charles s. kiptemas, mbchb, mph director south rift valley hiv care & treatment program kenya...
TRANSCRIPT
Charles S. Kiptemas, MBChB, MPH
Director
South Rift Valley HIV Care & Treatment Program
Kenya Medical Research Institute/Walter Reed Project
Track 1 Partners Meeting; Willard Intercontinental Track 1 Partners Meeting; Willard Intercontinental Hotel, Washington, DCWashington, DC August 11-12, 2008
Integration of ART Into MCH:Experience from Kericho District
Hospital One Client: Multiple Needs
Kenya National PMTCT Goal
• By 2005:
50% of all pregnant women should access PMTCT services.
Reduce proportion of infants infected with HIV by 20%.
• By 2008:
80% of all pregnant women should access PMTCT services.
Reduce proportion of infants infected with HIV by 50%.
Models of Providing HIV Care to Pregnant Women
• HIV counseling, testing, staging (clinical and immunological), care and treatment including PMTCT at MCH,
or
• HIV counseling, testing, staging (clinical and immunological), non ART care including PMTCT at MCH and referral for ART on/off site,
or
• HIV counseling, testing, and PMTCT at MCH and referral for care and treatment on/off site.
Rationale for Integration
• Maternal-child health clinics are often the point of entry to care for HIV-infected women and children.
• In Kenya over 90% of pregnant women seek antenatal care at least once.
• PMTCT program has been successfully integrated within the MCH framework.
• Enhances follow up of the mothers and the exposed infants since they are served under one roof.
• To support accelerated scale-up of HIV prevention, care, and treatment in resource-constrained settings.
The South Rift Valley PMTCT Program
• Started in August 2001
As a collaboration effort between USMHRP and EGPAF
• To date approximately 200, 000 pregnant women have
been counseled
• Because of the maturity of the PMTCT program at
Kericho District Hospital (KDH), the hospital was
selected to pioneer the integration of ART in MCH.
26,442 New ANC Clients
26,869 Counseled
24,477 (91%)Tested
23,510 (96%)Results
695 (90%)Mothers
519 (67%)Infants
772 (5%)HIV+ nevirapine
South Rift Valley PMTCT ProgramCounseling & Testing
andNevirapine Prophylaxis
(Jan 08- May 08)
Implementation of ART in MCH
• HIV clinic for pregnant women started in MCH due to: Loss to follow up, Poor uptake of more efficacious regimens, and Poor access to care and treatment.
• Run by clinical officers and nurses. Runs 5 days a week. Peer educators used to support the service.
• A file is opened for each patient. HIV care and PMTCT counseling provided by the clinical officer. Clinical Staging and blood for baseline evaluation that includes
CD4 cell count done in MCH. NVP for baby and mother given at first contact.
Implementation of ART In MCH, cont.
• HIV Care and PMTCT ARV prophylaxis initiated at next visit(s):
Prescriptions written in MCH and drugs dispensed from central pharmacy.
• Women encouraged to bring members of her family for HIV diagnosis.
• Mother and baby followed up in MCH till child is 18 months old:
Early HIV Infant Diagnosis by PCR done at 6 weeks.
Septrin prophylaxis provided to both infant and mother.
Recommendations for Initiating ARV Treatment in HIV Infected Pregnant Women
WHO clinical
stage
CD4 testing not available
CD4 testing
available
1
Do not treat
(Efficacious Prophylaxis)
Treat if CD4 <350* cells/mm3
2
3
Treat Treat4
* * CD4 >250/mm3 and <350/mm3 use PI based..
MCH Care of HIV Infected Pregnant Women: Kericho District Hospital (KDH)
(Jan 05-June 08)
17061543
1454
227
0
200
400
600
800
1000
1200
1400
1600
1800
HIV +ve Evaluation HIV care ART
Nu
mb
er o
f C
lien
ts
Uptake Of More Efficacious Regimen (KDH)
(Jan 08- June 08)
112 112
40
9
0
20
40
60
80
100
120
HIV +ve NVP-Mother AZT-Mother ART
Nu
mb
er o
f C
lien
ts
Male Involvement: Kericho District Hospital
(Aug 05-June 08)
1301
16367
0
200
400
600
800
1000
1200
1400
CT Male Partners HIV +ve ART
Nu
mb
er o
f C
lien
ts
Challenges & Issues
• Integrating ART into MCH with improved uptake of services in high volume sites is possible.
• Increased workload for the MCH/FP health care providers.
- Task shifting: auxiliary staff, peer counsellors.
• Requirement of additional & training of health care providers.
• Additional services will require additional resources that may include clinic space and furniture, diagnostic test, and ARV drugs.
• Disclosure issues.
Anticipated Challenges/Issues
• Maintaining quality services against the many facility
limitations and competing needs.
• Supervision, monitoring and evaluation.
• Early initiation of ARV's in pregnancy remains a challenge
(roll out of dual therapy).
• Health worker buy-in/motivation critical.
• Supply chain management.
Acknowledgements
Kenya Ministry of Health
• Dr. John Odondi
• KDH Staff
Kenya Medical Research Institute/Walter Reed Project HIV Program
• Leonard Soo
• Fredrick Sawe
United States Military HIV Research Program
• Dr. Tiffany Hamm
• Dr. Nelson Michael
• Ms. Lisa Reilly
• Dr. Doug Shaffer
Sponsors
• Kenya Ministry of Health
• Kenya Medical Research Institute
• United States Military HIV Research Program
• Presidents Emergency Plan for AIDS Relief
Asantenina
Karibuni Kericho, Kenya!
Women Presenting Below 38 Weeks Gestation Women Presenting Below 38 Weeks Gestation With Less Advance Disease With Less Advance Disease
• WHO clinical stage I or II with CD4 cell count > 350/mm3 OR
• WHO clinical stage I or II no CD4 cell count done– HB ≥7g/dl OR no clinical features of anaemia– AZT 300mg BD from 28 weeks
• At onset of labour– Administer Nevirapine 200mg and AZT 300mg stat and,
Combivir one tab BID to mother.• Post partum
– Give Infant sd Nevirapine 2mg/kg within 72 hours of birth and AZT syrup 4 mg/kg BD for 4 weeks.
– Give mother AZT300 mg / 3TC 150 BID for 7 days