PREVENTION OF MOTHER TO CHILD TRANSMISSION: A PANACEA FOR AN HIV – FREE GENERATION

1. PREVENTION OF MOTHER TO CHILD TRANSMISSION: A PANACEA FOR AN HIV – FREE GENERATION

2. INCREASING PREVENTION OF MOTHER TO CHILD TRANSMISSION SERVICE UPTAKE THROUGH INTEGRATED HEALTH CARE DELIVERY SYSTEM -Dr. Adeyanju A. O

3. Global impact of the HIV epidemicon children • 14 percent (370,000 of 2.7 million) of new global HIV/AIDS infections • 14 percent (270,000 of 2.0 million) of HIV/AIDS deaths annually • 6 percent (2.0 million of 33.0 million) of the persons living with HIV Over 90% of children acquire HIV through mother-to-child transmission (MTCT) Source: UNAIDS/WHO/UNICEF – Towards Universal Access 2008

4. NATIONAL HIV PREVALENCE TREND 1991 – 2010

6. No requiring ART- 1,512,720 - Adult-1,300,000 - Children-212,720 New infections - 281,180 -Adult-126,260 -Children-154,920 Total AIDS orphans - 2,229,883 HIV ESTIMATES BY END OF 2010

7. Nigeria and Global HIV Burden Nigeria now has the second highest number of people living with HIV in the world after South Africa. Nigeria, with about 2.98million PLWHIV, accounts for about 9% of the global HIV burden. Home to 30% of the global PMTCT Gap burden

8. The Global PMTCT Gap UNICEF Mid-Year Review Meeting July, 2011

9. Mother To Child Transmission of HIV can occur • In-utero [5-10%] • Postpartum [5-20%] • Labour/delivery [10-20%]

10. Background HIV prevalence (ANC): 4.1% HIV positive persons: 3.15million (1.83m female) HIV+ pregnant women(annual): 229,480 Children <15 years living with HIV: 331,150 • Transmission rates (at 6 weeks): from 2.34% (HAART) to 15.6% (no intervention)* • 58% of pregnant women attend ANC at least once; 45% attend at least 4 times • 35% of births occur in health facilities, 62% occur at home.

11. National PMTCT Programme Goal • To contribute to improved maternal health and child survival through accelerated provision of comprehensive PMTCT services Targets • At least 50% reduction in HIV incidence among 15-49yr old women by 2015 • At least 90% of all pregnant women have access to quality HIV counseling and testing by 2015 • At least 90% reduction in unmet need for Family Planning among women with HIV by 2015

12. National PMTCT Targets • At least 90% of all HIV positive pregnant women and their breastfeeding babies access more efficacious ARV prophylaxis by 2015 • At least 90% of HIV exposed infants have access to early infant diagnosis services by 2015 • At least 90% of pregnant women requiring ART for their own health receive life long ART by 2015

13. Score Board after nearly One Decade of Implementation UNICEF Mid-Year Review Meeting July, 2011 Nigeria South Africa HIV+ pregnant women: 210,000 210,000 Coverage of ARV/ART for PMTCT: 22% 88% Estimated HIV incidence (modelled): 0.39% 1.68% Contraceptive prevalence: 20% 62% Unmet need for FP: 20% 14% ANC at least 1 visit: 58% 92% Median duration of BF: 19 m 16 m MTCT rate in 2009: 32% 19% New child infections 2009: 64,700 40,500 Sources: WHO Universal access report 2010, Nigeria DHS 2008, South Africa DHS 2003, UNAIDS analysis

14. Problems peculiar to Developing Countries High fertility rate Lack of access to good antenatal and delivery care and support Absence of antiretroviral drugs/therapy

15. Historical Background Over the years prolongation of life with availability of better treatment options among HIV patients have been achieved. PMTCT has become an effective part of Obstetric practice in HIV/AIDS care Emerging issues then include: Integration of HIV prevention and care into other RH programmes Contraception, Fertility desires, options and management is an important component.

16. Previous Policy Initially, the Centers for Disease Control and Prevention (CDC - 1985) encouraged HIV-infected women to defer pregnancy because of poor prognoses associated with HIV infection and the risk of perinatal transmission

17. Previous Policy In 1987, the American College of Obstetrics and Gynecology (ACOG) advised physicians to encourage women infected with HIV NOT to become pregnant, and to inform pregnant HIV-infected women of termination options. The Ethics Committee of the American Society for Reproductive Medicine suggested in 1994 that physicians “counsel couples about the consequences of using potentially infected sperm and discuss the options of donor sperm, adoption, or not having children.

