Transcript McIntyre PEPFAR 2009 - Council on Foreign Relations

Meeting the Challenge of HIV/AIDS in South Africa:
Exploring Strategy and Tactics to Expand the
National Response
PMTCT
James McIntyre
Anova Health Institute,
Johannesburg, South Africa
“We have effective drugs.
There is no reason why any
mother should die of AIDS.
There is no cause for any child to
be born with HIV
If we work hard enough we can
virtually eliminate mother-to-child
transmission.”
Ban Ki Moon
NY, September 2009
NSP targets
NSP targets
What are the implications of inadequate PMTCT rollout?
Estimates from the WHO Access report 2008:
South Africa:
Women in need of
PMTCT intervention
220 000
(180 000 – 260 000)
Estimated PMTCT coverage
57%
(49 – 69%)
Estimated transmission in
unidentified HIV +ve women
25%
Results in:
23 650 additional infected children
annually
Towards Universal Access Scaling up priority HIV/AIDS interventions in the health sector
Progress Report 2008: WHO
Opportunities & Obstacles
HIV prevalence among pregnant women
in South Africa, 1990 to 2008
35
30
25
20
15
10
5
0
08
20
06
20
04
20
02
20
00
20
98
19
96
19
94
19
92
19
90
19
Prevalence (%)
Reality Check: a question of scale
Annual pregnancies in HIV positive women:
United States
Namibia
< 7,000
7,600
Botswana
14,000
Europe
15,000
Kenya
100,000
South Africa
300,000
Soweto
9,000
Reality Check
• CD4 counts need to be available for HIV positive pregnant
women in order to decide on appropriate treatment options,
and few PMTCT services have moved to include CD4 at all
health service levels
• Provision of more complex ART requires more laboratory and
toxicity monitoring, additional
procurement infrastructure,
and more intensive follow up
• Most PMTCT services
(based on antenatal care)
do not yet have the capacity
to deliver ART
Proportion of antenatal clients tested by district
National
Average:
80%
The average HIV testing coverage
rate for the metro districts was lower
than the national average.
Only two metro districts, City of Cape
Town and City of Johannesburg
achieved higher than the national
average.
The coverage in Ekurhuleni, Tshwane
and especially eThekwini, with a 52%
testing rate, is particularly
concerning…
T Doherty, District Health Barometer, 2007/2008., HST 2009
Nevirapine uptake by district
National
Average:
76%
T Doherty, District Health Barometer, 2007/2008., HST 2009
Opportunities and Obstacles
The
Implementation
Challenge
Coverage and linkages
• Efficacy of PMTCT programs is related to more than just
the PMTCT regimen used
• To provide PMTCT interventions - need to identify HIVinfected women during pregnancy.
• Regardless of what PMTCT intervention, it must reach
and be accepted by the woman.
.
• Program efficacy is likely to be more related to PMTCT
cascade efficacy than PMTCT regimen efficacy
The uptake of PMTCT programmes
Routine offer of testing
On-site rapid tests
100
90
80
70
60
50
40
30
20
10
0
CD4 tests
ANC clinic visits
HIV-positive
Accepting VCT
Post-test counselled
Receive results
ARV Mom
NVP baby
The Pearl Study: Coverage Cascade in HIV+ Women
0
1000
2000
3000
4000
Positive cord bloods (100%)
Information in folder (92%)
HIV test offered (84%)
HIV tested (81%)
Result in folder (74%)
Mother received NVP (71%)
NVP in cord blood (57%)
Coverage (50%)
Coetzee D et al. IAS, Capetown, South Africa, July 2009, Abs. WeLBD101
HIV Positive Pregnant Women Received ARVs to Reduce
MTCT in South Africa
* Overall 6% increase in Women Receiving ARV for PMTCT
Annual Report 2008/2009 National DOH, South Africa
Increasing uptake of testing and prophylaxis
T Doherty, District Health Barometer, 2007/2008., HST 2009
Estimates of PMTCT cascade: “typical” sites
1000 positive mothers
Attend ANC: 90%
Counseled and tested
for HIV, CD4: 70%
Enter into
program
Missed no PMTCT
900
100
630
270
685 No ARV
(25% MTCT):
172 infected
Get ARVs (pre- and
perinatal) 50%
315
Transmission rates:
• sdNVP (8% MTCT):
25 infected
• AZT/sdNVP (3% MTCT): 9 infected
• HAART (2% MTCT):
6 infected
315
Overall Program Efficacy:
• sdNVP:
19.7%
• AZT/ sdNVP: 18.1%
• HAART :
17.6%
Adapted from P. Barker, IHI, WHO PMTCT Mtg Nov 2008, L Mofenson, 2009
Estimates of PMTCT cascade: “excellent site”
1000 HIV +ve
mothers
Attend ANC: 96%
Counseled and tested
for HIV, CD4: 99%
Enter into
program
Missed no PMTCT
960
40
950
10
Soweto PMTCT
program 2008
69 No ARV
(25% MTCT):
17 infected
Get ARVs (pre- and
perinatal) 98%
931
Transmission rates:
• sdNVP (8% MTCT):
74 infected
• AZT/sdNVP (3% MTCT): 28 infected
• HAART (2% MTCT):
19 infected
19
Overall Program Efficacy:
• sdNVP:
9.1%
• AZT/ sdNVP: 4.5%
• HAART :
3.6%
Adapted from P. Barker, IHI, WHO PMTCT Mtg Nov 2008, L Mofenson, 2009
Resources and Coverage
• Challenges
• Human Resources
• Infrastructure
• Disaggregated Services
• Health Information System
• Expansion
• 2006 – 273 facilities
• 2007 – 362 facilities (80%)
• 55 laboratories (CD4) – 6:1
• 11 laboratories (Viral Load) – 33:1
• 7 laboratories (PCR) – 52:1
Moodley, AIDS Priorities, 2009
National DOH 2009
Opportunity: Appropriate treatment and care
PMTCT is a gateway to
treatment
Women who need ongoing
antiretroviral treatment
should start as soon as
possible in pregnancy
Opportunity: Regime change…..
