Policy on the Prevention of MothertoChild Transmission of HIV in Barbados

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Policy on the Prevention of Mother-to-Child
Transmission (of HIV) in Barbados
P. Anton R. Best, MBBS, MPHTM, Senior Medical
Officer of Health (CD) HIV/ AIDS
Program, Ministry of Health
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Outline

• Background
• Rationale
• Goal of Barbados PMTCT Policies

• Policy Components
• 1. HIV Testing in Pregnancy,
• 2. Referral System for HIV Pregnant Women,
• 3. Treatment and
• 4. Prevention

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Background Mother-to-child Transmission (of HIV)

• In 2007 there were 420 000 children under the age
  of 15 who were newly infected with HIV, globally.
  
• 90 of pediatric infections are due to
  mother-to-child transmission of HIV.

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Background

• The strategies recommended by the UN agencies to
  prevent mother-to-child transmission include
• 1. Primary prevention of HIV in women in
  general and among future parents,
• 2. Prevention of unintended pregnancies in
  HIV-infected women,
• 3. Prevention of HIV transmission from
  HIV-infected women to their infants and
• 4. Providing care and support for parents and
  families

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History of PMTCT in Barbados

• The PMTCT program started in 1995.
• Long course monotherapy with AZT was employed
  which resulted in a near 80 decline in
  transmission of HIV.
• In 2000, a NVP regimen was commenced for PMTCT.
• This resulted in an 8 transmission rate to
  infants born to HIV mothers.

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• In 2002 HAART became available to all PLHIV in
  Barbados who meet the criteria, free of cost, as
  part of the Comprehensive Program for the
  Management, Prevention and Control of HIV/ AIDS
  2001-2006.
• Utilizing HAART for the purposes of PMTCT reduces
  transmission to 1-2 (NEJM 2002)

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• A study on MTCT 2002-2006 revealed that HIV
  transmission rate was 2.5. (St. John et al)

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Uptake of HIV testing in ANC

• The proportion of pregnant women in Barbados
  being tested for HIV increased from 39.9 in 1993
  to 89.7 in 2004 (Kumar et al).
• We are currently aiming towards universal access.

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• The CHART network initiated the evaluation of the
  existing PMTCT programs with a view to scaling up
  PMTCT services throughout the region.
• Local guidelines for PMTCT were revised in 2006.

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Rationale

• Harmonization and standardization of such efforts
  to reduce MTCT in Barbados are required. We need
  to capitalize on current strengths and build on
  success, and adequately address deficiencies,
  hence the formulation of the Barbados Treatment
  Guidelines for the Prevention of Mother-to-child
  Transmission (of HIV) and these accompanying
  policies.
• This document articulates comprehensive policies
  for PMTCT that span the continuum of
  prevention-to-care illustrated in the following
  table

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Mother-to-child transmission The
prevention-to-care Continuum
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Goal of National Policies on PMTCT

• to guide the health sector of Barbados in
  effectively implementing a comprehensive program
  for the prevention and control of transmission of
  HIV from mother to child.

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• The overarching objectives of the policy document
  address the elements in the previous table and
  serve to strengthen service delivery in the
  following areas
• 1. HIV Testing in Pregnancy,
• 2. Referral System for HIV Pregnant Women,
• 3. Treatment and
• 4. Prevention.

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1. HIV Testing in Pregnancy

• Objective To determine the HIV status of all
  pregnant women.
• All pregnant women should be offered HIV testing
  at booking and re-offered HIV testing later in
  pregnancy between 30 34 weeks.
• PITC is the strategy employed for greater uptake
  of HIV testing.
• Pregnant women have the right to refuse HIV
  testing.

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HIV Testing in Pregnancy (2)

• Results should be clearly and accurately
  documented in the antenatal records of the
  patients using the standard coding system.
• In the Polyclinics, HIV testing may be done by a
  health sister or the VCT counselor.

