Beruflich Dokumente
Kultur Dokumente
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
Himachal Pradesh Punjab Chandigarh Haryana Delhi Sikkim Rajasthan Uttar Pradesh Arunachal Pradesh Assam Nagaland Meghalaya Manipur Tripura Mizoram
Gujarat
Madhya Pradesh
Orissa
HIV +
Andaman & Nicobar
U5MR
25/1000
933
Annual Pregnancies
ANC Coverage
27 M
65.4 %
Institutional Deliveries
[12.1% to 79.3%]
35.6 %
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
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
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
Nevirapine Administration
Mother: Screened for contraindications
Enrollment Procedure
ANC
One-To-One
Post-Test Counseling
HIV + HIV -
Pre-Test Counseling
One-To-One
Enrollment: AZT/NVP
Primary Prevention
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
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
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
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
15.
16.
17.
18.
19. 20.
10,66,365
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
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
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
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.
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 )
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