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IAPSM Conference 2004

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For every childHealth, Education, Equality, ProtectionADVANCE HUMANITY


Prevention of Parent- to- Child Transmission

( PPTCT) ( generally known as “ PMTCT”)

Dr. Bir SinghProject Officer, PPTCT

UNICEF, New Delhi

IAPSM Conference 2004 < 5 % high risk groups> 1 % antenatal women

HIV Prevalencereaches over 5%amongst high risk

group inMaharashtra and

Manipur

1.74 m infectedFirst case of HIV

detected inChennai

1986 1990 1994

> 5 % high risk groups

4.58 m. Indians living with HIV

3.5 m. infected

1998 2001 2002

4.01 m. infected 4.58 m. infected


Expanding Disease Burden1986 to 2002

00.2

1.75

3.53.7 3.86

3.974.58

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

No

. e

sti

ma

ted

as

HIV

in

fec

ted

(i

n m

illi

on

s)

1986 1990 1994 1998 1999 2000 2001 2002


Known modes of HIV transmission, 2002

7.24

2.61 2.992.87

84.29

Sexual IDUs Blood & blood proucts Perinatal Unidentified


No. of Children 0-14 Years with HIV= 1,70,000 ( UNAIDS, 2002)

No.of Children with AIDS =2,333 ( NACO, January, 2004)


Percent women aged 15-49 who know all threemodes of vertical transmission of HIV/AIDS

13.3

13

40.6

34.4

31.4

40.8

36.642.2

46.9

46.8

14

12.8

11.5

30.8

19

37.821.1

39.6 36.1

6.8

17.7

23.4

36.9

58.1

21

15

21.1

50.2

29.9

17.2

26.2

31.1

Per cent

< 2020 - 2930 - 3940 & above

MICS-2000


Percent women aged 15-49 who have heard of HIV/AIDS

21.6

26.2

65.8

76.1

59.7

84.7

8774.5

87.7

70.6

23.8

27.3

23.9

48.7

32

7441.3

54.3 74

12.7

35.4

43

56.3

88.3

43.4

31.1

59.2

92.8

54.7

41.1

54.8

63.9

Per cent

< 3030 - 4950 - 6970 & above

MICS-2000


M T C T in 1 0 0 H I V + M o th e rs- T h e m a j o r ity o f c h ild re n d o n o t g e tin fe c te d e v e n w h e n w e d o n o th in g

01 02 0

3 04 0

5 0

6 07 0

8 09 0

10 0# un infe cte d

# infec te d duringB F fo r 2 y rs

# infec te d duringde liv ery

# infants in fe cte ddurin gpreg nan cy

6 3

u n in fe c te d

1 5

1 5

7


Mother-Infant HIV Transmission in Hypothetical Cohort of 100 Children of HIV+ Mothers

Early antenatal

Late antenatal

Early postpartum

Late postpartum

36 wks 6 monthsLabor & Delivery

100 98

2 3

80

15

75

5

70 uninfected

5

95Childrenat Risk

ChildrenInfected 30 infected


Risk factors for postnatal transmission: Maternal immune status

HI V transmission from 6 w - 24 mo in

West Africa by maternal baseline CD4

14

1.40

5

10

15

CD4 < 500 CD4 >= 500

Cum

ulat

ive

HIV

tran

smis

sion

(%

)

Leroy et al 2002


PPTCT :The “Four Component” Strategy

Preventionof HIV inYoungPeople

Preventionof HIVinfection inwomen ofchild bearingage

PreventionofUnintendedpregnanciesin HIVpositivewomen

Prevention oftransmissionfrom a HIVinfectedwoman to herinfant

Care & Supportfor the motherand her family

IV II I III

WHO/UNFPA/UNICEF/UNAIDS


Prevention of Parent-To-Child Transmission of HIV in India

The Rationale for PPTCT


Rationale for PPTCT in India

27 million pregnancies per year

108,000 infected pregnancies

Annual Cohort of 32,000 infected newborns

0.4% prevalence

30% transmission

25,000-50,000 deaths within 2-5 years

PMTCT Feasibility Study AZT: March 2000 - August 2001

Total new ANC attendance : 192,474 No. of pregnant mothers counseled : 171,471 (89.1%)

No. of pregnant mothers accepted HIV tests : 103,681 (60.5%) No. of pregnant mothers detected HIV positive : 1,724 (1.7%) No. delivered with AZT : 726 (42.1%) No. of PCR samples at 48 hrs. tested : 427 No. of samples tested (+) positive : 34/427 (8.0%) No. of additional tested (+) at 2 months : 9

(adding a 2% transmission rate)

No. of women who opted for breastfeeding (620 : 135 (22%)