18. A ray of HOPE The introduction of potent ARV (HAART) in the last decades has changed both the decisions & discussions about HIV infection generally. People infected with human immunodeficiency virus (HIV) are living longer and experiencing improved health. Also, physicians now view HIV infection as a manageable chronic illness and encourage patients to maintain normal lives

19. Current Situation In 2001, the CDCamended its previous recommendations, stating that HIV-infected pregnant women should receive information about all reproductive options and that reproductive counseling should be nondirective and supportive of the patient’s decision. Currently ACOG now states that “assisted reproductive technologies should not be denied to HIV-infected couples solely on the basis of their positive HIV serostatus.”

20. Conception issues Women with HIV are similar to non-HIV infected women in what influences their desire to get pregnant Among those desiring children, 69% of women 59% of men Desired to have children in the future Women’s desire for children is more affected by personal health status vs. men’s Sowell RL et al. AIDS Care. 2002;14(2):181-191

21. Importance of getting pregnant 83.2% (74.7% M; 90.7% F) believed it is very important to have own biological child. Reasons: Low parity (57.5% parity ≤ 2) To continue family name Availability of better treatment Having a HIV negative baby from previous pregnancy Less stigmatisation

22. PRECONCEPTION CARE A specialized form of care for women of reproductive age group before the onset of pregnancy, to detect ,treat or counsel them about preexisting medical and social conditions that may militate against safe motherhood and the delivery of a healthy offspring. It is a component of comprehensive maternity care– PrCC, ANC, IntraPC, and PNC AIM: TO IMPROVE THE PROSPECT OF SAFE MOTHERHOOD

23. Objectives of Preconception Care • Avoidance of maternal exposure to teratogens during fetal organogenesis • Checking basic measurements e.g BP, Weight before conception • Introduction of intending mothers to social and medical interventions at a time they can have maximal effect on the outcome of pregnancy

24. National PMTCT Programme Goal • To contribute to improved maternal health and child survival through accelerated provision of comprehensive PMTCT services Targets • At least 50% reduction in HIV incidence among 15-49yr old women by 2015 • At least 90% of all pregnant women have access to quality HIV counseling and testing by 2015 • At least 90% reduction in unmet need for Family Planning among women with HIV by 2015

25. General Principles • Combination regimens are more effective than single or double drug regimens. • Combination Highly Active Antiretroviral Therapy is standard of care for treatment of maternal HIV infection and prevention of mother to child transmission of HIV. • Pregnancy in the HIV positive woman is an indication for prophylactic ART irrespective of CD4 count, viral load or clinical stage of the disease. • All efforts should be made to ensure that all HIV positive pregnant women have access to ART.

26. General Principles (II) • All patients placed on ART should be monitored clinically, biochemically and immunologically. • Pre-treatment evaluation should include: • Complete history and physical examination. • Checking laboratory parameters (FBC/ESR, FBS, LFT, E&U, Serum lipids, CD4 count and viral load). • WHO clinical and immunological staging of the client. • Ensuring availability of supportive measures (nutritional and psychosocial). • Patient-specific adherence strategy • If facility for CD4count is not available, the client should be referred or client’s specimen sent to the nearest centre with such facility. • Where the patient is on AZT only for prophylaxis, the minimum tests to be done will include HB /PCV, CD4 count and urinalysis.

27. Specific PMTCT Interventions • HCT- HIV Counseling and Testing • Modification of Obstetrics practices • Administration of ARV prophylaxis to mother-child pair •HIV and Infant Feeding Counselling • Care and Support for HIV positive women and their families (PMTCT plus).

28. PMTCT Strategies Primary prevention of HIV infection in women of reproductive age group and their partners. Prevention of unintended pregnancies among HIV positive women. Prevention of HIV transmission from HIV infected mothers to their unborn babies and infants. Care and support for HIV infected women, their infants and family members.

29. INTEGRATED HEALTH CARE DELIVERY SYSTEM Integration-stems from the Latin verb integer i.e to complete Integrated-=organic part of a whole or reunited part of a whole Used to express the bringing together or merging of elements or components that were formerly separate It is a desire to understand the relationship of elements that constitute the entirety

30. INTEGRATED SERVICE DELIVERY “The management and delivery of health services so that clients receive a continuum of preventive and curative services , according to their needs over time and across different levels of the health system.” Referrals and Linkages

31. We need a comprehensive , integrated approach to service delivery. We need to fight fragmentation— Dr Margaret Chan WHO Director General (2007)

32. INTEGRATED HEALTH SERVICES: A package of preventive and curative health interventions for a particular population group. Refers to multi-purpose service delivery points i.e a range of services for a catchment population is provided at one location. Achieving continuity of care over time i.e a life long care for chronic condition or a continuum of care between more specific stages in a person’s life cycle e.g ANC,PNC, Newborn and child care. Refer to the vertical integration of different levels of services. There is a well functioning procedures for referrals up and down the levels of the system, and between public and private providers. Refer to integrated policy- making and management which is organized to bring decisions and support functions across different parts of the health service. Mean working across sectors. It occurs when there are institutionalized mechanisms to enable cross-sectional funding, regulation and service delivery. E.g working with education services to develop effective school health promotion campaigns --NB: identify the most appropriate sector(s) to deal with a particular health issue and establish linkages with them.

