ART access for pregnant women living with HIV and follow-up care for HIV exposed infants: A four country assessment of key PMTCT interventions

Priscilla Idele, PhDCo-authors: Jessica Rodrigues, Chewe Luo, Ade Fakoya, Chinyere Omeogu, Rene Ekpini

SESSION: WEAD04 Surviving and Thriving: Children, Adolescents and HIVDate: 23/07/2014 (14:30-16:00 PM)Room: Plenary 2

#PMTCT #AIDSfreegeneration. #4change #AIDS2014

Background2010 WHO PMTCT guidelines included the following options:

• Lifelong ART for eligible HIV infected pregnant women

• Two ARV prophylaxis options• Option A – AZT backbone during pregnancy and prolonged ARV

prophylaxis to baby• Option B – ART to the mother during pregnancy through breastfeeding

for HIV infected women not eligible for treatment

• Implementation of recommendations could significantly reduce the risk of MTCT and ensure increased maternal and child survival.

• The Global Fund supported countries to reprogramme existing grants towards accelerating PMTCT scale-up with more efficacious regimens

• Assess status of adoption of 2010 WHO PMTCT guidelines at the time of the assessment

• Understand how nationally adapted guidelines had been translated into action at the service delivery level

• Identify successes and current operational challenges, and highlight operational feasibility

• Assess uptake of selected PMTCT and paediatric HIV care services

Objectives

• Assessment in Tanzania, Malawi, Zambia, Lesotho between November 2011 - February 2012

• Document review - national PMTCT guidelines, scale up plans and progress reports

• Key informant interviews - national PMTCT managers and partners; district health officers and health facility staff

• 10 health facilities purposively selected in each country with Ministry of Health– Implementing 2010 guidelines; – At least 2 regions and 2 districts within the region;– urban/rural;– level of facility; and– supported by IP or not

Data and Methods

• Structured health facility questionnaires

– Availability of guidelines & provider job aids– Staffing and training– Essential laboratory diagnostics– Availability of essential medicines– Service linkages & referral mechanisms– Record keeping and monitoring tools

• Data abstraction from health facility registers and clinical records at 10 health facilities in each country and for the last quarter

Data and Methods

Pregnant women1. Uptake of maternal HIV testing during antenatal care2. CD4 testing for HIV+ pregnant women3. Uptake of ARVs/ART for HIV+ mothers (both ARV

prophylaxis, ART for mothers)Infants4. ARV prophylaxis for HIV exposed infants5. Cotrimoxazole prophylaxis within 2 months of birth for

HIV exposed infants6. Infant HIV diagnosis (EID) within 2 months of birth

Data abstraction on selected indicators

Results

Adoption of 2010 WHO PMTCT guidelinesCountry Option

chosen Rationale summary (as reported by Programme Managers)

Lesotho A

Comparable efficacy of Options A and B Acceptability Cost (CHAI PMTCT costing model) Assumed better feasibility Potential for toxicity/adverse reactions

Tanzania A

Comparable efficacy of Options A and B Assumed ease of roll-out Cost and sustainability (CHAI PMTCT costing model)

Zambia A Comparable efficacy of Options A and B Cost (rapid costing, JSI) Note: 2011-2012 pilot of option B+ feasibility in two districts

Malawi B+

Comparable efficacy of Options A and B Benefits of ART for HIV prevention Ease of implementation MCH context in Malawi (high fertility, high infant HIV, low facility deliveries

& follow-up, high post-partum mortality)

Percentage of ANC staff trained in PMTCT and paediatric HIV care at 10 selected health facilities in each country, November 2011-February 2012

60

46

95

81

35 3124

6

0

20

40

60

80

100

Lesotho Malawi Zambia Tanzania

Perc

enta

ge (%

)

Trained in PMTCT Trained in paediatric HIV care

STAFF TRAINING ON NEW GUIDELINES

Source: UNICEF and Global Fund. Rapid Assessment of Implementation of 2010 WHO PMTCT Guidelines in Lesotho, Malawi, Tanzania, Zambia, November 2011- February 2012. November 2012

Maternal HIV testing during ANC

Maternal CD4 testing

Early infant HIV testing

Lesotho 9* 6 0

Malawi 10 7 2

Zambia 10 5 0

Tanzania 10 3 2*One urban filter clinic refers patients to another facility for HIV testing

Availability of essential laboratory tests at 10 selected health facilities in each country, November 2011-February 2012

Source: UNICEF and Global Fund. Rapid Assessment of Implementation of 2010 WHO PMTCT Guidelines in Lesotho, Malawi, Tanzania, Zambia, November 2011- February 2012. November 2012

AVAILABILITY OF ON SITE HIV, CD4 & EID TESTING

AZT NVP Cotrimoxazole 3TC TDF Efavirenz

Lesotho 9 10 7 9 10 10

Malawi - 8 9 10* 10* 10*

Zambia 7 7 8 7 _ _

Tanzania 9 9 9 9 _ _

*Available as a one-pill fixed dose combination; -- Those medicines were not assessed given the PMTCT Option

Number of facilities with no stock outs of essential medicines in the past 3 months at 10 selected health facilities in each country, November 2011-February 2012

