Unite for Children, Unite against AIDS.

PMTCT

Dr. Doreen Mulenga Senior Advisor, HIV/AIDS UNICEF New York

UNAIDS epidemic update November 2007

Children continue to be infected mainly through MTCT despite having tools to eliminate this infection

• 2.1 Million children living with HIV – Increase from 1.5 million reported in 2001 • 420,000 new HIV infections – Decline from 460,000 reported in 2001 • 290,000 children died

Commitments have been made 2001 United Nations Global Assembly Special Session on HIV/AIDS Reduce the proportion of infants infected with HIV by 20% by 2005 and 50% by 2010, by:

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Ensuring that 80% of pregnant women accessing antenatal care receive information, counseling and other HIV prevention services

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Providing access for HIV-infected women and babies to effective treatment to reduce MTCT of HIV…

TARGETED 1 Primary prevention 2 Preventing unintended pregnancy in HIV positive women The UN four- pronged approach Care and treatment of mothers and infants 4 3 Interventions to prevent MTCT in HIV positive pregnant women

Evidence Based Packaging of PMTCT Services

Prong I

1. HIV/PMTCT education targeting families, couples, young people, high risk populations 2. STI screening and Rx in MCH services 3. Condom promotion and use in the context of PMTCT targeting MCH couples, young people, VCT clients, ART clients, STI clients 4. Provider initiated HIV testing and counselling in key service points – PMTCT, STI, family planning 5. Adolescent life skills education

Prong II

1. Integrated FP services in PMTCT 2. Expansion of FP services in the context of PMTCT to ART, STI, VCT, youth friendly reproductive health services.

Evidence Based Package of PMTCT Services

Prong III 1. HIV/PMTCT education / on going prevention counselling 2. Provider initiated testing and counselling 3. ARV prophylaxis need – more efficacious combination treatment for PMTCT/HAART for women in 4. Safe delivery practices membranes; C/S – avoidance of invasive procedures and prolonged rupture of 5. IF counseling and systematic and institutionalised support to mothers 6. Condom promotion and use during pregnancy and lactation 25/04/2020 Prong IV 1. HIV prevention during lactation 2. Early Initiation and exclusive BF 3. Cotrimoxazole preventive treatment for + mothers in need and for exposed infants 4. Bednets and IPT for pregnant women 5. CD4 screening for positive mothers 6. ART pregnant and lactating mothers in need Rx 7. Psychosocial Support 8. Nutritional support including provision of food rations 9. Integrated HIV and IMCI screening and management at primary facility level 10. Human rights and legal protection

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Programme Coverage Reporting modality

Annual national data (Jan to Dec) through UNICEF and WHO country offices • 2007 data collected end Jan 2008 – being analysed.

• Validated by Ministry of Health in collaboration with in country partners • Analysed by UNICEF in collaboration with WHO and UNAIDS • Global data bases used as denominators to ensure standardisation • Data as good as what is reported • In some of the countries data collecting mechanisms very weak

Reporting status 2004-2006 108 countries reported in 2006

2004 2005 C.&S. America and Caribbean West and central Africa 8 14 East and South Africa C. & Eastern Europe East Asia and Pacific 16 10 8 South Asia Middle East & North Africa 1 1 All low- & middle-income countries 58 14 22 18 7 8 1 1 71 26 2006 24 20 16 11 7 4 108

16% of all pregnant women and 21% of women attending at least 1 ANC visit were HIV tested in 2006 111 million pregnant women 86.6 million women with at least 1 ANC visit 18.2 million pregnant women receving HIV testing and counselling 16% 18.2 million pregnant women receving HIV testing and counselling 21%

Increase in PMTCT ARV coverage to 23%; notable increase in East and Southern Africa to 31% (denominator is all estimated positive pregnant women)

