Transcript PREVENTION OF MOTHER TO CHILD TRANSMISSIONOF HIV IN INDIA: ISSUES AND CHALLENGES Dr .

PREVENTION OF MOTHER TO CHILD
TRANSMISSIONOF HIV IN INDIA:
ISSUES AND CHALLENGES
Dr . S.K CHATURVEDI
UNICEF
DR. KANUPRIYA CHATURVEDI
LESSON OBJECTIVES
• TO HAVE AN UNDERSTANDING OF THE
SERVICES RELATED TO PREVENTION
MOTHER TO CHILD TRANMISSION OF HIV(
PMTCT)
• TO APPRECIATE THE ISSUES AND
CHALLENGES
• TO UNDERSTAND THE SCALING UP OF
SERVICES
• TO IDENTIFY KEY ACTIONS POINTS RELATED
TO SCALING UP
Global HIV/AIDS IN 2004
• Effect on Children
• 39.4 -40.0 million people are living with HIV/AIDS
• 2.2 million are children under 15 years
• 6,40,000 children were newly infected with HIV in
2004
• 5,10,000 children died of HIV in 2004
NEW CHALLENGES …. NEW OPPORTUNITIES
Jammu & Kashmir
Himachal Pradesh
Punjab
Chandigarh
Haryana
Delhi
Sikkim
Uttar Pradesh
Rajasthan
Bihar
West Bengal
Madhya Pradesh
Gujarat
Daman & Diu
Dadra Nagar Haveli
Arunachal Pradesh
Assam
Nagaland
Meghalaya
Manipur
Tripura
Mizoram
Orissa
Maharashtra
Andhra Pradesh
Goa
Karnataka
Pondichery
Tamil Nadu
Lakshwadeep Kerala
HIV +
Andaman & Nicobar
U5MR
Adult HIV Prevalence
High Prevalence States
INDIA : MCH PROFILE
Total Population
1027 M
Crude Birth Rate
25/1000
Sex Ratio (F:M)
933
Annual Pregnancies
27 M
ANC Coverage
65.4 %
Institutional Deliveries
[12.1% to 79.3%]
35.6 %
Deliveries attended by skilled birth attendants 42.3 %
Feasibility studies
• PPTCT Feasibility Study
AZT: March 2000 - August 2001
– AZT 300 mg BD from 36 weeks onward
– AZT 300 mg / 3 hours during labour
– No AZT to the baby
• PPTCT Feasibility Study
NVP: October 2001 - June 2002
– 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
35
30
25
20
%
15
10
5
0
33
8
No ARV
With ARV
LESSONS LEARNT
Proportion of women who know how to avoid:
acquiring HIV/AIDS transmitting HIV/AIDS to baby
100
80
85.1
87.8
60
40
20
0
50.3
35.7
Before counselling
After counselling
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
Unicef role in PPTCT
1. Capacity building - which includes training
2. Quality assurance : Monitoring inputs provided through training,
counseling and Anti-Retro Viral( Nevirapine). Facilitates NVP
donation from Cipla.
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
PPTCT Intervention Package
1. Ante-Natal Care
2.Group Education / Pre-Test Counselling
3. HIV Testing : after Informed Consent
4. Post-Test Counselling
5. Institutional Delivery : Safe Birthing Practices
6. Administration
of Nevirapine to the woman
.
during labour
PPTCT Intervention Package…
7.Administration to the BABY
of SINGLE DOSE of Suspension
Nevirapine ( 2 mg./ Kg.) within first 72 hours
8. Counselling of mother for Infant Feeding Options
9. Care & Support
PPTCT Plus
10. Follow -up
Nevirapine Administration
Mother:
Screened for contraindications
Single Dose Tablet of 200 mg.
during First stage of Labour
Baby:
Single Dose of suspension within first 72 hours
Nevirapine Courtesy : Donation from CIPLA
Enrollment Procedure
Group
Education
ANC
Offered
HIV test
One-To-One
Post-Test
Counseling
HIV +
HIV
Test
One-To-One
HIV -
Enrollment:
AZT/NVP
Pre-Test
Counseling
Primary Prevention
Rationale for PPTCT in India
27 million pregnancies per year*
0.7% prevalence**
1,89,000 infected pregnancies per year
30% transmission
Cohort of 56,700 infected newborns per year
*Derived from population estimates (SRS) AND Crude Birth rate, adding 10% pregnancy wastage
**Weighted average of estimates numbers of rural and urban HIV prevalence amongst women15-19 years
SCALE UP STRATEGY
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 - 2003-2004
79 Medical Colleges
Low Prevalence States
Phase 4 - 2004-2005
450+ District Hospitals/
Maternity Hospitals
Low Prevalence States
Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs
India: PPTCT Performance: Analysis of Jan-Dec 2004
(Data Source: NACO , 04 August, 2005 )
S.