Source: UNICEF and Global Fund. Rapid Assessment of Implementation of 2010 WHO PMTCT Guidelines in Lesotho, Malawi, Tanzania, Zambia, November 2011- February 2012. November 2012

AVAILABILITY OF ESSENTIAL PMTCT MEDICINES

Maternal HIV testing during ANC

Maternal CD4 testing within one month of HIV

diagnosis*

Maternal ARVs or ART for HIV+ pregnant

women

Lifelong ART coverage for HIV+ pregnant

women

0

20

40

60

80

100 99

68

99

31

79

N/A

71 71

87

66

98

20

62

No data

33

5

Lesotho Malawi Zambia Tanzania

Perc

enta

ge (%

)

Coverage of selected PMTCT servicesPercentage coverage of selected PMTCT services among pregnant and HIV+ women in 10 health facilities in

each country, November 2011-February 2012

Source: UNICEF and Global Fund. Rapid Assessment of Implementation of 2010 WHO PMTCT Guidelines in Lesotho, Malawi, Tanzania, Zambia, November 2011- February 2012. November 2012

Coverage of selected paediatric HIV care services

Percentage coverage of selected paediatric HIV care services among HIV-exposed infants in 10 selected health facilities in each country, November 2011-February 2012

0

20

40

60

80

100 96

5749

93

83 8385

17

45

61

80

58

Zambia Lesotho Malawi Tanzania

Per

cen

tage

(%

)

• Community outreach common practice in all countries via community health workers, volunteers, lay counsellors, mentor mothers or expert patients

• Some involvement of community leaders, traditional healers, use of radio, health campaigns, and use of cell phones for appointment reminders and conveying test results

• Referrals community <-> health facilities often informal, verbal

• Some good examples of formal two-way referrals using forms and accompaniment of clients to health facilities in Malawi and Zambia

Community linkages and referral mechanisms

• Countries were in the process or had not yet adapted registers and monitoring forms to accommodate all of the 2010 WHO PMTCT recommendations

• Data on maternal HIV testing and maternal ARVs during pregnancy were easily available and with well completed registers in both ANC and maternity

• Data on post-natal follow up of HIV+ mothers and exposed infants were often incomplete or unavailable:– CD4 testing, infant HIV testing, cotrimoxazole, infant feeding, postnatal ARVs for PMTCT, and

follow-up care for HIV-exposed infants often lacking or incomplete

• Referral forms exist, but no formal mechanisms of documenting referrals and whether the service was received

• A few facilities improvise registers to capture information considered useful but not in the old registers

• Some partners have separate registers at specific sites they support to collect agency-specific data

Recording keeping and data availability and completeness

• Feasibility, ease of roll out, cost and health benefits were important considerations for adoption of guidelines in all countries

• Implementation of new guidelines requires considerations in:– Strategic planning, adapting and disseminating of new guidelines, along with job

aids to assist health care workers in following new PMTCT protocols.– Capacity development, i.e. training to update and provide new skills and

knowledge to health workers and managers– Ensuring essential logistics and supplies of medicines, laboratory tests and

equipment for all facilities delivering PMTCT interventions.– Strategic shifts e.g. task shifting, decentralization, and supervision and mentoring,

and community engagement (Malawi, Lesotho)– Revision of registers and monitoring tools to incorporate new recommendations

• Safe transport of laboratory samples and results between facilities, district hubs and national testing centres

Summary and Conclusions

• In Malawi, implementation of Option B+ accelerated ART access for HIV+ pregnant women, but not similar effects on paediatric HIV services – e.g. low HIV testing among infants

• Need for family-centred approach as mother’s and children get services from the same place

• Integration of paediatric HIV care into routine MCH services – immunization, community outreach, etc. to optimize access

• Improving longitudinal care for mother-infant pairs until confirmed HIV diagnosis at 18 months is critical regardless of PMTCT option

• Point of care diagnostics is important to minimise loss to follow up, long turnaround time and late initiation of care and treatment

Summary and Conclusions

Limitations• Rapid assessment of initial experiences in the roll out of the

2010 WHO PMTCT guidelines and did not cover all areas of importance

• Timing: national roll-out incomplete, countries in transition from previous guidelines

• Incomplete or lack of data: registers or clinical forms were not updated & referrals for CD4 & EID HIV testing led to long turnaround time for test results causing delays in updating records

• Data abstraction from only 10 facilities per country and hence not comprehensive and representative of the national status; though indicative of coverage

AcknowledgementsUNICEF HQ / ESA Regional OfficeKen LeginsEdward AddaiDorothy Mbori-Ngacha

Global FundAde Fakoya

UNICEF Country OfficesJoyce Mphaya - TanzaniaBlandinah Motaung - LesothoKondwani Ngoma - MalawiSitali Mwasenyeho - Zambia

International consultantsPaula MunderiCarolyn GreenCountry consultantsGivans Ateka – LesothoBellington Vwalika – ZambiaRose Mpembeni – TanzaniaJephter Mwanza – Malawi

National PMTCT Program ManagersMax Bweupe – ZambiaMalisepo Mphale – LesothoDeborah Kajoka – TanzaniaDalitso Midiani - Malawi

91 Key informants – in 4 countries

#PMTCT #AIDSfreegeneration. #4change #AIDS2014