Educational Objectives

AIHA’s Pilot Project in Odessa: A Comprehensive MTCT Prevention and Intervention ProgramZoya Shabarovazoya@dds.nlJames SmithAmerican International Health Alliancejim@aiha.com

Understand the main components of comprehensive mother-to-child HIV transmission prevention (pMTCT) program Learn about the implementation of effective comprehensive pMTCT program in the health care setting with limited resources in the region with concentrated stage of HIV/AIDS epidemic (Ukraine) Understand how to apply “hospital twinning” and “medical volunteer” methodology to pMTCT project Learn about a pilot project that can be used as a teaching laboratory to implement systemic change Educational Objectives

All women  prevent HIV infection (level 1) HIV+ women  prevent unintended pregnancy (level 2) HIV+ women  prevent MTCT (level 3) HIV+ women, their infant and family  provide care and support (level 4) Source: Prevention of HIV in infants and young children. Review of evidence and WHO’s activities. WHO/HIV/2002/08 Strategic Framework to Prevent HIV in Infants and Young Children

“+pMTCT+” First “Plus”: prevention of HIV among women of reproductive age pMTCT: Prevention of mother-to-child transmission of HIV End “Plus”: Follow up care and support for families Odessa Strategic Framework to Prevent HIV in Infants and Young Children

Tr. Rate During pregnancy 5-10% During labor and delivery 10-20% During breastfeeding 5-20% Overall without breastfeeding 15-30% Overall with breastfeeding till 6 months 25-35% Overall with breastfeeding till 18 to 24 months 30-45% *Source: de Cock, JAMA (2000) Timing and Risk of Transmission*

Prenatal voluntary counseling and testing (VCT) Prophylactic antiretroviral (ARV) regimens Safer delivery practices Infant feeding counseling and support Main Components of pMTCT (Level 3)

VCT – the entry point for HIV prevention and care HIV testing must be done with informed consent of the woman, using reliable laboratory tests and ensuring confidentiality (basic requirements) Availability of efficient referral system to other services (Family planning, STI treatment, MCH, MTCT, etc.) Choice of most appropriate and feasible model of VCT (individual, group) Prenatal Voluntary Counseling and Testing

USAID Donors JHPIEGO Family Planning Trainings including counseling component 1997-8, Odessa Oblast Hospital AIHA Consultation Training and Pre- and Post HIV Testing Counseling workshop, May 2002, Kiev. Attended by all AIHA WWCs and PHCs including OOH PATH VCT training, June 2002, Odessa Inter-Donor MSF: Provide Nevirapine, infant formula, C-section delivery kits for OOH and develop laboratory capacity UNICEF: Developed training materials on pMTCT in collaboration with OSMU and OOH Coordination of USAID Donor and Inter-Donor Efforts in Odessa

Ante- and intra-partum regimen: reduce viral load in mothers’ blood and genital fluids during pregnancy, labor and delivery Post-partum regimen: act as post-exposure prophylaxis (viral particles eventually transmitted during birth are eliminated) Main regimens (see handout “Use of antiretroviral regimens for MTCT prevention”) Prophylactic Antiretroviral Regimen

Planned, hemostatic C-section Avoidance of unnecessary invasive procedures (episiotomy, rupture of membranes, forceps, etc.): reduce infant contact with mothers infected blood and genital fluids. Birth canal cleansing with chlorhexidine Safer Delivery Practices

Avoidance of breastfeeding eliminates HIV transmission through breast milk, but carries other risks (infections other than HIV, malnutrition) Counseling: information about the risks and benefits of various infant feeding options, guidance in selecting the most suitable option for their situation. Infant Feeding: the Ukrainian Context

Comprehensive care for women: Primary and HIV specialty care OB/GYN and family planning services Mental health and substance abuse treatment as needed Coordination of care for entire family Support services Follow-up for Infants: HIV diagnostic testing to determine HIV status Referral to an HIV specialist PCP prophylaxis initiated at 6 weeks of age Long term follow-up of HIV-exposed infants Support services for entire family pMTCT+: Follow-up Care of Women and Infants