PMTCT Feasibility Study NVP: October 2001 - June 2002

Total new ANC attendance : 71,149 No. of pregnant mothers counseled : 61,901 (87%) No. of pregnant mothers accepted HIV tests : 56,913 (92%) No. of women detected HIV positive - ANC : 958 (1.68%) No. of women detected HIV positive - Labour : 140 (3.33%) No. of women who picked up their test result : 35,629 (62.6%) No. of (+) women who picked up their test result : 674 (70.4%) No. of husbands who accepted to be tested : 1,291 (33.4%) No. of mother-baby pairs who received NVP : 470 (72.3%)

384 (56.97%) / 86 (68.57%) No. of mothers who opted for breastfeeding : 335 (51.5%) No. of babies exclusively breastfed at 4 months : 168 (50%) No. of PCR (+) at 2 months: : 21/270 (7.8%)

Anti-retroviral ProtocolsFeasibility Study Phase 1: modified CDC-Thailand

Regimen

AZT 300 mg BD from 36 weeks onward

AZT 300 mg / 3 hours during labour

No AZT to the babyFeasibility Study Phase 2: modified HIVNET 012

NVP 200 mg single dose to mother at onset of labour

NVP 2 mg/kg single dose to newborn within 72 hours

During the 2 phases: “informed choice on infant feeding”


33

80

10

20

30

40

%

No ARV With ARV

who acquired HIVProportion of infants of HIV (+) mothers

Some Lessons Learnt:Reduced transmission of HIV from mother to infant


Some Lessons Learnt:Increased knowledge about how to prevent HIV/AIDS

50.335.7

85.187.8

0

50

100

Before counselling After counselling

Proportion of women who know how to avoid:

acquiring HIV/AIDS

transmitting HIV/AIDS to baby


PPTCT: Goals & Objectives

Goals:Reduced HIV prevalence among pregnant

women age 15-49 to below 3% in the 6 high prevalence States and below 1% in other States by 2005

Reduced the transmission rate of MTCT of HIV to below 20% by 2005 and below 10% by 2010

PPTCT

1) Scaling up

Expected outputs An operational

network of health facilities providing quality PPTCT services established

PPTCT used as an opportunity to strengthen MCH services.

2) District Models

Expected outputs A comprehensive,

integrated and sustainable distrit- based PPTCT programme

Pre and in-service training modules for care providers to integrate youth friendly services

Key results:

• Operational network of health facilities for PPTCT established• A National Policy for PPTCT • Replicable district PPTCT models• Partnerships and resources mobilized for scaled up

3) Learning for Policy Development

Expected outputs A Feasibility

Study of “PPTCT Plus”

Studies on HIV and infant feeding


.

The PPTCT Intervention Package

1. Ante-Natal Care

2.Group Education / Pre-Test Counselling

4. Post-Test Counselling

5. Institutional Delivery

6. Administration of Nevirapine to the woman during labour

3. HIV Testing


7.Administration to the BABY of SINGLE DOSE of Suspension Nevirapine ( 2 mg./ Kg.) between 24-72 hours

8. Counselling of mother for Infant Feeding Options

9. Care & Support

10. Follow -up

The PPTCT Intervention Package…

Enrollment Procedure

ANC GroupEducation

OfferedHIV test

Post-TestCounseling

HIV Test

Pre-TestCounseling

Enrollment:AZT/NVP

HIV + HIV -

Primary Prevention

One-To-One

One-To-One


Nevirapine Administration

Mother:Screened for contraindications

Single Dose Tablet of 200 mg.during First stage of Labour

Baby:Monitored for First 24 HoursScreened for ContraindicationsSingle Dose of suspension 24 to 72 hours

Nevirapine Courtesy : Donation from CIPLA


Training in PPTCT

“Cascade Effect”

Centres of Excellence ( CEs)

