A Multicultural Caribbean United Against HIV/AIDS Dominican Republic March 5-7, 2004

1. Integrating Women’s Health with Scale-up of AIDS Prevention and Care: Five Lessons from Rural HaitiDr. Maxi RaymonvilleDirector, Proje Sante Fanm, Zanmi Lasante, Cange, Haiti A Multicultural Caribbean United Against HIV/AIDS Dominican Republic March 5-7, 2004

2. HIV/AIDS in Haiti • 250-400,000 living with HIV/AIDS, end of 2002 • Highest prevalence in the Western Hemisphere • 30,000 new cases annually • Accounts for 50 % of hospital bed occupancies • Leading cause of death:30,000 HIV/AIDS deaths in 2001 • 200,000 AIDS orphans by end of 2001 Source: UNAIDS 2002

3. Prevalence of HIV Infection Among Pregnant Women in Haiti • Haiti’s HIV epidemic is now generalized: Sex ratio is 1:1, male to female • In 2000 over 11,000 pregnant women were HIV positive. • 5% among asymptomatic women attending rural antenatal clinics >10% in asymptomatic women attending antenatal clinics in urban slums

4. Introduction of HIV Prevention and Care, Central Haiti • 1986: First case of HIV in Central Plateau • 1988: Free serologic testing to diagnose HIV • 1990: Intensified prevention efforts • hampered by political violence and resulting migration • hampered by gender inequality and deep poverty • 1995: AZT to pregnant women in order to block mother-to-child transmission • Transmission reduced from 30% to 8% with AZT and breast milk substitution

5. Proje Sante Fanm • Free standing women’s health clinic • Founded in 1998 based on needs recovered by Groupe d’étude du SIDA dans la Classe Paysanne (GESCAP) research project on HIV vulnerability among women • Proje Sante Fanm provides family planning, prenatal care, and treatment for symptomatic STIs • 2 OB/GYN specialists, 5 Nurse midwives

6. Picture of Proje Sante Fanm

7. HIV Testing and Treatment Algorithms

8. Interventions to prevent HIV transmission from mother to child • A pregnant woman seen at Clinique Bon Sauveur or public health clinics in the central plateau. • VCT is offered by midwife nurse • Lab examinations routine for prenatal care • HIV test • Pregnant women with HIV positive is referred to the ID clinic

9. HIV Testing Algorithm:(Abbott Determine rapid test) Positive Negative Confirmatory test: Capillus Routine prenatal care, HIV prevention Negative Positive Discordant results: Western Blot Refer to HIV clinic Positive Negative

10. What did MTCT teach us about prevention and care of HIV? • Access to medications increases the uptake of VCT: • prior to offering AZT about 40% of women refused HIV testing, once AZT was made available (1995), >90% of women accept testing. • Comprehensive approach is required • Because the benefit of AZT lost if infants are breast fed intervention requires access to breast milk substitution • water projects

11. Global Fund to Fight AIDS, TB and Malaria • In 2003, Zanmi Lasante received part of the Haiti grant for the expansion of AIDS prevention and care in the central plateau • Expansion based on a comprehensive HIV program integrated into the provision of primary health care in the public sector • 4 public health clinics in 2003, 2 additional in 2004 and 3 more clinics by 2007. • Program based on the “Four pillars.” Programs that link prevention, testing and care.

12. Use of CD4 Monitoring and HAART

13. Further Reducing MTCT • Combination antiretroviral therapy has led to perinatal transmission rates of less than 2% in developed countries • ZL has implemented measures to further reduce transmission. • Women in all expansion sites have access to OB/GYN care

14. Maternal Factors Associated with HIV Transmission • Presence of sexually transmitted diseases: addressed in the ZL program • Anemia: addressed in the ZL program • Increased viral load • Low CD4 counts: addressed in the ZL program • multiple sexual partners: addressed in the ZL program

15. HIV positive women are treated based on CD4 and symptoms >350 and asymptomatic <350 or clinical symptoms Mother: AZT at 36 wks until labor. During labor administer 300mg po Q 3 hours. Infant: AZT 2mg/kg/day Q 6hrs for1 wk Mother: AZT/3TC/NVP at 28 weeks until birth. Infant: 1 dose of NVP at birth and AZT/3TC for 1 week.

16. Picture of FACS machine/Tanya

17. CD4 >350Number of women 65/125 • CD4 count relying on a FACTS COUNT machine • If CD4 >350 protocol regimen by the MOH, AZT monotherapy at the 36th week of pregnancy: 300mg (BID/day) until delivery • During delivery 300mg every 3 hours • Infant:2mg/kg every 6 hours during 7 days • Breast milk substitution • Nevirapine is given when the pregnant woman is new to the clinic

18. CD4 count <350Number of women 23/125 • CD4<350: three-drug regimens are applied: AZT, 3TC, NVP • Treatment will continue post partum • If pregnant woman with symptoms treatment will be provided for infection opportunistic • Three-drug regimens are more effective than both AZT and NVP monotherapy in preventing mother-to child transmission and in improving maternal survival

19. Four Pillars of HIV Prevention and Care • Access to Voluntary Counseling • Screening and treatment for TB • Screening and treatment for all STIs • Prenatal care and women’s health

20. HIV prevention, case detection, care, ARV treatment Detection and Treatment of TB Maternal Child Health & MTCT Voluntary Counseling and Testing Detection and Treatment of STI Implementing an HIV Program in the Public Sector Public Health Clinic

21. Expansion sites

22. MTCT in the Expansion Project • 6,306 pregnant women tested for HIV from December 02 to December 03 • 100% acceptance of VCT • 125 pregnant women newly diagnosed as HIV positive (2% sero-prevalence)— • transmission rate cannot be determined until 18 months from start of program • 70% of HIV positive pregnant women on ARV: HAART 23, AZT 44

23. Expansion Sites and Integration of Traditional Birth Attendants • 160 pregnant women referred by TBAs • 303 TBAs trained in MOH corriculum • Monitoring number of pregnant women referred by TBAs as the TBA training is still in process in some sites • Pregnant women were referred to the public health clinics in the expansion sites or Clinique Bon Sauveur where PMTCT services are integrated with prenatal care.

24. Use of Community Health Workers • Medications are delivered by accompagnateur (village health worker) or traditional birth attendants • Health workers can observe for complications of pregnancy and of treatment • Adherence issue will be addressed

25. Breast milk substitution • Our program relies on breast milk substitution as well antiretrovirals • Kitchen utensils are offered as well as education about clean water • Efforts to improve quality water and water quantity • Zanmi Lasante has engaged a full time sanitary engineer as part of this effort

26. Conclusions:Integration of Women’s Health Services in Public Health Sector • Access to obstetrical care • Prenatal care including nutrition, vaccinations for tetanus • Family planning, condoms • Post partum care • Ongoing primary and secondary prevention in the context of enhanced HIV care and improve clinical outcomes