Nande Putta MD MPH Technical Assistant PMTCT & Paediatric HIV Care Ministry of Health

1. Human Resource Constraints and Roll out of more efficacious regimens for PMTCT The Zambian experience Nande Putta MD MPH Technical Assistant PMTCT & Paediatric HIV Care Ministry of Health

2. HIV in Zambia • Prevalence rate of HIV is 16% (15-49 yrs) • One in fivepregnant women is HIV positive (19% ANC seroprevalence) • Estimated 150,000 children are living with HIV • Mother-to-child transmission accounts for over 90% of childhood HIV infections • Estimated 97,000 HIV infected pregnant women (~~HIV exposed infants) • Each year estimated 28,000-40,000 children acquire the virus from their mother

3. Zambia's Program • Scale Up plan for pMTCT and Paed. ART developed with clearly outlined objectives and strategies • Overall objectives for Zambia by 2010: • To provide comprehensive prevention of mother-to-child transmission services to at least 80% of pregnant women • To provide ART to at least 80% of HIV-positive children in need of ART

4. Progress in Service Provision • Steady progress from 74 sites in 2003 to 678 in 2007

5. Performance 2007 • 678 PMTCT sites (53% coverage) • Of estimated 500,000 annual pregnancies, 306,000 tested (61%) • Of estimated 97,000 HIV positive pregnant women, 52,800 identified (54%) • Of estimated 97,000 HIV positive pregnant women, 35,300 accessed ARVs (36%)

6. Performance 2007 contd. • Of estimated 97,000 HIV exposed babies, 15600 accessed ARV proph. (16%) • Of estimated 97,000 HIV exposed babies, 11,900 receive Cotrimoxazole proph.(12%) • Of estimated 97,000 HIV exposed babies, 7600 received a virological test within 2 months (8%)

7. Performance 2007 contd.

8. Progress over last 3 years (2005-2007)

9. Guidance for PMTCT regimens in Zambia • More efficacious regimens incorporated into revised pMTCT guidelines and training package • Adapted from the WHO guidelines • Single dose NVP dispensed at first contact to be taken at onset of labor • AZT dispensed beginning at 28 weeks • AZT/3TC given at onset of labor with NVP • AZT/3TC given through labor and as a tail for 7 days

10. Guidance for PMTCT regimens in Zambia For baby • Single dose Nevirapine soon after birth • 7 day tail of AZT (28 days if mother received less than 4 weeks of ARVs)

11. Guidance for PMTCT regimens in Zambia as quoted from the guidelines “At the first visit after confirming the mother is HIV positive, the woman can be given her single NVP dose to take home so she can take it at the onset of labour. Where blister packs are available she may be given the full course of drugs for her to take during antenatal, labour, delivery and in the postpartum period………

12. Guidance for PMTCT regimens in Zambia as quoted from the guidelines ………… How ever it needs to be emphasized that she will need to be seen every four weeks for review. At these visits assess adherence and other issues such as disclosure, side effects and testing of other family members…………

13. Guidance for PMTCT regimens in Zambia as quoted from the guidelines …………These visits can also be used to reinforce messages such as infant feeding, family planning, early infant HIV testing and other aspects of continuum of care. She will also be given the babies NVP dose at the 32 week visit to be taken soon after birth and she should be advised on safe storage.”

14. Uptake of ARVs by Pregnant women for PMTCT • Of HIV positive women identified through ANC testing and counseling, 67% are taking ARVs for PMTCT • Of all estimated HIV positive women 36% are taking ARVs for PMTCT • Current estimates show about 25% of women taking ARVs are using more efficacious regimens (sdNVP and AZT)

15. Constraints contributing to low uptake of more efficacious regimens • Late 1st ANC visit booking and low average frequency of ANC visits • Low institutional deliveries and postnatal attendance • Lack of holistic care within MCH • Poor linkages to other facets of treatment and care • Poor reporting and recording • Data tools not integrated and all inclusive • Inadequate training of staff (refer to mapping exercise) • Inadequate community involvement

16. Constraints contributing to low uptake of more efficacious regimens • Suboptimal logistic and supply management at all levels (refer to mapping exercise) • Slow dissemination of guidelines • Inadequate Monitoring and Evaluation (mentorship, support supervision and feedback on these) • Inadequate or inappropriate staff • Inadequate integration of PMTCT into outreach visits

17. Human resource situation in Zambia • Human resource inadequacy is a huge problem facing the health sector • Staff attrition caused by job seeking outside the country, job seeking to private and non governmental sector and illness & death • Average estimate is that most health institutions are running at 50% capacity • Some health facilities being run by unqualified staff

18. Human resource situation in Zambia in PMTCT care provision • High turn over of trained staff with inadequate compensatory training of staff • Inadequate retraining or updating of staff trained when single dose Nevirapine was standard of care • Human resource retention strategies in place though competing with time to provide universal access for PMTCT (rural retention scheme, direct entry midwifery training)

19. Effect of Human Resource inadequacy on roll out of more efficacious regimens • Poor quality of counseling and care • Poor reporting and recording • Suboptimal logistic management at facility level • Inadequate follow up of clients • Inadequate performance self assessment

20. Possible solutions to Human Resource inadequacy and roll out of more efficacious regimens • Task shifting • Involvement of the community in mother baby tracking • Involvement of peer support through initiatives like Mother2mother • Easier delivery mechanisms such as blister packs • Strengthen Supervision, mentoring and feedback mechanisms • Over and above – “Health Systems Strengthening” to cope with evolution of Scientific based recommendations

21. Thank You Zikomo Natotela Any Questions?