33. Comprehensive HIV/AIDS Service Provision of HIV prevention, treatment, care and support services through • VCCT--HCT • PMTCT • HOME BASED CARE • CLINICAL CARE • LABORATORY SUPPORT • SUPPORT GROUP • OVC

34. Specific PMTCT Interventions • HCT- HIV Counseling and Testing • HIV and Infant Feeding Counselling • Modification of Obstetrics practices • Administration of ARV prophylaxis to mother-child pair • Care and Support for HIV positive women and their families (PMTCT plus).

35. Essential commodites for PMTCT Programme HIV test Kits/reagents IEC materials Consumables Antiretroviral drugs Drugs for opportunistic infections Starter packs for PEP Family planning commodities National PMTCT Guidelines

36. Essential commodities for PMTCT Programme-- continue Registers and forms for Monitoring and Evaluation Items for Universal precautions Supplies for cervical screening

42. OYO STATE • 5 State Hospitals • 27 General Hospitals • 351 Primary Health Centers • 166 Primary Health Clinics • 113 Rural Health Centers or Posts Most of the PLWHA can be reached if all these are involved in their treatment, care and support

43. Meeting the needs of growing number of PLWHA, their care givers and their family members requires the collective effort of many facilities and organizations It also requires appropriate policies, supportive social attitude and community support system

44. Number of Service Delivery Points Offering PMTCT Services

45. COMMUNITY BASED PMTCT • Definition: Is the provision of PMTCT services by formal or informal caregivers outside the hospital or facility settings What is the need: • Most deliveries in Nigeria and sub-Saharan Africa occur in homes, churches etc; and attended by mothers, family relatives, TBA. • Studies in Nigeria have shown that home deliveries account for about 80% of deliveries in Nigeria. Although about 60-80% attend at least one ANC visit; only approximately 20-30% deliver in Hospitals.

46. Community based PMTCT • There are low number of hospitals and maternity homes • Low coverage of PMTCT services (10%). Mostly in urban areas. • Predictors of home deliveries • Poor maternal education, multiparity, low socioeconomic status, distance from health facility, political instability, industrial strikes, poor attention at facilities etc

47. Components of a community based PMTCT A strong facility based PMTCT Cultural accepted health based education programs Strong support group ( facility & community) Lay counselors ( Peer) Incorporation and training of retired midwives/nurses Incorporation and training of TBA Involvement of District , local government health Authorities CT as an important entry point for PMTCT Encourage the involvement of CBO, FBO, Traditional healers and Leaders

48. Models for implementation • PMTCT facility networking to lower cadres of care (Network model) • Community programs using retired midwives, TBA • Community referral programs using Lay counselors, Chews, • PMTCT mobilization with retired midwives, TBA, Lay counselors, Chews, Potential areas for linkages • Health sector: Family planning; Safe motherhood, child survival, TB, Malaria • Other developmental linkages: education, food and nutrition, economic strengthening.

49. ART PMTCT HCT Labs – CD4, FBC, Chemistry FP QC/QI HUB & SPOKE MODEL PHC PHC PHC Secondary Facility eg Onikan Health centre • Community • Prev. message • Treatment literacy • Treatment support • Adherence • Patient tracking • Comm. Based services • IEC • FP • BCK • Condoms • DOTS • Out reaches • BCC • Treatment message • HCT • Advocacy HCT PMTCT STI CXT BCK DOTS ?ART refills FP Multivitamins PHC PHC eg Irru

50. ART PMTCT HCT Labs – CD4, FBC, Chemistry FP QC/QI HUB & SPOKE MODEL Molete, Mapo Ayeye Orieru, Ayeye Adeoyo Maternity Hospital, yemetu • Community • Prev. message • Treatment literacy • Treatment support • Adherence • Patient tracking • Comm. Based services • IEC • FP • BCK • Condoms • DOTS • Out reaches • BCC • Treatment message • HCT • Advocacy HCT PMTCT STI CXT BCK DOTS ?ART refills FP Multivitamins Oniyanrin Odo-ona