100% 88% 90% 79% 80% 80% 70%

2004 2005 2006

60% 47% 48% 40% 50% 27% 27% 30% 40% 31% 30% 19% 20% 10% 11% 2% 4% 7% 0%

East and Southern Africa West and Central Africa East Asia and Pacific

5% 3% 10%

South Asia: India Latin Am erica

6% 2% 6%

Djibouti Central & Eastern Europe

10% 15% 23%

Total

Countries reaching 40% ARV coverage in 2005 (2005 target) Argentina Brazil Botswana *Ecuador Georgia *Jamaica Namibia *Republic of Moldova Russia Thailand Ukraine Total number 11 Countries reaching 48% ARV coverage, 2006 (on track to achieving 80% in 2010) Argentina *Barbados *Belarus Benin *Bhutan Botswana Brazil Burkina Faso *Cuba *Fiji *Georgia *Jamaica Kenya Namibia *Republic of Moldova Russia Rwanda South Africa Swaziland Thailand Ukraine Total number 21

Regional coverage of paediatric ART 2006

Significant progress is being made in sub-Saharan Africa where the vast majority of all children under 15 years in need of ART live

90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 48,981 84,817 11,248 4,174 East and Southern Africa West and Central Africa No. of HIV-infected children (<15) receiving ARV treatment, 2005 No. of HIV-infected children (<15) receiving ARV treatment, 2006

All other regions are also making progress

20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 10,674 16,949 5,964 9,749 C. & S. America and the Caribbean East Asia and the Pacific 1,300 2,982 South Asia 810 1,444 8 78 C. & E. Europe and the Caucasus Middle East and North Africa No. of HIV-infected children (<15) receiving ARV treatment, 2005 No. of HIV-infected children (<15) receiving ARV treatment, 2006

Failure to Deliver Co-trimoxazole prophylaxis for HIV-exposed children in 2006

1.25 out of 1.5 million infants born to HIV positive mothers are unprotected from opportunistic infections C. & E. Europe , C. & S. America , 35,000 13,000 East Asia and the Pacific, 28,000 South Asia, 74,000 M. East and N. Africa, 2,000 West and Central Africa, 522,000 East and Southern Africa, 1,022,000 Less than 2% of infants born to HIV infected mothers were initiated on cotrimoxizale prophlyaxis

Key Achievements

40 30 20 10 0 90 80 70 60 50

Evidence-based PMTCT and paediatric care and treatment programmatic approaches are increasingly being implemented throughout low and middle income countries

82 2005 55 52 2006 48 39 16 24 32 17 25

sdNVP reported as m ost com m on ARV regim en PITC im plem ented into PMTCT sites DBS technology available PMTCT scale-up plans w ith pop.

based targets Paed. HIV Care scale-up plan w ith pop. based targets

Remaining challenges and gaps

• Limited human resources and infrastructure for scale up • Inadequate integration into maternal and child health Goal is HIV-free child survival PMTCT is still viewed as a vertical programme PMTCT not included in the basic MCH package of services Prong 1 and 2 are the weakest components • Inadequate follow-up of women and children for HIV care, support and treatment • Weak counseling, monitoring and support of Infant Feeding

Summary We are gaining momentum

• • • • Most countries have national strategies Access is going up nearly everywhere • In 2006, 16% , compared with 11% in 2005, of the total estimated number of women giving birth tested for HIV • The proportion of HIV positive pregnant women who received ARVs for PMTCT has increased from 10% in 2004 to 15% in 2005 to 23% in 2006 • In all regions, more HIV-infected children have greater access to ART • with over 50% increases HIV testing in young children using dry blood spots increasing Improved scientific evidence on more effective ARV regimens ; infant feeding to guide program implementation We need to do more to build the evidence for models of SRH/PMTCT integration scale up.

What can you do?

•Link up with the national technical working group -National policies and plans -Standard operating procedures -Training and networking opportunities -Procurement policies -National tracking of progress •Identify the priority entry points based on the access and utilisation of services and the characteristics of your countries epidemic; MNCH services, HIV care and treatment services, STI and VCT services. Additionally under five and support groups of women living with HIV.

Policies Mother-Baby Package: Implementing safe motherhood in countries Health Systems Making Pregnancy Safer Strategy Global action for skilled attendants Tools Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants Individuals, families and communities