Clinton Foundation HIV/AIDS Initiative: Global Prevention of Mother-to-Child Transmission of HIV

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Clinton Foundation HIV/AIDS Initiative Global
Prevention of Mother-to-Child Transmission of HIV
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Eight Years into PMTCT Efforts in Resource Poor
Regions
New Infections
Deaths
Impact of current PMTCT efforts
Net Impact
HIV

• 20 of women in developing countries receive
  PMTCT services
• The quality of services are varied
• Resulting in an annual increase in the number of
  children living with HIV
• Net result failure of the current efforts

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Current PMTCT and CHAIs Hopes
lt28 weeks before birth
18 months after birth
EID system rare, majority of children LTF most
women mixed feed, primarily breastfeeding
Most women give birth in the home- births are
assisted by untrained individuals
Sd-NVP with only 40-50 efficacy no linkages to
ct most women attend only 1 ANC
Current Failure
Focus on prevention of HIV transmission and less
on mothers health resulting in orphans. No
strong linkages to continued care
Less than 20 of pregnant women are tested
Early infant testing at 4-8 weeks, 6 months after
weaning and Serology at 12-18 mos. Counsel
mothers on importance of Exclusive feeding and
support her choice, if EFF, provide water
treatment supplies and formula
Support women (through CHWs, transport etc) to
give birth in facilities- train staff on
non-invasive procedures and Intra-partum testing
Our Vision
Support Govts to provide the highest possible
standard of care at a minimum HAART preferred
min. is WHO 2006 recommended. increase uptake
of all ANC visits
Support governments in building systems that will
support both HIV and MCH programs - child
survival, family planning nutrition, malaria
Reach and test all pregnant women. Huge
opportunity for primary prevention
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CHAIs Goal

• To demonstrate that a dramatic reduction of
  mother-to-child-transmission of HIV is achievable
  in resource-limited settings, by significantly
  increasing access to care and quality of PMTCT
  services
• The program will target the two main challenges
  in the provision of PMTCT services
• The need to provide high quality services
• The need to reach all pregnant women
• The program will serve as a vehicle to
  demonstrate that the proposed interventions can
• Dramatically reduce transmission of HIV from
  mothers to their children
• Be brought to scale

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CHAI Approach

• CHAI is working with all partner governments and
  local implementing partners to ensure that all
  HIV pregnant women and their infants have access
  to a full cascade of quality PMTCT services at
  all stages of transmission risk
• This cascade is defined by the following stages
• 1. Identification/Testing of all HIV Pregnant
  Women
• 2. Prenatal Care and Treatment
• 3. Delivery
• 4. Post-Partum/Early Infant Care and Treatment
• 5. Referral and Continued Care for Mother-Infant
  Pair
• w/in program catchment area

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Identification/Testing of all HIV Positive
Pregnant Women

• In order to reduce HIV transmission to infants,
  pregnant women must be identified as early as
  possible. Once in ANC, availability of
  counseling, testing and education are key to
  identifying HIV positive women and preventing
  primary infections in uninfected women
• Current Situation
• While most ANC sites provide testing, not all
  pregnant women attend ANC
• Staff are overburdened and counseling is not
  always a priority
• Goals
• To locate all pregnant women in catchment and
  encourage them (through education/community
  outreach) to attend ANC
• Thru network of community outreach and
  mobilization increase awareness
• Ensure that pre-test, opt-out and post-test
  counseling and testing are offered to all
  pregnant women, regardless of when they present
  to ANC (or during delivery)
• Bolster HR task shifting with lay counselors

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Prenatal Care and Treatment

• Current Situation The majority of sites offering
  PMTCT are only providing, at most, Sd-NVP at
  delivery.
• 1. Treatment
• Evidence has indicated that early treatment
  for those who are eligible results in
• quality and quantity of life-years as well
  as reduces HIV transmission to infant.
• Eligibility is based on staging, which
  includes CD4 and clinical
• Goals
• CD4 and clinical evaluation to be obtained at
  time of positive HIV test results, and results
  returned to mother as quickly as possible
• Facilitating transport
• Raise CD4 threshold (for treatment with HAART) to
  350
• 2. Prophylaxis
• Evidence suggests that the more aggressive
  the regimen, the lower the rate of
• HIV transmission to the infant.
• Goal
• Where possible, HAART for all. At minimum, the
  2006 WHO recommendations

