versions of the conference abstracts and five posters were presented at the conference.

Project Milestones
fy03 workplan
Improve the system of follow up care for women with HIV and babies born to HIV infected women in cooperation with UNICEF/Kiev and MSF/Kiev

Enhance the HIV ELIZA testing capabilities at OOH lab to provide primary HIV testing for pregnant women

Strengthen the nursing component of healthcare delivery to HIV+ pregnant women, their infants and families

Develop consecutive and interactive pMTCT management model of primary prevention, prenatal, delivery, postnatal care, infant preventive care and monitoring, including follow up care for families with HIV

Improve the health care of HIV infected women who are IDUs and their babies

Initiate cross-border collaboration on pMTCT (Constanta, Romania)

FY03 Workplan
incidence of babies born to hiv mothers at odessa oblast hospital
Incidence of Babies Born to HIV+ Mothers at Odessa Oblast Hospital

*represents first nine months of 2002

** represents projection for 2002 (Jan-Dec)

preliminary project results

HIV test result availa-

ble before delivery

ARV therapy (mother and baby)

C-section

Episiotomy (vag. del.)

Birth canal cleansing

Formula feeding

MTCT

Rate*

Baseline group (1997-99)

56%

2%

10%

20%

75%

97%

24%

MTCT group (2001-present)

100%

100%

50%

10%

95%

100%

12%

Preliminary Project Results

*HIV status of all babies are verified by HIV PCR tests/ELISA and WB tests

mtct practical guides
Purpose: Provide improved practice guidelines for OB/GYNS,

neonatalogists, pediatricians, family physicians, nurses, midwives, social

workers, microbiologists and lab technicians on various aspects of treating

HIV+ patients.

Prevention and Treatment of STIs

Treatment of STIs in HIV+ Pregnant Women

Infection Control Practices

Voluntary Counseling and Testing

Lab Testing

Prenatal Care for HIV+ Women

Prevention of MTCT During Delivery

Pediatric Care for Infants Born to HIV+ Mothers

Primary Health Care for HIV+ Patients

Family Planning

Infant Feeding

MTCT Practical Guides
other mtct products for dissemination
1. Questionnaires

Purpose: Assess knowledge of HIV/AIDS and MTCT of healthcare

workers in maternity houses and pediatric settings. Questionnaires have also

been developed for parents and guardians of children born to HIV infected

Mothers and for HIV+ pregnant women

2. Information Packages

Purpose: Disseminate information among women of reproductive age and HIV+

women on HIV prevention, pregnancy and HIV testing, HIV, newborn and infant

care

3. Patient Charts

Purpose: Collect and maintain information about HIV infected women and

infants

Other MTCT Products for Dissemination
integration of pmtct into the mch system
Integration of pMTCT into the MCH System

MCH schedule

PMTCT interventions

Prenatal visit 1

HIV/STD counseling

HIV testing, STI screening

Anemia prevention

Prenatal visit 2

Confirmation of HIV+, post-test counseling

STI treatment

ARV treatment counseling

Infant feeding counseling

Prenatal visit 3

Initiation of ARV treatment

Individual counseling

Labor/Delivery

Intrapartum ARV component

Avoidance of unnecessary invasive procedures

Universal precautions

Postpartum

ARV treatment for infant (if needed)

Support for infant feeding

Family planning counseling

Referral to support groups

Infant follow up

Growth and development monitoring

Nutritional and infant feeding counseling

Infections prevention/treatment

Possible vaccination

HIV screening schedule

HIV testing of baby

Referral for pediatric care if baby is HIV+

national and regional support for pmtct activities
Ministry of Health: Support for project activities and possibility of implementing pilot project in other sites across the country

Odessa Oblast Health Administration: Support for restructuring the referral system, facilitating communication between healthcare institutions that provide care to HIV+ patients, healthcare worker training and allocation of limited resources

National and Regional Support for pMTCT Activities
applying aiha partnership methodology to the pmtct project
Partnering/Hospital Twinning: Long term commitment that brings people, institutions and communities together to achieve common goals through sharing of ideas, labor and even risks.

Volunteering: The project is founded on a community-based approach and volunteerism to create effective sustainable change in health care.

Project Buy-in: Instill a strong sense of ownership within the partner communities by focusing on appropriate and sustainable solutions to healthcare problems.

Applying AIHA Partnership Methodology to the pMTCT Project