Rapid Scale Up of HIV Care in Mozambique

1
The Integration Challenge pMTCT and HIV
treatment For pregnant women in Mozambique
2
HIV prevalence in Mozambique, 2004
North 9.3
Central 20.4
South 18.1
Country 16.2
3
Background MozambiqueHealth and Development
Indicators

• Total Population 18.5 million
• GNI Per Capita (US) 220 USD
• GNI/Capita Average Annual Growth Rate 4.4
• Per Capita Expenditure of Health 8 USD
• Govt Budget Spent on Health Care 11
• Human Development index rating 168/177
• Adult Female Literacy Rate 26
• Infant Mortality Rate (per 1,000 live births)
  100.7
• Maternal Mortality Rate (per 100,000 live births)
  980

4
Distribution of pMTCT Sites
Cabo Delgado 0
Niassa 1
Nampula 0
Tete 7
Zambezia 6
Sofala 14
Manica 9
Inhambane 5

• Total number of pMTCT sites 23 in Central
  Region

Gaza 7
Maputo Province and City 7
5
Current Status-pMTCT
NB Through September 2005
6
pMTCT Program

• Apparently simple technology
• Prevents transmission to children no long-term
  benefit for mothers
• Began in 2002 in Mozambique
• Regimen SD NVP for mothers, and SD NVP for
  infants. For exposed children whose mothers did
  not get NVP SD NVP 1 wk of AZT. Option for
  AZT from 3rd trimester but only available at HIV
  treatment centers
• NVP given at 36 wk PN visit and in Maternities.
  Mothers who do not have institutional births
  encouraged to return in 72 hours pp for infant
  dose
• National guidelines follow AFASS counseling for
  infant feeding practices, no MOH/national
  provision of formula. Some NGOs (MSF, San
  Egidio) have provided formula

7
National results (2002 a Set. 2005)
28
53
15 das testadas
Grávidas HIV
Grávidas HIV que Receberam Profilaxia comARV
Mulheres grávidas Atendidas na CPM
Grávidas aconselhadas e testadas
8
National NVP Cascade (2002 a Set. 2005)
53
63
95 das testadas
3 das HIV
Grávidas HIV que receberam Profilaxia com ARV
Recém- Nascidos Com ARV
Crianças testadas
Crianças HIV-
Mulheres em TARV
Partos HIV
Grávidas Testadas HIV
9
Access to Services

• 43 have institutional births
• 70-80 have at least one PN visitover 50 at 32
  weeks or later
• 22 participate in positive mothers groups.
• lt40 arrive at the Day Hospital

10
Program Coverage2004
73
92
12 pMTCT sites in both provinces by the end of
2004
11
Access to services for HIV mothers
Manica and Sofala, 2004
18
33 of HIV
43
103
76
12
HIV cases prevented by pMTCT 2004
3795
1244
759
249
124

• 124 transmissions prevented plus 30 women on
  HAART before delivery 154 expected HIV
  transmissions prevented. (20 of total without
  intervention)

13
Late PNC visits in IPT study
14
HAART Treatment for Pregnant Women

• All women referred to the Day Hospital
• 5 pMTCT sites located close to treatment from
  beginning of HAART availability (3 in Chimoio, 2
  in Beira)
• Approximately 36 of women eligible for HAART
  during pregnancy
• Criteria for HAART
• CD4 count under 350
• Phase 4 with any CD4 count

15
pMTCT Flow Efficeincy to HAART treatmentChimoio1
4 months from June 2004 to August 2005
(47)
16
Arrival at Clinic to HAART
21.1 arrive while pregnant, 586 women lost
36.6 Eligible for TARV
17
Efficiency?

• 4-5 visits needed for HAART (2-3 counseling,
  one lab, 1-2 clinician)
• Each visit increases chances of HAART 2.6X
• Failure of Eligibles to get HAART
• Too short (less than 2 months to delivery) 4
  (16.7)
• Failure of clinical management 8 (33.3)
• Pt failed to return 12 (50)
• Only 3.7 of all HAART eligilbe pregnant women
  with access to testing and treatment got HAART
  before delivery

18
Program Improvements-NVP

• NVP at 36 weeks to take at home may only reach up
  to 20 of mothers
• NVP at 32 weeks would reach over 50 of women
• Third trimester AZT in PNC sites may also reach
  over 50 of women.
• Testing all women at maternities or universal NVP
  in high prevalence settings???
• Opt out testing???
• Community delivery of NVP, provision of NVP for
  all women at first visit? Improve family
  involvement
• Integration of services

19
INTEGRATION

• pMTCT with ANC services
• Opt out testing
• At risk child consult protocols
• Follow up for feeding practices
• Testing at 18 months
• Simple protocols for referrals to treatment

20
Improving Definitive Treatment for Women

• Decentralize and better integrate HIV
  treatmentCD4 testing at PN visit
• Fast track or prioritize pregnant women for
  HAART evaluation
• Better efficiency of visits
• Improve charting to better identify pregnancy and
  EDD

21
TECHNOLOGY and IMPLEMENTATIONpMTCT and HAART

• Easier not always easier
• Difference in perceived benefit to community
  served?
• Resource Allocation trade offs?
• Socio-economic-cultural barriers?
• Implementation requires
• Commitment of policy makers
• Integration with public health system
• Community acceptance/understanding
• Understanding of constraints and barriers
• Sustainable systems and funding