Programmatic issues around PMTCT -
Ruth Nduati
Senior Lecturer
Department of Pediatrics
University of Nairobi
Urban antenatal HIV prevalence in sub
Sahara Africa
0 5 10 15 20 25 30 35 40%
W Africa
C Africa
E Africa
S Africa
Infant mortality rates by maternal HIV status (Coulter 1993, Boerma 1998)
0
5
10
15
20
25
30
35
40
Kinshasa Kigali Brazzaville Malawi Kampala
HIV exposed HIV unexposed
Magnitude of MTCT transmission of HIV
Transmission rate
During pregnancy 5-19%
During labour and delivery 10-20%
During breastfeeding 5-20%
Overall without breastfeeding 15-30%
Overall with breastfeeding <6mths 25-25%
Overall with breastfeeding 18-24mths
30-45%
Mortality among HIV-1 seropositive breastfeeding and formula-feeding women(Nduati
et al. Lancet 2001)
0
2
4
6
8
10
12
6wks 6mths 12mths 18mths 24mths
BreastfeedersFormula-feeders
Effect of mother’s death on infant survival
“Independent of infection status HIV exposed infants were at an 8 fold increased risk of death following their mother’s death
Nduati et al., Lancet 2001;357:1651
Efficacy of short course AZT in a breastfeeding population (Leroy AIDS 2002;16:631-641)
0
5
10
15
20
25
30
35
2 wks 6 mths 24 mths
ZDVplacebo
Cumulative mortality at 24 months
Breastfed Formula Hazard ratio (95% CI)
Overall 24.4% 20% 1.1 (0.7-1.7)
Uninfected 8.1% 10% 1.3 (0.6-8.0)
Infected 46% 40.2% 0.9 (0.5-1.8)
HIV AND INFANT FEEDING: THE DILEMMA
Strategic approaches to prevention of HIV related morbidity and mortality in children
• Prevention of HIV in young women
• Prevention of unintended pregnancies in HIV infected individuals
• Prevention of MTCT transmission of HIV
• Provision of c are to HIV infected women and their families.
Steps in implementing a PMTCT
• Program level– Advocacy with District Health Management
Teams and other important stake holders– Consensus building on the package of services– Development of guidelines– Development of IEC materials– Development of monitoring and evaluation
tools
The PMTCT package
• Quality antenatal care• Universal HIV counseling and voluntary testing • Partner involvement in counseling• Provision of anti-retroviral prophylaxis • Counseling on replacement feeding and safer
breastfeeding practices • Safe delivery• Post-natal care for the infant
Provision of quality antenatal care
• Health education• Screening and treatment of STD’s• Screening for anaemia• Micronutrient supplementation• Malaria chemoprophylaxis• Immunization against tetanus• Screening for other pregnancy related
complications eg. Diabetes or eclampsia• Family planning counseling
Screening for syphilis with RPR
Kakamega
N=3754
Busia
N=3597
Karatina
N = 5316
Homa Bay
N=4169
% tested 40% 46% 86% 18%
% RPR +ve
4.8% 3.4% 1.6% 9%
Proportion treated
98% 59% 82% 82%
Guidelines to support PMTCT
• National Infant feeding policy
• Guidelines for the care of HIV infected women
• Guidelines on the use of anti-retroviral drugs
IEC materials to support PMTCT
• Posters to be used within the health facility and at community level
• Take home brochures to help women initiate discussion on PMTCT
• Flip charts with detailed information to help the health worker provide accurate information
• Badges for counselors to help clients identify who they can approach for information
• Video to be used in antenatal clinic • Counseling cards on infant feeding
Tools for monitoring PMTCT at health facility level
• Modified antenatal card• Modified institutional registers
– Antenatal register– Laboratory register– Delivery register– Bin cards– Drug registers (maternity, MCH, pharmacy)
• New register– Counselors register
• Weekly summary sheets
Steps in implementing PMTCT at facility level
• Advocacy with the staff• Needs assessment to
– Determine the existing resources and gaps
– existing package of services being provided
• Development of training materials• Training of health workers• Establishment of appropriate client flow• Carrying out monitoring and evaluation
Factors affecting uptake of testing
• Counseling case load • Prevalence of HIV• Counseling strategy –
– Group versus one-one counseling– Opt-in versus opt-out approach to testing
• Client flow– one-stop service provision versus production
line approach
Uptake of HIV-test results and ARV’s
0
100
200
300
400
500
600
KTN HBY Busia Kakamega
HIV+Collect resultsTake ARV Px
Content of Health education & counseling before and 9 months after a PMTCT program in Karatina
0
5
10
15
20
25
30
%
Maternalnutrition
Infantnutrition
MTCT HIV riskreduction
Before PMTCTAfter PMTCT
Content of Health education & counseling before and 9 months after a PMTCT program in Homa Bay
0
5
10
15
20
25
30
%
Maternalnutrition
Infantnutrition
MTCT HIV riskreduction
Before PMTCTAfter PMTCT
Quality of HIV testing in Homa Bay District Hospital
94%
6%
Correctly classifiedWrongfully classified
Quality of HIV testing in Karatina District Hospital
99%
1%
Correctly classifiedWrongly classified
Counseling Environment
22
100
11
5647
64
0
20
40
60
80
100
Privacy No
interuptions
No barriers
Baseline Follow-up
Communication Skills in HIV counseling sessions (1)
44
97
33
88
33
86
44
75
0
20
40
60
80
100
Rapport Confid Listen Explore
Baseline Follow-up
Communication Skills in HIV counseling sessions (2)
38
91
29
80
11
77
33
79
33
85
0102030405060708090
100
Fe
ed
ba
ck
sile
nc
e
No
n-
ve
rba
l
Op
en
-en
d
Cla
rify
Baseline Follow-up
CHALLENGES
• Sustaining the consumables – HIV Test kits, IEC Materials
• Providing essential package of services such as syphilis screening, and antenatal multivitamin supplements
• Improving uptake of test results and intervention among HIV infected women..
• Providing standardized messages and ensuring quality of counseling.
Partnerships
• Joan Kreiss
• Grace John
• Barbrar Richardson
• Julie Overbaug
• Dana Pantaleef
• Christine Rousseau
• Population Council
• Family Health International
• Ruth Nduati• Dorothy Mbori-
Ngacha• J Ndinya Acholla• J Bwayo• Anthony Mwatha• James Ochieng