No.
Activities
%
Numbers
1.
Total No. of New ANC Registrations in 288 PPTCT Centers
11,34,839
2.
Total No. of women counseled
9,40,853
82.9
Total No. of women accepted HIV test
8,29,164
88.13
8,839
1.07
3.
4.
No. of women found HIV positive
5.
No. of women who collected their HIV results
6,81,610
82.2
6.
No. of women who received post test counseling
6,43,336
77.5
7.
No. of HIV positive women who collected their results
6,987
79
8.
No.of Spouses/ partners of HIV positive women counseled
4,781
54
No. of spouses/partners of HIV positive women accepted HIV test
4,533
94.8
No. of Husbands / partners detected HIV positive
3,759
82.9
9.
10.
11.
No. of women coming directly in labour without ANC Reg.
2,11,518
S. No.
Activities
Numbers
%
12.
No. of women counseled who arrived in labour without
ANC
1,25,512
59.3
13.
No. of women who accepted HIV test
1,08,288
86.24
14.
No. of women detected HIV positive
1,872
1.73
15.
Total HIV Tests Done in PPTCT Centers for pregnant
women
9,37,452
Cummulative HIV Positivity Rate among Pregnant
women
1.14%
(8839+1872)=
10,711/937452
16.
17.
Total no. of mother-baby pairs received NVP
4,451
18.
No. of mother-baby pairs received NVP who were
registered for ANC
3,223
19.
No. of mother-baby pairs received NVP who came
directly in labour
1,228
20.
Total pregnant women availing PPTCT Services
counseling onwards…(Booked 9,40,853+ Unbooked
1,25,512 )
* Uttaranchal, Bihar, West Bengal, Delhi, Chandigarh
10,66,365
41.56
Increase in Facility based coverage
However Nevirapine uptake is static at 40-42%
100
Nos of women
counselled
90
80
Nos of women
accepting HIV
test
Nos of mother
baby pairs
receiving NVP
70
60
50
40
30
2003
2004
2005
Current level of PPTCT coverage
• PPTCT services are available in all
states at tertiary and secondary levels
and currently 14 per cent of all
pregnant women currently access such
services. However, in 2004, only 3.94
per cent of all pregnant women
received HIV counselling and testing
and 2.35 per cent of the HIV-positive
pregnant women received ARV
prophylaxis.
Gaps
• Inadequate expansion of PPTCT services beyond the large delivery
units
• The low proportion of women identified to be HIV infected that
receive the nevirapine prophylaxis (40-42%) or ART where eligible.
• Insufficient linkages with HIV are and support services, and unclear
application of CD4 testing policies for pregnant women.
• The focus on identifying infected women and the little attention
given to HIV uninfected
• Decentralised management and coordination is up to state level and
there are limited structures at sub-state level
• Prioritisation of high prevalence states and facilities with high
delivery numbers and not high volume antenatal units
• No clear of the contribution from private sectors as the monitoring
system does not currently include them
Conclusions from India 2004 Data when projected to a population base
Every year in India:
: Total number of pregnant women : 270,00,000 ( 27m)
: Pool of HIV infected pregnant women: 1,89,000 ( 0.7 % prevalence, NACO-2004)
: Pool of HIV infected babies : 56,700 ( @ 30% transmission)
Only 3.94% of all (27 million) pregnant women are availing PPTCT
services (Counseling onwards…) in 288 PPTCT centres (10,66,365 /
270,00,000)
Only 2.35 % of pregnant women living with HIV are being
covered with NVP (4,451/ 1,89,000) ( all-India)
Reduction in proportion of infected babies on All –India basis
: 668 / 56,700 = 1.17 %
For achieving the UNGASS goal of 2005, we need to protect a total of
11,340 (20 % of 56,700) babies in the country .
For protecting 11,340 babies, we need to cover, 22,680 babies
with NVP in the country.
For covering 22,680 babies with NVP, we need to administer
NVP to 74,844 pregnant mothers with HIV ( 22,680 x 3.3), i.e,
39.5 % of all HIV+ mothers in the country (74,844 / 1,89,000).