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HIV Testing in Pregnancy (5)

• In other health care settings, HIV testing is the
  responsibility of a trained healthcare provider.
  Timely acquisition and accurate documentation of
  HIV test results shall be done by that provider.

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HIV Testing in Pregnancy (6)

• A rapid test should be offered to all un-booked
  women presenting in labor or to those booked
  women presenting in labor whose recent HIV status
  is unknown or not documented.

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2. Referral System for HIV Pregnant Women

• Objective To ensure that all HIV women have
  joint antenatal and postnatal care by an HIV
  specialist, an obstetrician and a pediatrician
  for the purposes of PMTCT.

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Referral System for HIV pregnant women
HIV Pregnant Woman

HIV Specialist at the LRU or in private setting
Polyclinic
Private OBGYN or Family Physician


ANC (QEH)
Private Delivery
Labour Ward for Delivery (QEH)
Private Paediatrician or Paediatrics Outpatient
clinic, QEH follow-up care of the mother
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Referral System for HIV Pregnant Women (3)

• Ideally, all HIV pregnant women should be known
  to the physician, nurses and counselors at the
  Antenatal Clinic, QEH and the LRU.
• Whether the woman was previously diagnosed HIV
  or is newly diagnosed HIV, she should be
  referred for specialist obstetric care.
• All HIV pregnant women should be regarded as
  high risk pregnancies.
• All HIV pregnant women should be referred for
  specialist care and management of their HIV
  disease and for the purposes of PMTCT.

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Referral System for HIV Pregnant Women (4)

• At all times effective and highly confidential
  communication amongst all health care workers
  involved in the care of the patient is expected
  to ensure that she follows through from one
  referral to another.

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3. Treatment

• Objective To reduce the risk of mother-to-child
  transmission (of HIV) through the use of ARVs and
  other treatment modalities.
• NOTE Treatment for PMTCT is outlined in the
  current Barbados Guidelines for PMTCT.

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Treatment (2)

• All HIV pregnant women should be adequately
  counseled on HIV infection the potential benefits
  and risks of ARVs.
• All HIV pregnant women should be offered ARVs,
  whether for prophylaxis or for treatment, to
  reduce the risk of transmission of HIV to her
  child.
• All HIV pregnant women residing in Barbados may
  be given free ARV therapy.

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Treatment (3)

• Specialist HIV physicians seeing HIV pregnant
  women should make clear and concise written
  entries in the antenatal notes of the patient.
  These entries should comprise pertinent
  information such as recent CD4 and Viral Load
  results and the ARV regimen being used.

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Treatment (4)

• Healthcare providers (physicians and nurses) at
  the LRU are responsible for providing and
  supervising ARVs for all HIV pregnant women.
• After delivery comprehensive care, support and
  treatment should be provided to the HIV woman
  and her family.

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4. Prevention

• Objective To reduce the risk of mother-to-child
  transmission (of HIV) through prevention
  interventions (prevention of HIV transmission and
  prevention of unintended pregnancies)

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Prevention (2)

• Strategies should be employed to prevent women
  from being infected by HIV.
• Women who are HIV should be counseled on safer
  sexual practices and on comprehensive family
  planning options.
• Prevention also includes combinations of advocacy
  for safer sex, HIV testing, ARV and other
  interventions to prevent the child from acquiring
  HIV from its mother.

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Prevention (3)

• It is the policy of the MOH that HIV mothers
  should not breast feed.
• The MOH supports alternative forms of infant
  feeding.
• All HIV mothers should be counseled and provided
  with general information about the advantages and
  disadvantages of various infant feeding options.

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Conclusion

• Rationale for PMTCT Policies.
• GOAL to guide the health sector of Barbados in
  effectively implementing a comprehensive program
  for the prevention and control of transmission of
  HIV from mother to child.
• 1. HIV Testing in Pregnancy,
• 2. Referral System for HIV Pregnant Women,
• 3. Treatment and
• 4. Prevention.

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Thank you!