Transcript No Slide Title

Greetings from
For every child
Health, Education, Equality, Protection
ADVANCE HUMANITY
IAPSM Conference 2004
Prevention of Parent- to- Child Transmission
( PPTCT)
( generally known as “ PMTCT”)
Dr. Bir Singh
Project Officer, PPTCT
UNICEF, New Delhi
IAPSM Conference 2004
1986
First case of HIV
detected in
Chennai
1990
HIV Prevalence
reaches over 5%
amongst high risk
group in
Maharashtra and
Manipur
1994
1.74 m infected
4.58 m. Indians living with HIV
1998
3.5 m. infected
> 1 % antenatal women
2001
4.01 m. infected
> 5 % high risk groups
2002
4.58 m. infected
IAPSM Conference 2004
< 5 % high risk groups
Expanding Disease Burden
1986 to 2002
4.58
No. estimated as HIV infected
(in millions)
4.5
4
3.5
3.7
3.86
1999
2000
3.97
3.5
3
2.5
1.75
2
1.5
1
0.5
0
0.2
0
1986
1990
1994
1998
2001
2002
IAPSM Conference 2004
Known modes of HIV transmission,
2002
84.29
7.24
2.61
Sexual
IDUs
2.99
2.87
Blood & blood proucts
Perinatal
Unidentified
IAPSM Conference 2004
No. of Children 0-14 Years with HIV= 1,70,000
( UNAIDS, 2002)
No.of Children with AIDS
( NACO, January, 2004)
=2,333
IAPSM Conference 2004
Percent women aged 15-49 who know all
three
modes of vertical transmission of HIV/AIDS
19
31.1
39.6 36.1
21.1
37.8
17.2
21.1
13.3
12.8
15
26.2
21
6.8
50.2
17.7
29.9
58.1
13
11.5
23.4
30.8
14
31.4
46.8
Per cent
40.8
40.6
< 20
20 - 29
30 - 39
40 & above
36.9
46.9
42.2
36.6
MICS-2000
34.4
IAPSM Conference 2004
Percent women aged 15-49 who
have heard of HIV/AIDS
32
63.9
54.3
74
41.3
74
41.1
59.2
21.6
27.3
31.1
54.8
43.4
12.7
92.8
35.4
54.7
88.3
26.2
23.9
43
48.7
23.8
59.7
Per cent
< 30
30 - 49
50 - 69
70 & above
70.6
84.7
65.8
56.3
87.7
74.5
87
MICS-2000
76.1
IAPSM Conference 2004
MTCT in 100 HIV+ Mothers
- The majority of children do not get
infected even when we do nothing
100
90
80
70
60
50
40
30
20
10
0
# uninfected
63
# infected during
BF for 2 yrs
uninfected
# infected during
delivery
15
15
7
#infants infected
during
pregnancy
IAPSM Conference 2004
Mother-Infant HIV Transmission
in Hypothetical Cohort of 100
Children of HIV+ Mothers
Children
Infected
Children
at Risk
2
100
3
98
5
15
95
Early
Late
antenatal antenatal
80
5
75
30 infected
70 uninfected
Late
Early
postpartum postpartum
36 wks
6 months
Labor &
Delivery
IAPSM Conference 2004
Risk factors for postnatal transmission:
Maternal immune status
HIV transmission from 6 w - 24 mo in
transmission (%)
Cumulative HIV
West Africa by maternal baseline CD4
15
14
10
5
1.4
0
CD4 < 500
CD4 >= 500
Leroy et al 2002
IAPSM Conference 2004
PPTCT :
The “Four Component” Strategy
I
 Prevention
of HIV in
Young
People
 Prevention
of HIV
infection in
women of
child bearing
age
II
 Prevention
of
Unintended
pregnancies
in HIV
positive
women
III
Prevention of
transmission
from a HIV
infected
woman to her
infant
IV
Care & Support
for the mother
and her family
IAPSM Conference 2004
WHO/UNFPA/UNICEF/UNAIDS
Prevention of Parent-To-Child
Transmission of HIV in India
IAPSM Conference 2004
The Rationale for PPTCT
Rationale for PPTCT in India
27 million pregnancies per year
0.4% prevalence
108,000 infected pregnancies
30% transmission
Annual Cohort of 32,000 infected newborns
25,000-50,000 deaths within 2-5 years
IAPSM Conference 2004
PMTCT Feasibility Study
AZT: March 2000 - August 2001
 Total new ANC attendance
: 192,474
 No. of pregnant mothers counseled
: 171,471 (89.1%)
 No. of pregnant mothers accepted HIV tests
: 103,681 (60.5%)





No.
No.
No.
No.
No.
of pregnant mothers detected HIV positive
delivered with AZT
of PCR samples at 48 hrs. tested
of samples tested (+) positive
of additional tested (+) at 2 months
:
:
:
:
:
1,724 (1.7%)
726
(42.1%)
427
34/427
(8.0%)
9
(adding a 2% transmission rate)
 No. of women who opted for breastfeeding (620: 135
(22%)
PMTCT Feasibility Study
NVP: October 2001 - June 2002
 Total new ANC attendance




No.