For reaching these 74,844 HIV + pregnant women, we need to
strategize differently for high prevalence states and other states
PPTCT coverage for High Prevalence States
•
High prevalence States account for 21% of the pool of
pregnancies from HIV positive women
•
For UNGASS goal of 2005 for the HPS, we need to protect
7,882 babies from acquiring infection. For this, we need to
administer NVP to 15,764 babies …likely to be born to 52,000
HIV + mothers.
•
For reaching these 52,000 HIV+ pregnant women, we need to
cover a total of 2,184,874 pregnant women.
•
Of these, 841,750 are already being reached, an additional
13,43,124 pregnant women to be reached with PPTCT
services.
Strategies for HP states are:
1. Scale up services to all CHCs and PHCs …. At least to 50 % by
2005/ 2006.
2. Provide PPTCT services through the private sector ….. At least to 50
% by 2005/ 2006
3. Improve quality of services in the existing centres to retain all
women coming to these centres.
8,41,750 pregnant women in these states, the actual reach for
Nevirapine administration is only 3,47,581 and we are losing
5,02,258 pregnant women despite “ reaching them”.
4. Care, Support and Treatment services for women and children to be
a priority.
PPTCT coverage for Other States
•
These states have a combined population of about 700 million .
They being “low prevalence states” contribute about 17,300
infected babies (30 % of the total ) every year to the national pool
of 56,700 HIV infected babies.
•
If we need to achieve UNGASS goal for 2005 for these states, we
need to protect 3,460 babies from acquiring HIV infection……For
this to happen, 6,920 babies need to be administered NVP.
•
For achieving this, we need to target 22,836 HIV+ pregnant
women for NVP administration. For reaching these many women,
we need to have 87,83,076 pregnant women availing PPTCT
services (approx. 33 % of all 27 million ). Of these, 1,74,533 are
already being reached , we need to reach an additional 87,00,000
pregnant women in these 28 states and UTs.
• PPTCT Programme will be one of the Entry
Points for ART
• ( Others are: VCCTCs
•
T.B. DOTS Centres
•
STD Clinics
•
Blood Banks
•
Networks of Positives )
•
Convergence of PPTCT with
ART Programme
• Convergence in Counselling
• Convergence in Training
• Linkages for Care and Support
Issues and challenges
•
•
•
•
•
Scaling up the access to PPTCT services
Focus on quality Counseling services
Streaming Patient Flow
Emergency counseling and testing
Operationalizing a “single window”
system
Issues and challenges(contd).
•
•
•
Strengthening referral links and
services
Increased focus and action on Prongs
1,2 and 4
Strategies for alternative delivery of
Counseling and PPTCT services to be
formulated in NE states
Broad Strategies
•
•
•
•
Developing and implementing a costed populationbased PPTCT scale-up plan with clear operational
targets based on state level burden of disease
estimates;
Defining a minimum package of services to be
provided at the different levels of care including
standard operating procedures for strengthening
linkages between PPTCT and ART services;
Strengthening follow up services for HIV positive
mothers and their children within a continuum of
prevention and care, and
Intensifying HIV/STI/RH preventive interventions for
HIV negative pregnant women in the context of
PPTCT
Key action points
• Decrease the loss to follow up in the existing
PPTCT centers
• Strengthening the Emergency counseling
and testing service at all PPTCT sites:
• Scale up PPTCT services to cover all public
health care sites:
Action points (contd.)
• Public private partnerships
• Increasing access to quality counseling services to women in
the reproductive age group and enhance institutional
deliveries.
• Building capacity of all health care providers (up to grassroots
level) in HIV /AIDS counseling and management of HIV /AIDS
cases.
• Linking PPTCT programme to existing primary prevention and
care and support programs for HIV /AIDS in the State and
strengthening links with People Living with HIV /AIDS networks
(PLHA) of all PPTCT service sites.
Tools for Scale Up
1. Standardized training packages for PPTCT team(Gynaecologists, technician, pediatricians and staff
nurse) and Counsellors
• 5 day training package for all team members
• 12 day training package for counselors that also
includes infant feeding
2. Cadre of master trainers at state level
3. PPTCT indicators capturing process and outcomes
4. Data flow – Facility to national level
5. Communication strategy in place (Phase I being
implemented, Phase II creatives being developed)
6. Testing supported by EQUAS