Transcript Virtual elimination of mother-to-chilfd transmission of HIV: progress, remaining challenges, opportunities and way forward Rene Ekpini E Senior Adviser UNICEF, New York.

Virtual elimination of mother-to-chilfd
transmission of HIV: progress,
remaining challenges, opportunities
and way forward
Rene Ekpini E
Senior Adviser
UNICEF, New York
Expenditure in HIV care and treatment,
prevention and PMTCT in selected countries
PMTCT
Total prevention
Care & Treatment
Rwanda
Cote d'Ivoire
Haiti
Mozambique
Botswana
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
Source: UNAIDS
2008 Global Report
Remaining challenges-1
•
Lack of translation of political commitment into catalytic
actions with accountability mechanisms at the country
level between central and sub-national authorities and
health management structures
•
Donor-driven programmes with limited national
ownership, parallel funding, M&E and PSM systems with
concentration in limited urban settings
•
Weak health systems with low access to and uptake of
services, the use of less efficacious interventions (e.g. SdNVP) and poor continuum of care for mothers and children
The gap between antenatal care coverage and
HIV testing and counseling in the context of
PMTCT in selected countries – 2007
ANC
120
HIV T&C
80
60
40
20
R
C
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oi
re
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oz Ha
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e
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en
y
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t
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am
ib
ia
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w
an
da
M
al
aw
Za i
m
bi
a
D
e
Co
t
hi
op
i
N a
ig
Ca er
m ia
er
oo
n
0
Et
Percentage
100
Countries
Building up PMTCT on weak health
systems in resource-limited settings
Coverage of PMTCT services
HIV T&C
Infant ARV for PMTCT
70
60
50
40
30
20
10
0
ARV for PMTCT
CTP for infant by 2 months
65
50
Coverage of antenatal care
and skilled attendant at birth
1+ visit 4+ visits Births with skilled attendant
120
100
47
80
32
96
91
74
68
60.5
60
21
17
16
12
43.4
40
20
Malawi
Zambia
0
Malawi
Zambia
Sources: 1- ANC coverage: Antenatal care in developing countries-Promise, achievements and missed
opportunities – An analysis of trends, level and differentials, 1990-2001 updates 2- Skilled attendant at birth 2006
Current system performance (KZN province)
Attend ANC
clinic 92%
30
Counseled and tested
for HIV, CD4 75%
In PMTCT programme
Outside PMTCT pg
25
25
transmission rate (%)
Get ARVs (pre- and
perinatal) 50%
All
25
19.5
20
17.2
15
10
8
5
2.2
0
Sd-NVP
Adapted from Pierre Baker & Nigel Rollins
AZT/Sd-NVP
95% efficiency of the system (KZN province)
Attend ANC
clinic 92%
30
Counseled and tested
for HIV, CD4 95%
In PMTCT programme
Outside PMTCT pg
25
25
transmission rate (%)
Get ARVs (pre- and
perinatal) 95%
All
25
20
15
11.1
10
8
6.1
5
2.2
0
Sd-NVP
AZT/Sd-NVP
Quality of antenatal and delivery care before
and after the implementation of PMTCT;
Cote d’Ivoire
90
Before PMTCT
After PMTCT
80
Percentage
70
60
50
40
30
20
10
0
nutrition
Family Prevention Measure Partograph Check
during
planning
of STIs
foetal
ever filled uterine
pregnancy
heart rate
in
retraction
Individual counselling
Therese Delvaux et al.