"Shall I repeat garlic, shall I talk about
beetroot, shall I talk about lemon...
these delay the development of HIV to
Aids-defining conditions, and that's the
truth."
Health Minister Manto Tshabalala Msimang,
7 June 2006
“We need extraordinary measures to reverse
the trends we are seeing in the health profile
of our people…. we will be treating
significantly larger numbers of HIV positive
patients. It means that people will live longer
and more fulfilling lives. ”
President Jacob Zuma: 1 December 2009
Opportunity: Regimen change…..
2002 –
SdNVP
March 2008 –
“dual therapy”
AZT from 28 weeks and SdNVP
ART at CD4 < 200/mm3
April 2010 -
AZT from 14 weeks/ sdNVP
+ “tail cover”
ART at CD4 < 350/mm3
Impact of dual therapy introduction in Kwazulu
Natal
• The province rapidly implemented the revised PMTCT guidelines,
bringing down transmission to as low as 4.3 percent in one district,
and 7 percent on average.
• 38,000 women included in study: 36% HIV positive
•
66% received dual therapy, 14% NVP only, 13% started ART
• Transmission rates:
•
8,013 babies aged between four weeks and eight weeks tested
at immunisation clinics, and found that of those whose mothers
had received dual therapy, 5.6 percent were HIV-positive
compared to 13.5 percent of babies whose mothers only
received nevirapine.
Dr Christiane Horwood,
Centre for Rural Health at the University of KwaZulu-Natal.
Gauteng: Declining % positive PCR results in
infants accessing early tests
Gayle Shermann, NHLS
PCR tests per District (age <3 mo)
Gayle Shermann, NHLS
Jan-Dec 2008 versus 2009
Gayle Shermann, NHLS
Soweto PMTCT Programme: HIV transmission rate
PCR positive stats
10
%
8
6
M
J
A
4
2
0
J
NSP
Target
N
S
F
J
M
J
O
A
D
O
M
J
N
A
F
Jan 2008 to Dec 2009
M
A
S
D
J
Total number of PCR tests done:
2008 – 5 572 -
2009 – 5 534
64% HIV-exposed babies tested
Coceka Mnyani, James McIntyre, PHRU/ANOVA
Inner City Johannesburg PMTCT Programme: HIV
transmission rate Oct 2008 – Aug 2009
M
J
A
J
N
S
F
NSP
Target
J
M
J
O
A
D
O
M
J
N
A
F
M
A
S
D
J
Vivian Black, RHRU
Infant feeding
Infant feeding and HIV
• Infant feeding is one of the most difficult
and most emotive issues in HIV
management in low-resource settings
• Even with complete coverage of an
effective peripartum ART intervention, an
estimated 30,000 children will acquire
infection through breastfeeding each year
• HIV transmission during this period
remains a challenge in places where
infant formula cannot be safely provided
A new postpartum transmission ABC……….?
A
bstain
A
void breastmilk
B
e Faithful
B
reastmilk only
C
ondomise
C
over with ARV
ARV prophylaxis of breastmilk transmission
Maternal or infant prophylaxis:
For women with CD4 >350/mm3, who do
not need ongoing ART, either
• Infant ARV Prophylaxis (with extended
nevirapine dosing)
or
• Maternal HAART for the duration of
breastfeeding
may be options to prevent Postnatal HIV
transmission through breast milk
ARV prophylaxis through breastfeeding
The 2009 Revised WHO Recommendations … provide two
alternative options for women who are not on ART and
breastfeed in resource-limited settings:
1) If a woman received AZT during pregnancy, daily nevirapine
is recommended for her child from birth until the end of the
breastfeeding period.
OR
2) If a woman received a three-drug regimen during
pregnancy, a continued regimen of triple therapy is
recommended through the end of the breastfeeding period.
Future Directions
• Improving coverage of PMTCT services
• Improving access to more efficacious
regimens
• Starting HAART in symptomatic women or
those with CD4 < 350
• Providing prophylaxis through
breastfeeding – either as extended daily
nevirapine to babies or as HAART to
mothers
• PMTCT services remain key to achieving
MDGs 4 & 5
PMTCT Program linkages
• Improving links to reproductive health services to prevent
unwanted pregnancies
• Strengthening links to treatment and care services to
ensure ongoing care
Prevention of new
infections in women
Prevention of transmission
to sexual partners
Prevention of
transmission to infants
Infant
diagnosis
and care
Family planning &
reproductive health
services
PMTCT
services
Nutrition Support
services
Male health care
Pre-ART care
Circumcision
Antiretroviral
therapy
Towards eradication of MTCT in low resource settings
6
• Access
• Acceptance of testing
• ART for those in need
’s
• Appropriate PMTCT
regimen
• Attitude of staff and
community
• Advocacy
Acknowledgements……
With thanks to:
Lynne Mofenson
Vivian Black
Coceka Mnyani
Ashraf Coovadia
Daya Moodley
And others
for use of their data and slides