No.
No.
No.
of
of
of
of
No.
No.
No.
No.
of
of
of
of
pregnant mothers counseled
pregnant mothers accepted HIV tests
women detected HIV positive - ANC
women detected HIV positive - Labour
:
71,149
:
:
:
:
61,901
56,913
958
140
women who picked up their test result
:
(+) women who picked up their test result :
husbands who accepted to be tested
:
mother-baby pairs who received NVP
:
384 (56.97%) / 86 (68.57%)
 No. of mothers who opted for breastfeeding
:
 No. of babies exclusively breastfed at 4 months
:
 No. of PCR (+) at 2 months:
:




35,629
674
1,291
470
(87%)
(92%)
(1.68%)
(3.33%)
(62.6%)
(70.4%)
(33.4%)
(72.3%)
335
168
21/270
(51.5%)
(50%)
(7.8%)
Anti-retroviral Protocols
Feasibility Study Phase 1: modified CDC-Thailand
Regimen
AZT 300 mg BD from 36 weeks onward
AZT 300 mg / 3 hours during labour
No AZT to the baby
Feasibility Study Phase 2: modified HIVNET 012
NVP 200 mg single dose to mother at onset of
labour
NVP 2 mg/kg single dose to newborn within 72
hours
Some Lessons Learnt:
Reduced transmission of HIV from mother to infant
Proportion of infants of HIV (+) mothers
who acquired HIV
40
30
33
% 20
10
0
8
No ARV
With ARV
IAPSM Conference 2004
Some Lessons Learnt:
Increased knowledge about how to prevent HIV/AIDS
Proportion of women who know how to avoid:
acquiring HIV/AIDS
transmitting HIV/AIDS to baby
100
85.1 87.8
50
0
50.3
35.7
Before counselling
After counselling
IAPSM Conference 2004
PPTCT: Goals & Objectives
Goals:
Reduced HIV prevalence among pregnant
women age 15-49 to below 3% in the 6 high
prevalence States and below 1% in other States
by 2005
Reduced the transmission rate of MTCT of HIV
to below 20% by 2005 and below 10% by 2010
IAPSM Conference 2004
PPTCT
Key results:
•
•
•
•
Operational network of health facilities for PPTCT established
A National Policy for PPTCT
Replicable district PPTCT models
Partnerships and resources mobilized for scaled up
1) Scaling up
Expected outputs
 An operational
network of health
facilities providing
quality PPTCT services
established
 PPTCT used as an
opportunity to
strengthen MCH
services.
2) District Models
Expected outputs
 A comprehensive,
integrated and
sustainable distritbased PPTCT
programme
 Pre and in-service
training modules for
care providers to
integrate youth
friendly services
3) Learning for Policy
Development
Expected outputs
 A Feasibility Study
of “PPTCT Plus”
 Studies on HIV and
infant feeding
The PPTCT Intervention
Package
1. Ante-Natal Care
2.Group Education / Pre-Test Counselling
3. HIV Testing
4. Post-Test Counselling
5. Institutional Delivery
.
6. Administration
of Nevirapine to the woman
during labour
IAPSM Conference 2004
The PPTCT Intervention Package…
7.Administration to the BABY
of SINGLE DOSE of Suspension
Nevirapine ( 2 mg./ Kg.) between 24-72 hours
8. Counselling of mother for Infant Feeding Options
9. Care & Support
10. Follow -up
IAPSM Conference 2004
Enrollment Procedure
Group
Education
ANC
Offered
HIV test
One-To-One
Post-Test
Counseling
HIV +
HIV
Test
HIV -
Enrollment:
AZT/NVP
Pre-Test
Counseling
One-To-One
Primary Prevention
Nevirapine Administration
Mother:
Screened for contraindications
Single Dose Tablet of 200 mg.
during First stage of Labour
Baby:
Monitored for First 24 Hours
Screened for Contraindications
Single Dose of suspension 24 to 72 hours
Nevirapine Courtesy : Donation from CIPLA
IAPSM Conference 2004
Training in PPTCT
“Cascade
Effect”
Centres of Excellence ( CEs)
Medical Colleges
District Hospitals & Maternity Homes
IAPSM Conference 2004
PPTCT Team
Consists of : Obs-Gynaecologist -1
: Pediatrician
-1
: Microbiologist
-1
: Counsellor
-1
: Senior Staff Nurse -1
Trained for 5 Days : Structured ,Module based Training
IAPSM Conference 2004
Teams
SACS /NACO
UNICEF
Request
for Training
TRAINING
PROCESS
PPTCT
Centre
at DH & MH
established
SACS
Funds
M &E
QA
Teams from District
& Maternity Hospitals
Trained
CE
Teams from
Medical
Colleges
Trained
Sensitization
PPTCT Center
at M C Established
29
IAPSM Conference 2004
Scaling Up Strategy:
Training Component
11 Centers of Excellence
Phase 1- 2002
74 Medical Colleges
High Prevalence States
Phase 2 - 2002
159 District Hospitals/
Maternity Hospitals
High Prevalence States
Phase 3 - 2002-2003
79 Medical Colleges
Low Prevalence States
Phase 4 - 2003-2004
450+ District Hospitals/
Maternity Hospitals
Low Prevalence States
Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs
IAPSM Conference 2004
Prevention of Parent to Child Transmission (PPTCT) of HIV in India
Status of PPTCT Services as of 31 October 2003
State
Andhra Pradesh
Karnataka
Maharashtra
Manipur
Nagaland
Tamil Nadu
Mumbai
Delhi
Gujarat
Goa
Kerala
Pondicherry
J&K
H.P.