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Delivery

• Evidence indicates that prolonged labor,
  premature rupture of membranes and invasive
  procedures during delivery is associated with
  increase risk of HIV transmission to the infant.
  Furthermore, many women present for the first
  time in labor and HIV status is not known.
• Current Situation
• Majority of women deliver at home
• If attended, usually by untrained birth
  attendants
• Rarely are women offered HIV testing in labor
• Goals
• With the assistance of Community Health Workers,
  mobilize communities and assist women into health
  facilities for safe deliveries (non-invasive
  procedures whenever possible) support transport
• Ensure that all MCH staff are trained on
  intra-partum testing for mothers
• whose status is unknown
• 3. Ensure that all staff are trained and have
  job aides available to reinforce safe delivery
  practices

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Postpartum/Early Infant Care and Treatment

• Infant testing/Treatment
• Early infant diagnosis is key to improving the
  long-term health of HIV positive infants. Current
  WHO recommendation is to obtain at DNA-PCR test
  at 4-8 weeks of life and Serology at 18 mos
• Desired standard of treatment (and WHO
  recommended) is ARV prophylaxis with Sd-NVP AZT
  for 7 28 days and Cotrim from six weeks of age
  until HIV status determined 6 weeks post-weaning
• Current Situation Many women in developing
  countries will breastfeed their children up to 24
  months of life and availability and uptake of
  infant testing is generally low
• Goals
• Obtain PCR DNA at 6 weeks of age, 6 weeks
  post-weaning and serology at 18 mos. If the
  child is not breastfeeding, the serology can be
  obtained earlier.

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Postpartum/Early Infant Care and Treatment
(contd)

• Infant Feeding
• Whether formula or breastmilk, the most important
  aspect here is exclusivity.
• Current Situation
• The vast majority of women in our program
  countries breastfeed, in part because of cultural
  significance and in part because they do not have
  the resources required (financial and water
  treatment) to formula feed. Many will mixed feed.
• Goals
• Promote Mothers Choice- and where agreed to by
  Gov partners, provide formula, water treatment
  supplies and support for mothers that choose
  Exclusive Formula Feeding (EFF)
• Ensure proper counseling for mothers and staff on
  the risks and benefits of both methods (breast
  and replacement), and ensure close monitoring for
  exclusive feeding
• Work with all partners to develop clear
  guidelines and support for complimentary feeds

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Referral and Continued Care for Mother-Infant
Pair

• In order to ensure continued health for both the
  HIV infected woman and child, all need to be
  linked to post-delivery care
• Current Situation weak to non-existent systems
  in place to ensure smooth transition into long
  term care
• Goals
• At each point of the cascade, community
  mobilization to reduce stigma and other
  identified cultural barriers to access
• All HIV infected women and children will be
  referred post-delivery for appropriate follow up
  CHWs to ensure and assist in follow-thru

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CHAI Global PMTCT Country Partners and Site
Descriptions
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Indias Perinatal Prevention of Mother-to-Child
Transmission of HIV (PPTCT)

• Objectives
• Universal coverage the program aimed to reduce
  transmission of HIV infection to under 5 by 2011
  in program districts
• Increase capacity of government and
  nongovernmental agencies and scope of services
  provided
• Pilot the most effective prevention strategy -
  HAART for all HIV-positive pregnant women from 28
  weeks weaning
• Strengthen infrastructure and human resource
  capacity of PPTCT centers and delivery rooms
• Expand training and utilization of various
  community health workers, to accompany
  HIV-positive mothers and navigate through
  Reproductive and Child Health and ART services to
  ensure patient follow-up.
• Address stigma by partnering with BCC-focused
  NGOs to enhance IEC through schools, village
  meetings, CHWs and PLHA organizations

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CHAI/India Back of the Envelope Cost
Calculations