Ukraine – epicenter of the HIV/AIDS epidemic in Eastern Europe and Central Asia. In Eastern Europe and Eurasia HIV is growing faster than anywhere else in the world (UNAIDS, 2002) Concentrated stage of HIV/AIDS epidemic (USAID, UNAIDS, WHO classification, 2000) – HIV prevalence rate: adults -1% (2001); male STI patients – 13.3% (1996); IDUs – 8.6% (1998)*, pregnant women – 0.22% (2001)** *Report on the Global HIV/AIDS Epidemic, July 2002, UNAIDS ** Ukrainian AIDS Prevention Center Ukraine HIV Profile

Prenatal HIV screening is widely available Prenatal, perinatal and postnatal coverage is almost universal High percentage of HIV+ women are IDUs; high percentage of infants are born addicted to drugs Replacement feeding can be carried out by HIV infected mothers without major risks and obstacles Because numbers of identified HIV infected women is still limited, it is still affordable to provide pMTCT interventions The current, relatively low number of MTCT cases provides a window of opportunity to prepare the health care system to cope with the emerging problem Ukrainian Context for MTCT Strategy

Reduce the incidence of HIV in women of reproductive age (+pMTCT) Prevention of MTCT during pregnancy, delivery and postpartum (pMTCT) Provide follow up care and support to infants, mothers and families to ensure that children born to HIV+ mothers grow up in a sustainable, nurturing environment (pMTCT+) Prevent occupational exposure to HIV among healthcare workers Create a model that is adaptable to other cities and a teaching laboratory to facilitate dissemination and replication (scaling up) AIHA MTCT Pilot Project Goals

Pre-project background: Active AIHA partnerships in Odessa (IC, WWC, NRP, PHC) developing long-term relationship with Odessa Oblast Hospital (OOH) and Odessa State Medical University (OSMU) Fall 2000: Identification of Odessa, Ukraine as MTCT project site (hot spot for region) to be a replicable model for change in Ukraine February 2001: Key Ukrainian participants attend 8th Conference on Retroviruses and Opportunistic Infections in Chicago Spring 2001: Collaboration scheme developed with Medicins sans Frontieres (MSF) Spring 2001: Development of workplan, training needs identified (role of AIHA partnership) March - August 2001: Cooperation with Cook County Hospital, Chicago September 2001 – present: Collaboration with Denver Health Medical Center,University of Colorado Health Sciences Center, Children’s Hospital of Denver, Boulder Community Hospital (“hospital twinning” and “medical volunteer”) August 2001 to present: AIHA project team collects data, performs monitoring, develops materials for dissemination, conducts clinical training Project History

Develop a comprehensive strategy and establish widespread community support for key components Creation of a “center of excellence” at a designated healthcare facility (OOH) Restructuring of health care delivery system: effective communication and referral system between health institutions, effective allocation of limited resources Development and implementation ofrelevant, evidence-based protocols, practical guides, informational brochures, and patient charts among others Training of healthcare professionals Assure high quality of care at designated health care facility (OOH) Provision (including substantial donations) of essential medical equipment and supplies Coordination of activities with other donor organizations (MSF, UNICEF, PATH) and NGOs Main Components of AIHA’s Odessa Pilot Project

A catalogue of reference documents was developed (practical guides for healthcare workers, patient’s charts, and patient education materials). A clinical training program was initiated in Denver in April 2002. MTCT supplies and equipment were delivered to the Odessa Oblast Hospital. A Monitoring and Evaluation database was developed, data entry is in progress; preliminary results are available. A MTCT training course curriculum was developed and approved by the Odessa Oblast Health Administration. Odessa Oblast Health Administration issued an order requesting HCWs from all women's consultations in Odessa to participate in the MTCT training course. Developed a patient flowchart and redesigned the referral system for MTCT. Odessa Oblast Health Administration issued an order in May 2002 that all HIV-positive pregnant women be referred for prenatal care to the Odessa WWC and for delivery to OOH Five abstracts based on project results were published in the XIV International AIDS Conference abstract book, six articles were published in the special volume containing the extended versions of the conference abstracts and five posters were presented at the conference. Project Milestones