West Bengal
Chandigarh
Punjab
Haryana
MP
Assam
Rajasthan
Bihar
Sikkim
Total
Medical Colleges
Number of
Number
Institutions providing
trained
services
14
14
18
18
30
30
01
01
19
19
05
05
04
03
10
01
01
06
01
01
02
09
01
06
02
05
03
06
03
01
149
91
District/ other hospitals
Number of
Number
institutions
providing
trained
services
23
23
22
22
25
25
08
05
08
08
31
31
18
14
06
05
01
01
142
134
Total trained
37
40
55
06
08
50
19
08
10
01
06
02
01
02
09
03
06
02
05
03
06
03
01
291
Between 01 November and 31st December, 2003, 10 more teams have been trained. Total now , the number is
IAPSM Conference 2004
301.
UNICEF’ s Role in PPTCT
Research
Infant
Feeding
Monitoring and
Evaluation
Study
design
PPTCT
“Plus”
Counseling
Data
District
Models
Dissemination
of results
Quality assurance
of services
Training
Drugs
IAPSM Conference 2004
UNICEF Support to PPTCT
1. Capacity building - which includes training
2. Quality assurance : Monitoring inputs provided through training,
counseling and Anti-Retro Viral( Nevirapine).
3. Monitoring and evaluation
- Supporting NACO in Data collection, compilation and
analysis
- Dissemination of results
4. Research: which focuses on:
 District Integrated Approach: Linking Institution based PPTCT
services with primary prevention among young women and with
community based services for care and support
 Infant feeding - to support development on a India specific Policy
 PPTCT Plus
IAPSM Conference 2004
Infant Feeding and HIV:
Current recommendations
Informed Choice
through COUNSELLING
IAPSM Conference 2004
Global recommendations on IYCF
when HIV-negative or unknown HIV
status
 Early initiation with exclusive breastfeeding for 6
months
 Appropriate complementary feeding with
continued breastfeeding up to 2 years or beyond
 Appropriate feeding in exceptionally difficult
circumstances (HIV, emergencies, LBW, sickness,
malnutrition)
IAPSM Conference 2004
Recommendations on feeding
by HIV-positive mothers: WHO
consultation Oct.2000
 When replacement feeding is “AFASS” ,i.e. Acceptable,
Feasible, Affordable, Sustainable and Safe, avoidance
of all breastfeeding is recommended. Otherwise EBF is
recommended for the first (6) months of life with early
 and abrupt cessation…weaning.
 Counselling should include information about the risks and
benefits of various infant feeding options, and guidance in
selecting the most suitable option
IAPSM Conference 2004
Reducing risk of HIV transmission
through breastfeeding
Shorter duration – 6 months
Exclusive breastfeeding during 1st 6 months
Safe sex practices of mother during lactation
period to prevent infection or re-infection
Good lactation management (attachment,
positioning, frequency) to avoid mastitis
No feeding from cracked nipple
ARVs?
IAPSM Conference 2004
BF transmission of HIV: Ghent meta-analysis
(Read et al, 2002). - Early cessation can
reduce BF transmission with about 60%
Cumulative rates of late postnatal HIV infection (> 4 wks)
20
16
15
9
10
5
4
0
4 w to 6 mo
up to 12 mo
up to 18 m
IAPSM Conference 2004
Early cessation is possible but:
 Early, rapid cessation is possible (Uganda, Zambia,
Botswana)
 Problems encountered
breast engorgement; mastitis; babies crying, trouble sleeping,
appetite loss, diarrhea; financial constraints with replacement
feeding; family objections
more problems when cessation < 6 months (Botswana)
 Trained counselors were able to help mothers overcome
problems
 Provision of replacement feeds, family support facilitated
process
 Impact on HIV transmission, survival not yet
IAPSM Conference 2004
known
Key Findings:
Data : January to September 2003
Overall prevalence rate in ANCs : 2.1%
VCCT acceptance rate
: 61.5%
Intervention uptake
: 87.6%
IAPSM Conference 2004
PPTCT:
Challenges,Issues,Concerns
How to maintain QA while going to scale?
(Training, Counselling). “ Counsellors based
programme”.
PPTCT only for institutional deliveries?
Out -reach, District Model)
(
Completion of the ‘PPTCT package’ with Primary
Prevention and continuum of care:
Infant Feeding dilemma
Integration into the National Reproductive & Child
Health programme.
Stigma, Discrimination, Attitude of health care
IAPSM Involvment
Conference 2004
providersCommunication Strategy, Male
IAPSM Conference 2004