Impact of PMTCT on institutional deliveries
in Rwanda – HIV-positive women
At health facility
89%
2008 (N=1,253)
11% In the
87%
2007 (N=1,053)
13%
80%
2006 (N=966)
20%
72%
2005 (N=499)
20%
40%
general
population
45% of
women
delivered
at HF
(IDHS
2007-08)
28%
69%
2004 (N= 412)
0%
Home
31%
60%
80%
Bangendanye, L; Price, J.E.; Micomyiza E.; Shumbusho F.; Wesson
100%
Remaining challenges - 2
•
Insufficient integration and linkages within maternal,
newborn and child health services, and other sexual and
reproductive health services, including family planning
•
Limited resources and operational guidance for effective
implementation of primary prevention and prevention of
unintended pregnancies among women living with HIV in
the specific context of PMTCT
PMTCT as an opportunity to operationalize
combination prevention
Preventing HIV infection
in women
Preventing HIV infection
in all women
(and their partners)
Preventing HIV infection
in pregnant women
(and their partners)
Within national
multi-sectoral
prevention strategies
Specific interventions
targeting
pregnant women
Prevention of unintended pregnancies among
women living with HIV
•
•
Provide HIV testing and counselling at family planning
clinics (on-site or through referrals)
Provide FP services with focus on condom-based dual
protection at PMTCT sites, STIs clinics and ART centers
•
Provide access to emergency contraception services
and post-abortion care services
•
Capacity-building of service providers in addressing
SRH needs and rights of women living with HIV
Remaining challenges-3
•
Lack of operationalisation of community-based
interventions (lay counselors, peer support
groups, Mother2Mother) as integral components of
national scale-up strategies
•
Poor data collection, reporting, analysis and use, and
limited capacity for operation research to inform
policy formulation, advocacy and programming
Opportunities
•
Current momentum for health systems strengthening
(IHP+, H4, etc)
•
Current momentum for virtual elimination of mother-tochild transmission of HIV
⁃
⁃
⁃
UNAIDS joint programme: focus of all the UNAIDS cosponsors
on PMTCT as a priority area by making the resources of the
UN work for results at the country level
The Global Fund has declared PMTCT a priority:
reprogramming existing grants to accelerate scale-up in 10
countries (Ethiopia, Kenya, Malawi, Mozambique, Nigeria,
South Africa, Tanzania, Uganda, Zambia, and Zimbabwe)
PEPFAR’s second five-year authorization includes as target
PMTCT coverage of 80%
Global strategic vision for virtual
elimination of mother-to-child transmission
of HIV - 1
1. Strategic shift from HIV infection averted and HIV-free
survival focus towards the overall goal of improved
maternal and child health and survival for an HIV-free
and AIDS-free generation
2. Increasing access and coverage by bringing services
closer to those in need through decentralization and
devolution to subnational authorities and subnational
health management structures
Global strategic vision for virtual
elimination of mother-to-child transmission
of HIV - 2
3. Using implementation of PMTCT as an opportunity to
strengthen health systems with special attention to
MNCH services
4. Operationalising integration and linkages within
MNCH services, other SRH services including FP and
HIV care and treatment services to ensure better
continuum of care for women and children
Way forward -1
1.
Alignment and harmonization among national programmes
(HIV/PMTCT, MNCH, Nutrition, SRH, …) and partners
around population-based national scale up plans and subnational operational plans to address programme
fragmentation and parallel funding
2.
Promoting and supporting decentralisation and devolution:
operationalizing planning, financing and implementation of
decentralised delivery of services using sub-national level
as unit of planning, implementation and M&E and making
resources available
3.
Scaling up innovations as integral components of
continuum of care for children and mothers (Point of care
CD4; Mother-Baby-Packs; Rapid SMS) to accelerate
expansion of services
•
Way forward - 2
4.
Making resources available and fostering sustainability
through induction of changes in resource allocation
including innovative approaches such as performancebased financing
5.
Improvement of infrastructure and equipment,
optimizing working conditions, and improve efficient
delivery of services:
-
Rehabilitation and equipment of ANC, delivery care,
laboratory and pharmacy facilities
Reorganization of service delivery mechanisms
Way forward - 3
4.
Closing the gap between health facility-based approach
and communities through partnering with individuals,
families and communities, including PLWH and male
partners in service provision, curbing stigma and
discrimination and demand creation
6.
Closing the knowledge gap through promotion of and
support to impact evaluation and operational research
to inform policies, advocacy, and programming
Ways forward - 4
7.
8.
Promoting and supporting access to the best available
science for all in need by:
Scaling up more efficacious ARV regimens for PMTCT
Early diagnosis and ART for infants and children
Redoubling our efforts for optimal and safe infant and
young child feeding practices
Building national capacity in M&E (data collection, analysis
and use), progress tracking, and operational research
(including impact assessment) to inform advocacy,
programming and scale up
Two Worlds, Two Realities, One Hope:
addressing inequity for social justice