Title: PREVENTION OF MOTHER TO CHILD TRANSMISSIONOF HIV IN INDIA: ISSUES AND CHALLENGES
1PREVENTION OF MOTHER TO CHILD TRANSMISSIONOF HIV
IN INDIA ISSUES AND CHALLENGES
- Dr . S.K CHATURVEDI
- UNICEF
- DR. KANUPRIYA CHATURVEDI
2LESSON 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
3Global HIV/AIDS IN 2004
- Effect on Children
- 39.4 -40.0 million people are living with
HIV/AIDS - 2.2 million are children under 15 years
- 6,40,000 children were newly infected with HIV in
2004 - 5,10,000 children died of HIV in 2004
4NEW CHALLENGES . NEW OPPORTUNITIES
HIV
U5MR
5Adult HIV Prevalence
High Prevalence States
6INDIA MCH PROFILE
- Total Population 1027 M
- Crude Birth Rate 25/1000
- Sex Ratio (FM) 933
- Annual Pregnancies 27 M
- ANC Coverage 65.4
- Institutional Deliveries 12.1 to
79.3 35.6 - Deliveries attended by skilled birth
attendants 42.3
7Feasibility 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
- PPTCT Feasibility Study NVP October 2001 - June
2002 - NVP 200 mg single dose to mother at onset of
labour - NVP 2 mg/kg single dose to newborn within 72
hours
8Some Lessons Learnt Reduced transmission of HIV
from mother to infant
9LESSONS LEARNT
10(No Transcript)
11Unicef role in PPTCT
12 PPTCT Intervention Package
1. Ante-Natal Care
2.Group Education / Pre-Test Counselling
3. HIV Testing after Informed Consent
4. Post-Test Counselling
5. Institutional Delivery Safe Birthing
Practices
6. Administration of Nevirapine to the woman
during labour
.
13 PPTCT Intervention Package
7.Administration to the BABY of SINGLE DOSE
of Suspension Nevirapine ( 2 mg./ Kg.) within
first 72 hours
8. Counselling of mother for Infant Feeding
Options
9. Care Support
10. Follow -up
PPTCT Plus
14 Nevirapine Administration
Mother Screened for contraindications Single
Dose Tablet of 200 mg. during First stage of
Labour
Baby Single Dose of suspension within first 72
hours
Nevirapine Courtesy Donation from CIPLA
15Enrollment Procedure
Group Education
Offered HIV test
ANC
One-To-One
Post-Test Counseling
HIV Test
Pre-Test Counseling
One-To-One
HIV
HIV -
Primary Prevention
Enrollment AZT/NVP
16Rationale for PPTCT in India
27 million pregnancies per year 1,89,000
infected pregnancies per year Cohort of 56,700
infected newborns per year
0.7 prevalence
30 transmission
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
17SCALE UP STRATEGY
11 Centers of Excellence
780 Health Facilities
Phase 1- 2002
74 Medical Colleges High Prevalence States
Phase 2 - 2002
Phase 3 - 2003-2004
159 District Hospitals/ Maternity Hospitals High
Prevalence States
79 Medical Colleges Low Prevalence States
Phase 4 - 2004-2005
450 District Hospitals/ Maternity Hospitals Low
Prevalence States
Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs
18India PPTCT Performance Analysis of Jan-Dec
2004 (Data Source NACO , 04 August, 2005 )
S. No. Activities Numbers
1. Total No. of New ANC Registrations in 288 PPTCT Centers 11,34,839
2. Total No. of women counseled 9,40,853 82.9
3. Total No. of women accepted HIV test 8,29,164 88.13
4. No. of women found HIV positive 8,839 1.07
5. No. of women who collected their HIV results 6,81,610 82.2
6. No. of women who received post test counseling 6,43,336 77.5
7. No. of HIV positive women who collected their results 6,987 79
8. No.of Spouses/ partners of HIV positive women counseled 4,781 54
9. No. of spouses/partners of HIV positive women accepted HIV test 4,533 94.8
10. No. of Husbands / partners detected HIV positive 3,759 82.9
11. No. of women coming directly in labour without ANC Reg. 2,11,518
19S. No. Activities Numbers
12. No. of women counseled who arrived in labour without ANC 1,25,512 59.3
13. No. of women who accepted HIV test 1,08,288 86.24
14. No. of women detected HIV positive 1,872 1.73
15. Total HIV Tests Done in PPTCT Centers for pregnant women 9,37,452
16. Cummulative HIV Positivity Rate among Pregnant women 1.14 (88391872) 10,711/937452 1.14 (88391872) 10,711/937452
17. Total no. of mother-baby pairs received NVP 4,451 41.56
18. No. of mother-baby pairs received NVP who were registered for ANC 3,223
19. No. of mother-baby pairs received NVP who came directly in labour 1,228
20. Total pregnant women availing PPTCT Services counseling onwards(Booked 9,40,853 Unbooked 1,25,512 ) 10,66,365
Uttaranchal, Bihar, West Bengal, Delhi,
Chandigarh
20Increase in Facility based coverage However
Nevirapine uptake is static at 40-42
21Current level of PPTCT coverage
- PPTCT services are available in all states at
tertiary and secondary levels and currently 14
per cent of all pregnant women currently access
such services. However, in 2004, only 3.94 per
cent of all pregnant women received HIV
counselling and testing and 2.35 per cent of the
HIV-positive pregnant women received ARV
prophylaxis.
22Gaps
- 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
23Conclusions from India 2004 Data when
projected to a population base
Every year in India
Total number of pregnant women 270,00,000 (
27m)
Pool of HIV infected pregnant women 1,89,000
( 0.7 prevalence, NACO-2004)
Pool of HIV infected babies
56,700 ( _at_ 30 transmission)
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
24For 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
25PPTCT coverage for High Prevalence 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.
26- Strategies for HP states are
-
- Scale up services to all CHCs and PHCs . At
least to 50 by 2005/ 2006. - Provide PPTCT services through the private sector
.. At least to 50 by 2005/ 2006 - 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. - Care, Support and Treatment services for women
and children to be a priority. -
27PPTCT 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.
28- 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 )
-
29Convergence of PPTCT with ART Programme
- Convergence in Counselling
- Convergence in Training
- Linkages for Care and Support
30Issues and challenges
- Scaling up the access to PPTCT services
- Focus on quality Counseling services
- Streaming Patient Flow
- Emergency counseling and testing
- Operationalizing a single window system
31Issues and challenges(contd).
- 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
32Broad Strategies
- Developing and implementing a costed
population-based 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
33Key action points
- Decrease the loss to follow up in the existing
PPTCT centers - Strengthening the Emergency counseling and
testing service at all PPTCT sites - Scale up PPTCT services to cover all public
health care sites
34Action points (contd.)
- Public private partnerships
- Increasing access to quality counseling services
to women in the reproductive age group and
enhance institutional deliveries. - Building capacity of all health care providers
(up to grassroots level) in HIV /AIDS counseling
and management of HIV /AIDS cases. - Linking PPTCT programme to existing primary
prevention and care and support programs for HIV
/AIDS in the State and strengthening links with
People Living with HIV /AIDS networks (PLHA) of
all PPTCT service sites.
35 Tools for Scale Up
- Standardized training packages for PPTCT
team-(Gynaecologists, technician, pediatricians
and staff nurse) and Counsellors - 5 day training package for all team members
- 12 day training package for counselors that also
includes infant feeding - Cadre of master trainers at state level
- PPTCT indicators capturing process and outcomes
- Data flow Facility to national level
- Communication strategy in place (Phase I being
implemented, Phase II creatives being developed) - Testing supported by EQUAS