Human Resource Constraints and Roll out of more efficacious regimens for PMTCT The Zambian experience

1
Human Resource Constraints and Roll out of more
efficacious regimens for PMTCT The Zambian
experience

• Nande Putta MD MPH
• Technical Assistant PMTCT Paediatric HIV Care
• Ministry of Health

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HIV in Zambia

• Prevalence rate of HIV is 16 (15-49 yrs)
• One in five pregnant women is HIV positive (19
  ANC seroprevalence)
• Estimated 150,000 children are living with HIV
• Mother-to-child transmission accounts for over
  90 of childhood HIV infections
• Estimated 97,000 HIV infected pregnant women
  (HIV exposed infants)
• Each year estimated 28,000-40,000 children
  acquire the virus from their mother

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Zambia's Program

• Scale Up plan for pMTCT and Paed. ART developed
  with clearly outlined objectives and strategies
• Overall objectives for Zambia by 2010
• To provide comprehensive prevention of
  mother-to-child transmission services to at least
  80 of pregnant women
• To provide ART to at least 80 of HIV-positive
  children in need of ART

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Progress in Service Provision

• Steady progress from 74 sites in 2003 to 678 in
  2007

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Performance 2007

• 678 PMTCT sites (53 coverage)
• Of estimated 500,000 annual pregnancies, 306,000
  tested (61)
• Of estimated 97,000 HIV positive pregnant women,
  52,800 identified (54)
• Of estimated 97,000 HIV positive pregnant women,
  35,300 accessed ARVs (36)

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Performance 2007 contd.

• Of estimated 97,000 HIV exposed babies, 15600
  accessed ARV proph. (16)
• Of estimated 97,000 HIV exposed babies, 11,900
  receive Cotrimoxazole proph.(12)
• Of estimated 97,000 HIV exposed babies, 7600
  received a virological test within 2 months (8)

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Performance 2007 contd.
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Progress over last 3 years (2005-2007)
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Guidance for PMTCT regimens in Zambia

• More efficacious regimens incorporated into
  revised pMTCT guidelines and training package
• Adapted from the WHO guidelines
• Single dose NVP dispensed at first contact to be
  taken at onset of labor
• AZT dispensed beginning at 28 weeks
• AZT/3TC given at onset of labor with NVP
• AZT/3TC given through labor and as a tail for 7
  days

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Guidance for PMTCT regimens in Zambia

• For baby
• Single dose Nevirapine soon after birth
• 7 day tail of AZT (28 days if mother received
  less than 4 weeks of ARVs)

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Guidance for PMTCT regimens in Zambia as quoted
from the guidelines

• At the first visit after confirming the mother
  is HIV positive, the woman can be given her
  single NVP dose to take home so she can take it
  at the onset of labour. Where blister packs are
  available she may be given the full course of
  drugs for her to take during antenatal, labour,
  delivery and in the postpartum period

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Guidance for PMTCT regimens in Zambia as quoted
from the guidelines

• How ever it needs to be emphasized that she
  will need to be seen every four weeks for review.
  At these visits assess adherence and other issues
  such as disclosure, side effects and testing of
  other family members

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Guidance for PMTCT regimens in Zambia as quoted
from the guidelines

• These visits can also be used to reinforce
  messages such as infant feeding, family planning,
  early infant HIV testing and other aspects of
  continuum of care. She will also be given the
  babies NVP dose at the 32 week visit to be taken
  soon after birth and she should be advised on
  safe storage.

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Uptake of ARVs by Pregnant women for PMTCT

• Of HIV positive women identified through ANC
  testing and counseling, 67 are taking ARVs for
  PMTCT
• Of all estimated HIV positive women 36 are
  taking ARVs for PMTCT
• Current estimates show about 25 of women taking
  ARVs are using more efficacious regimens (sdNVP
  and AZT)

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Constraints contributing to low uptake of more
efficacious regimens

• Late 1st ANC visit booking and low average
  frequency of ANC visits
• Low institutional deliveries and postnatal
  attendance
• Lack of holistic care within MCH
• Poor linkages to other facets of treatment and
  care
• Poor reporting and recording
• Data tools not integrated and all inclusive
• Inadequate training of staff (refer to mapping
  exercise)
• Inadequate community involvement

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Constraints contributing to low uptake of more
efficacious regimens

• Suboptimal logistic and supply management at all
  levels (refer to mapping exercise)
• Slow dissemination of guidelines
• Inadequate Monitoring and Evaluation (mentorship,
  support supervision and feedback on these)
• Inadequate or inappropriate staff
• Inadequate integration of PMTCT into outreach
  visits

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Human resource situation in Zambia

• Human resource inadequacy is a huge problem
  facing the health sector
• Staff attrition caused by job seeking outside the
  country, job seeking to private and non
  governmental sector and illness death
• Average estimate is that most health institutions
  are running at 50 capacity
• Some health facilities being run by unqualified
  staff

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Human resource situation in Zambia in PMTCT care
provision

• High turn over of trained staff with inadequate
  compensatory training of staff
• Inadequate retraining or updating of staff
  trained when single dose Nevirapine was standard
  of care
• Human resource retention strategies in place
  though competing with time to provide universal
  access for PMTCT (rural retention scheme, direct
  entry midwifery training)

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Effect of Human Resource inadequacy on roll out
of more efficacious regimens

• Poor quality of counseling and care
• Poor reporting and recording
• Suboptimal logistic management at facility level
• Inadequate follow up of clients
• Inadequate performance self assessment

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Possible solutions to Human Resource inadequacy
and roll out of more efficacious regimens

• Task shifting
• Involvement of the community in mother baby
  tracking
• Involvement of peer support through initiatives
  like Mother2mother
• Easier delivery mechanisms such as blister packs
• Strengthen Supervision, mentoring and feedback
  mechanisms
• Over and above Health Systems Strengthening
  to cope with evolution of Scientific based
  recommendations

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Thank You Zikomo Natotela

• Any Questions?