Meeting the Challenge of HIV/AIDS in South Africa: Exploring Strategy and Tactics to Expand the National Response

PMTCT

James McIntyre

Anova Health Institute,Johannesburg, South Africa

“We have effective drugs.

There is no reason why any mother should die of AIDS.

There is no cause for any child to be born with HIV

If we work hard enough we can virtually eliminate mother-to-child transmission.”

Ban Ki MoonNY, September 2009

NSP targets

NSP targets

What are the implications of inadequate PMTCT rollout?Estimates from the WHO Access report 2008:

South Africa:

Women in need of PMTCT intervention 220 000 (180 000 – 260 000)

Estimated PMTCT coverage 57% (49 – 69%)

Estimated transmission in unidentified HIV +ve women25%

Results in: 23 650 additional infected children

annuallyTowards Universal Access Scaling up priority HIV/AIDS interventions in the health sector Progress Report 2008: WHO

Opportunities & Obstacles

HIV prevalence among pregnant women in South Africa, 1990 to 2008

0

5

10

15

20

25

30

35

Prevalence (%)

Reality Check: a question of scaleAnnual pregnancies in HIV positive women:

United States < 7,000

Namibia 7,600

Botswana 14,000

Europe 15,000

Kenya 100,000South Africa 300,000

Soweto

9,000

Reality Check

• CD4 counts need to be available for HIV positive pregnant women in order to decide on appropriate treatment options, and few PMTCT services have moved to include CD4 at all health service levels

• Provision of more complex ART requires more laboratory and toxicity monitoring, additional procurement infrastructure, and more intensive follow up

• Most PMTCT services (based on antenatal care) do not yet have the capacityto deliver ART

Proportion of antenatal clients tested by district

T Doherty, District Health Barometer, 2007/2008., HST 2009

The average HIV testing coverage rate for the metro districts was lower than the national average. Only two metro districts, City of Cape Town and City of Johannesburg achieved higher than the national average. The coverage in Ekurhuleni, Tshwane and especially eThekwini, with a 52% testing rate, is particularly concerning…

National Average:

80%

Nevirapine uptake by district

T Doherty, District Health Barometer, 2007/2008., HST 2009

National Average:

76%

Opportunities and Obstacles

The Implementation Challenge

.

• Efficacy of PMTCT programs is related to more than just the PMTCT regimen used

• To provide PMTCT interventions - need to identify HIV-infected women during pregnancy.

• Regardless of what PMTCT intervention, it must reach and be accepted by the woman.

• Program efficacy is likely to be more related to PMTCT cascade efficacy than PMTCT regimen efficacy

Coverage and linkages

0

10

20

30

40

50

60

70

80

90

100

ANC clinic visits Accepting VCT Receive results

HIV-positive Post-test counselled ARV Mom NVP baby

The uptake of PMTCT programmes

Routine offer of testing

On-site rapid tests

CD4 tests

0 1000 2000 3000 4000

Positive cord bloods (100%)

I nformation in folder (92%)

HI V test offered (84%)

HI V tested (81%)

Result in folder (74%)

Mother received NVP (71%)

NVP in cord blood (57%)

Coverage (50%)

The Pearl Study: Coverage Cascade in HIV+ Women

Coetzee D et al. IAS, Capetown, South Africa, July 2009, Abs. WeLBD101

HIV Positive Pregnant Women Received ARVs to Reduce MTCT in South Africa

* Overall 6% increase in Women Receiving ARV for PMTCT

Annual Report 2008/2009 National DOH, South Africa

T Doherty, District Health Barometer, 2007/2008., HST 2009

Increasing uptake of testing and prophylaxis

Attend ANC: 90%

Counseled and tested for HIV, CD4: 70%

Get ARVs (pre- and perinatal) 50%

1000 positive mothers

Estimates of PMTCT cascade: “typical” sites

Adapted from P. Barker, IHI, WHO PMTCT Mtg Nov 2008, L Mofenson, 2009

Overall Program Efficacy:

• sdNVP: 19.7%• AZT/ sdNVP: 18.1%• HAART : 17.6%

Transmission rates:• sdNVP (8% MTCT): 25

infected• AZT/sdNVP (3% MTCT): 9 infected• HAART (2% MTCT): 6 infected

685 No ARV (25% MTCT):

172 infected

900

630

315

Enter into program

100

270

315

Missed - no PMTCT

Attend ANC: 96%

Counseled and tested for HIV, CD4: 99%

Get ARVs (pre- and perinatal) 98%

1000 HIV +ve mothers

Estimates of PMTCT cascade: “excellent site”

Adapted from P. Barker, IHI, WHO PMTCT Mtg Nov 2008, L Mofenson, 2009

Overall Program Efficacy:

• sdNVP: 9.1%• AZT/ sdNVP: 4.5%• HAART : 3.6%

Transmission rates:• sdNVP (8% MTCT): 74

infected• AZT/sdNVP (3% MTCT): 28 infected• HAART (2% MTCT): 19

infected

69 No ARV (25% MTCT):

17 infected

960

950

931

Enter into program

40

10

19

Missed - no PMTCT

Soweto PMTCT program 2008

Resources and Coverage

• Challenges• Human Resources• Infrastructure• Disaggregated Services• Health Information System

