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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 Rajasthan Uttar Pradesh Arunachal Pradesh Assam Nagaland Meghalaya Manipur Tripura Mizoram

Bihar West Bengal

Gujarat

Madhya Pradesh

Daman & Diu Dadra Nagar Haveli Maharashtra

Orissa

Andhra Pradesh Goa Karnataka

HIV +
Andaman & Nicobar

U5MR

Pondichery Tamil Nadu Lakshwadeep Kerala

Adult HIV Prevalence

High Prevalence States

INDIA : MCH PROFILE


Total Population 1027 M

Crude Birth Rate


Sex Ratio (F:M)

25/1000
933

Annual Pregnancies
ANC Coverage

27 M
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 60 40 20 0 50.3 35.7


Before counselling After counselling

85.1

87.8

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
63 uninfected

# uninfected # infected during BF for 2 yrs # 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
ANC
One-To-One

Group Education HIV Test

Offered HIV test

Post-Test Counseling
HIV + HIV -

Pre-Test Counseling
One-To-One

Enrollment: AZT/NVP

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 Phase 3 - 2003-2004

159 District Hospitals/ Maternity Hospitals High Prevalence States

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. 1. 2. 3. Activities Total No. of New ANC Registrations in 288 PPTCT Centers Total No. of women counseled
% Numbers

11,34,839 9,40,853 82.9

Total No. of women accepted HIV test


4. 5. 6. 7. 8. 9. No. of spouses/partners of HIV positive women accepted HIV test 10. 11. No. of Husbands / partners detected HIV positive No. of women coming directly in labour without ANC Reg. No. of women found HIV positive No. of women who collected their HIV results No. of women who received post test counseling No. of HIV positive women who collected their results No.of Spouses/ partners of HIV positive women counseled

8,29,164
8,839 6,81,610 6,43,336 6,987 4,781 4,533 3,759 2,11,518

88.13
1.07 82.2 77.5 79 54 94.8 82.9

S. No. 12. 13. 14.

Activities No. of women counseled who arrived in labour without ANC No. of women who accepted HIV test No. of women detected HIV positive Total HIV Tests Done in PPTCT Centers for pregnant women Cummulative HIV Positivity Rate among Pregnant women Total no. of mother-baby pairs received NVP No. of mother-baby pairs received NVP who were registered for ANC No. of mother-baby pairs received NVP who came directly in labour Total pregnant women availing PPTCT Services counseling onwards(Booked 9,40,853+ Unbooked 1,25,512 )

Numbers

1,25,512 1,08,288 1,872 9,37,452

59.3 86.24 1.73

15.
16.

1.14% (8839+1872)= 10,711/937452 4,451 3,223 1,228 41.56

17.

18.
19. 20.

10,66,365

* Uttaranchal, Bihar, West Bengal, Delhi, Chandigarh

Increase in Facility based coverage


However Nevirapine uptake is static at 40-42%

100 90 80 70 60 50 40 30 2003 2004 2005 Nos of women counselled Nos of women accepting HIV test Nos of mother baby pairs receiving NVP

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 infectionFor 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

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