Medical Colleges

District Hospitals & Maternity Homes


PPTCT Team

Consists of : Obs-Gynaecologist -1

: Pediatrician - 1

: Microbiologist - 1

: Counsellor - 1

: Senior Staff Nurse -1

Trained for 5 Days : Structured ,Module based Training


SACS /NACO UNICEF

CE

Teams from Medical Colleges Trained

SACS

PPTCT Centerat M C Established

Teams from District& Maternity Hospitals

Trained

PPTCT Centre

at DH & MHestablished

Requestfor Training

Teams

Funds

TRAINING PROCESS

29

M &EQA

Sensitization


Scaling Up Strategy: Training Component

11 Centers of Excellence

74 Medical CollegesHigh Prevalence States

159 District Hospitals/Maternity Hospitals

High Prevalence States

450+ District Hospitals/Maternity Hospitals

Low Prevalence States

79 Medical CollegesLow Prevalence States

Phase 4 - 2003-2004

Phase 1- 2002

Phase 2 - 2002 Phase 3 - 2002-2003

Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs


Prevention of Parent to Child Transmission (PPTCT) of HIV in India

Status of PPTCT Services as of 31 October 2003

Medical Colleges District/ other hospitalsStateNumber ofInstitutions

trained

Numberprovidingservices

Number ofinstitutions

trained

Numberprovidingservices

Total trained

Andhra Pradesh 14 14 23 23 37Karnataka 18 18 22 22 40Maharashtra 30 30 25 25 55Manipur 01 01 08 05 06Nagaland - - 08 08 08Tamil Nadu 19 19 31 31 50Mumbai 05 05 18 14 19Delhi 04 03 06 05 08Gujarat 10 - - - 10Goa 01 01 - - 01Kerala 06 - - - 06Pondicherry 01 - 01 01 02J & K 01 - - - 01H.P. 02 - - - 02West Bengal 09 - - - 09Chandigarh 01 - - - 03Punjab 06 - - - 06Haryana 02 - - - 02MP 05 - - - 05Assam 03 - - - 03Rajasthan 06 - - - 06Bihar 03 - - - 03Sikkim 01 - - - 01Total 149 91 142 134 291

Between 01 November and 31st December, 2003, 10 more teams have been trained. Total now , the number is301.


Monitoring and Evaluation

Quality assurance of

services

UNICEF’ s Role in PPTCT

Research

Training

Drugs

Counseling

Data

Disseminationof results

Studydesign

PPTCT“Plus”

DistrictModels

Infant Feeding


1. Capacity building - which includes training

2. Quality assurance : Monitoring inputs provided through training,counseling and Anti-Retro Viral( Nevirapine).

3. Monitoring and evaluation- Supporting NACO in Data collection, compilation and

analysis- Dissemination of results

4. Research: which focuses on:

District Integrated Approach: Linking Institution based PPTCTservices with primary prevention among young women and withcommunity based services for care and support

Infant feeding - to support development on a India specific Policy PPTCT Plus

UNICEF Support to PPTCT

Infant Feeding and HIV:Current recommendations

Informed Choice through COUNSELLING


Global recommendations on IYCF when HIV-negative or unknown HIV status

Early initiation with exclusive breastfeeding Early initiation with exclusive breastfeeding for 6 monthsfor 6 months

Appropriate complementary feeding with Appropriate complementary feeding with continued breastfeeding up to 2 years or continued breastfeeding up to 2 years or beyondbeyond

Appropriate feeding in exceptionally Appropriate feeding in exceptionally difficult circumstances (HIV, emergencies, difficult circumstances (HIV, emergencies, LBW, sickness, malnutrition)LBW, sickness, malnutrition)


Recommendations on feeding by HIV-positive mothers: WHO consultation Oct.2000

When replacement feeding is “AFASS” ,i.e. Acceptable, Feasible, Affordable, Sustainable and Safe, avoidance of all breastfeeding is recommended. Otherwise EBF is recommended for the first (6) months of life with early

and abrupt cessation…weaning.

Counselling should include information about the risks and benefits of various infant feeding options, and guidance in selecting the most suitable option


Reducing risk of HIV transmission through breastfeeding

Shorter duration – 6 months Shorter duration – 6 months Exclusive breastfeeding during 1Exclusive breastfeeding during 1stst 6 months 6 months Safe sex practices of mother during Safe sex practices of mother during

lactation period to prevent infection or re-lactation period to prevent infection or re-infectioninfection

Good lactation management (attachment, Good lactation management (attachment, positioning, frequency) to avoid mastitispositioning, frequency) to avoid mastitis

No feeding from cracked nippleNo feeding from cracked nipple ARVs?ARVs?


BF transmission of HIV: Ghent meta-analysis (Read et al, 2002). - Early cessation can reduce BF transmission with about 60%

4

9

16

0

5

10

15

20

4 w to 6 mo up to 12 mo up to 18 m

Cumulative rates of late postnatal HIV infection (> 4 wks)


Early cessation is possible but:

Early, rapid cessation is possible (Uganda, Zambia, Botswana)

Problems encountered breast engorgement; mastitis; babies crying, trouble

sleeping, appetite loss, diarrhea; financial constraints with replacement feeding; family objections

more problems when cessation < 6 months (Botswana) Trained counselors were able to help mothers

overcome problems

Provision of replacement feeds, family support facilitated process

Impact on HIV transmission, survival not yet known


Key Findings:Data : January to September 2003

Overall prevalence rate in ANCs : 2.1%

VCCT acceptance rate : 61.5%

Intervention uptake : 87.6%


PPTCT: Challenges,Issues,Concerns

How to maintain QA while going to scale? (Training, Counselling). “ Counsellors based programme”.

PPTCT only for institutional deliveries? ( Out -reach, District Model)

Completion of the ‘PPTCT package’ with Primary Prevention and continuum of care:

Infant Feeding dilemma Integration into the National Reproductive & Child

Health programme.Stigma, Discrimination, Attitude of health care

providersCommunication Strategy, Male Involvment

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