• Expansion

• 2006 – 273 facilities• 2007 – 362 facilities (80%)

• 55 laboratories (CD4) – 6:1• 11 laboratories (Viral Load) – 33:1• 7 laboratories (PCR) – 52:1

Moodley, AIDS Priorities, 2009

National DOH 2009

Opportunity: Appropriate treatment and care

PMTCT is a gateway to treatment

Women who need ongoing antiretroviral treatment should start as soon as possible in pregnancy

“We need extraordinary measures to reverse the trends we are seeing in the

health profile of our people…. we will be treating significantly larger numbers of

HIV positive patients. It means that people will live longer and more fulfilling

lives. ”

President Jacob Zuma: 1 December 2009

"Shall I repeat garlic, shall I talk about beetroot, shall I talk about lemon... these delay the development of HIV to Aids-defining conditions, and that's the truth." Health Minister Manto Tshabalala Msimang, 7 June 2006

Opportunity: Regime change…..

Opportunity: Regimen change…..

2002 – SdNVP

March 2008 – “dual therapy”AZT from 28 weeks and SdNVP

ART at CD4 < 200/mm3

April 2010 - AZT from 14 weeks/ sdNVP

+ “tail cover”

ART at CD4 < 350/mm3

Impact of dual therapy introduction in Kwazulu Natal

• The province rapidly implemented the revised PMTCT guidelines, bringing down transmission to as low as 4.3 percent in one district, and 7 percent on average.

• 38,000 women included in study: 36% HIV positive

• 66% received dual therapy, 14% NVP only, 13% started ART

• Transmission rates:

• 8,013 babies aged between four weeks and eight weeks tested at immunisation clinics, and found that of those whose mothers had received dual therapy, 5.6 percent were HIV-positive compared to 13.5 percent of babies whose mothers only received nevirapine.

Dr Christiane Horwood,

Centre for Rural Health at the University of KwaZulu-Natal.

Gauteng: Declining % positive PCR results in infants accessing early tests

Gayle Shermann, NHLS

PCR tests per District (age <3 mo)

Gayle Shermann, NHLS

Jan-Dec 2008 versus 2009

Gayle Shermann, NHLS

Soweto PMTCT Programme: HIV transmission rate

PCR positive stats

0

2

4

6

8

10

Jan 2008 to Dec 2009

% J

F

M

A

M

J

J A

S

O

N

DJ

F M A

M

J

J

AS

O

ND

Total number of PCR tests done: 2008 – 5 572 - 2009 – 5 534

64% HIV-exposed babies tested

Coceka Mnyani, James McIntyre, PHRU/ANOVA

NSP Targe

t

Inner City Johannesburg PMTCT Programme: HIV transmission rate Oct 2008 – Aug 2009

J

F

M

A

M

J

J A

S

O

N

DJ

F M A

M

J

J

AS

O

ND

Vivian Black, RHRU

NSP Targe

t

Infant feeding

• Infant feeding is one of the most difficult and most emotive issues in HIV management in low-resource settings

• Even with complete coverage of an effective peripartum ART intervention, an estimated 30,000 children will acquire infection through breastfeeding each year

• HIV transmission during this period remains a challenge in places where infant formula cannot be safely provided

Infant feeding and HIV

A new postpartum transmission ABC……….?

AA bstain

BB e Faithful

CC

ondomise

AA void

breastmilk

B B reastmilk

only

CC over with ARV

ARV prophylaxis of breastmilk transmission

Maternal or infant prophylaxis:

For women with CD4 >350/mm3, who do not need ongoing ART, either

•Infant ARV Prophylaxis (with extended nevirapine dosing)

or•Maternal HAART for the duration of breastfeeding

may be options to prevent Postnatal HIV transmission through breast milk

ARV prophylaxis through breastfeeding

The 2009 Revised WHO Recommendations … provide two alternative options for women who are not on ART and breastfeed in resource-limited settings:

1) If a woman received AZT during pregnancy, daily nevirapine is recommended for her child from birth until the end of the breastfeeding period.

OR

2) If a woman received a three-drug regimen during pregnancy, a continued regimen of triple therapy is recommended through the end of the breastfeeding period.

Future Directions

•Improving coverage of PMTCT services

•Improving access to more efficacious regimens

•Starting HAART in symptomatic women or those with CD4 < 350

•Providing prophylaxis through breastfeeding – either as extended daily nevirapine to babies or as HAART to mothers

•PMTCT services remain key to achieving MDGs 4 & 5

PMTCT Program linkages

Prevention of new infections in women

Prevention of transmission

to sexual partners

Prevention of transmission to

infants

Family planning & reproductive health services

Pre-ART care

Antiretroviral therapy

Infant diagnosis and care

Male health care

Circumcision

PMTCT services

Nutrition Support services

•Improving links to reproductive health services to prevent unwanted pregnancies

•Strengthening links to treatment and care services to ensure ongoing care

• Access

• Acceptance of testing

• ART for those in need

• Appropriate PMTCT regimen

• Attitude of staff and community

• Advocacy

6

A’s

Towards eradication of MTCT in low resource settings

Acknowledgements……

With thanks to:Lynne

MofensonVivian

BlackCoceka

MnyaniAshraf

CoovadiaDaya

MoodleyAnd

othersfor use of their data and slides