Improve the system of follow up care for women with HIV and babies born to HIV infected women in cooperation with UNICEF/Kiev and MSF/Kiev Enhance the HIV ELIZA testing capabilities at OOH lab to provide primary HIV testing for pregnant women Strengthen the nursing component of healthcare delivery to HIV+ pregnant women, their infants and families Develop consecutive and interactive pMTCT management model of primary prevention, prenatal, delivery, postnatal care, infant preventive care and monitoring, including follow up care for families with HIV Improve the health care of HIV infected women who are IDUs and their babies Initiate cross-border collaboration on pMTCT (Constanta, Romania) FY03 Workplan

Incidence of Babies Born to HIV+ Mothers at Odessa Oblast Hospital *represents first nine months of 2002 ** represents projection for 2002 (Jan-Dec)

HIV test result availa- ble before delivery ARV therapy (mother and baby) C-section Episiotomy (vag. del.) Birth canal cleansing Formula feeding MTCT Rate* Baseline group (1997-99) 56% 2% 10% 20% 75% 97% 24% MTCT group (2001-present) 100% 100% 50% 10% 95% 100% 12% Preliminary Project Results *HIV status of all babies are verified by HIV PCR tests/ELISA and WB tests

Purpose: Provide improved practice guidelines for OB/GYNS, neonatalogists, pediatricians, family physicians, nurses, midwives, social workers, microbiologists and lab technicians on various aspects of treating HIV+ patients. Prevention and Treatment of STIs Treatment of STIs in HIV+ Pregnant Women Infection Control Practices Voluntary Counseling and Testing Lab Testing Prenatal Care for HIV+ Women Prevention of MTCT During Delivery Pediatric Care for Infants Born to HIV+ Mothers Primary Health Care for HIV+ Patients Family Planning Infant Feeding MTCT Practical Guides

1. Questionnaires Purpose: Assess knowledge of HIV/AIDS and MTCT of healthcare workers in maternity houses and pediatric settings. Questionnaires have also been developed for parents and guardians of children born to HIV infected Mothers and for HIV+ pregnant women 2. Information Packages Purpose: Disseminate information among women of reproductive age and HIV+ women on HIV prevention, pregnancy and HIV testing, HIV, newborn and infant care 3. Patient Charts Purpose: Collect and maintain information about HIV infected women and infants Other MTCT Products for Dissemination

Integration of pMTCT into the MCH System MCH schedule PMTCT interventions Prenatal visit 1 HIV/STD counseling HIV testing, STI screening Anemia prevention Prenatal visit 2 Confirmation of HIV+, post-test counseling STI treatment ARV treatment counseling Infant feeding counseling Prenatal visit 3 Initiation of ARV treatment Individual counseling Labor/Delivery Intrapartum ARV component Avoidance of unnecessary invasive procedures Universal precautions Postpartum ARV treatment for infant (if needed) Support for infant feeding Family planning counseling Referral to support groups Infant follow up Growth and development monitoring Nutritional and infant feeding counseling Infections prevention/treatment Possible vaccination HIV screening schedule HIV testing of baby Referral for pediatric care if baby is HIV+

Ministry of Health: Support for project activities and possibility of implementing pilot project in other sites across the country Odessa Oblast Health Administration: Support for restructuring the referral system, facilitating communication between healthcare institutions that provide care to HIV+ patients, healthcare worker training and allocation of limited resources National and Regional Support for pMTCT Activities

Partnering/Hospital Twinning: Long term commitment that brings people, institutions and communities together to achieve common goals through sharing of ideas, labor and even risks. Volunteering: The project is founded on a community-based approach and volunteerism to create effective sustainable change in health care. Project Buy-in: Instill a strong sense of ownership within the partner communities by focusing on appropriate and sustainable solutions to healthcare problems. Applying AIHA Partnership Methodology to the pMTCT Project

Educational Objectives