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Introduction of the new PMTCT Policy and Guidelines
Parliamentary Portfolio Committee on Health
4 March 2008
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Purpose
Policy and Guidelines in brief
Recommended approach to implementation
Conclusion
Recommendations
Outline
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Purpose To provide an update to the Health
Portfolio Committee on progress with the introduction of dual therapy for PMTCT, for Information, Discussion, and Advice
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Guidelines in brief Approved by the Minister on the 12
February 2008 Policy approach addresses four
stages of intervention Primary prevention
Especially among women of child bearing age Antenatal care activities Activities during labour and delivery Postnatal care including safe infant
feeding
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Guidelines in brief
Early booking Routine offer of HIV testing
Approach and algorithm outlined Repeat test at 34 weeks if HIV
negative Counselling on safe infant feeding
Affordable, Feasible, Acceptable, Safe, Sustainable (AFASS) criteria emphasised
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Guidelines in brief Dual therapy – AZT + sdNVP
AZT from 28 weeks (or as soon as possible thereafter but before the onset of labour) and through labour + sdNVP at labour
Baby – sdNVP + AZT (7 OR 28 days)
Cotrimoxazole – mothers and babies
Nutrition interventions Supplements – HIV positive pregnant women, and or Food supplements
Other social security interventions
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Guidelines in brief CD4 count at HIV positive diagnosis OR earliest
afterwards HAART if < 200 and/or WHO stage 4
Comprehensive plan guideline Prioritisation of pregnant women at service points
O&G units to consider providing HAART Safe obstetric procedures Intensive infant feeding education and support Early testing - PCR for babies Data management and reporting Document is on the Departmental website
Being prepared for printing and distribution with training
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Guidelines in brief Major developments relate to
Addition of AZT to sdNVP Infant feeding policy
Implications Longer course of therapy Require more complex health systems support Drug adherence support is critical for the realisation of health
outcomes Especially for safe infant feeding
Expected improvement in efficacy > 90% in clinical trials (sdNVP was 50% in clinical trials)
Reduction in risk of resistance development Challenges
Access Monitoring Budgets Communication
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Approach to implementation Considerations for readiness to
provide the service may include: A facility manager Trained team on site Adequate physical space Other relevant services- BANC, FP, basic
HIV & AIDS services Reasonable access to laboratory services
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Approach to implementation Efficient Information management systems Good record of adherence to drug dispensing
SOPs for OI Management & ARVs Reasonable demand, utilisation & supply
numbers on the current PMTCT Programme Maximise access and efficiency
Patient/treatment tracking system in place Efficient links with district & province Efficient links with community-based
organisations
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Approach to implementation The following health facilities may be
considered during the introduction phase: Comprehensive Plan (CCMT) service points Non-CCMT hospitals with O & G units & ANC
services CHCs with Maternal and Obstetric Units &
established comprehensive HIV & AIDS and MCWH programmes
Other PHC facilities that fulfill the criteria above
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Approach to implementation
District-based approach District manager
Mapping of current PMTCT services in each sub district Identification of facilities for implementation of full package
new PMTCT guideline Establishment of effective referral systems in each sub
district Seamless information management
Identify elements for the different levels with minimal negative impact on access
Work closely with local municipality health services Supporting coordination of implementation
PMTCT and MCWH coordinators Sub district “complexes” of facilities to inform
provincial implementation plans
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Approach to implementation “Medicine Act” of 1965 and the “Nursing Act” of 1978
provide regulatory framework for the handling of medicines
All ARVs are Schedule 4 drugs Require a prescription by a Doctor (Medicines Act) Nursing Act, 1978
Handling of medicines by nurses (Section 38A) Examine, diagnose illness or defect Authorisation
DG, HOD, Medical Officer of Health in Local Authority, medical officer of an organisation – DG designated after consultation with pharmacy Council
Consultation with Nursing Council Only whenever the services of a medical practitioner or
pharmacist are not available Adhere to regulations GN R2418 of 1984
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Approach to implementation Small clinics and PHC centres with ANC services
VCT Infant feeding counselling and support CD4 testing TB screening Nutrition support Social support PCR testing Haemoglobin monitoring
Larger centres with easy access to a doctor should be considered for prescription of dual therapy
Clients may be referred to these centres for the original prescription AZT could be delivered to the smaller clinics on patient-name
Consider invoking the regulatory provisions in order to increase access
Quality assurance will be critical
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Laboratory services Haemoglobin monitoring
Point-of-care, hand held devices used Laboratory tests may be required in complicated cases More training to be done
VCT Rapid test kits used Quality assurance system in place – provinces to improve adherence to
programme Access to CD4, Viral load, and PCR has improved considerably over the
comprehensive plan period Turn-around-times to be improved Courier services to be expanded to meet demand
Resistance surveillance Annual antenatal survey Virologic failure amongst comprehensive plan clients
Opportunity to improve technology for better efficiency Especially in remote areas
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Information management and research Cover core indicators outlined in guideline
document Starting with 13 (currently 7 reported on) Facility to District to Province to National
Feedback to all who need information To be expanded after twelve months
Cover all indicators in the guideline Operational research and questions
Awareness and knowledge, uptake, health systems issues, quality, access
Outcomes Part of training programme
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Communication and Social Mobilisation
Provincial EXCOs Provincial Councils on AIDS
District AIDS Councils General public
By the NDOH By the Provinces
Communities Mass media, Province and District-based
Indaba’s, etc
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Communication and Social Mobilisation What to communicate
The PMTCT package Primary HIV Prevention Early ANC booking Benefits of VCT Male and partner involvement Community involvement & support Safe infant feeding Adherence and support Where to access all relevant services Importance of follow up
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Approach to training Update current PMTCT manual – MCWH &
HIV and AIDS Clusters Manual to be printed by 25 March 2008 Training to start on 31 March 2008
Short term in-service information updates Course is envisaged to be 7 days
Counselling, haemoglobin monitoring, other drug toxicities, PCR, safe infant feeding, nutrition for the mother, dual therapy, programme monitoring and evaluation, and other relevant aspects
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Approach to training Master trainers and course directors - 10 per
province – critical mass Over three weeks in April Train-the-trainer
Down-cascade Prioritise identified service points Facility managers, hospital CEOs, all participating staff,
support services staff District managers and local health municipal services All relevant units in province
Health service providers to be trained by midMay in all nine provinces
Pre-service through the relevant institutions
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Provincial support NDOH
Printing and distribution of all relevant materials Information dissemination and provincial workshops Monthly provincial support visits for the first 12
months MCWH and Nutrition, HIV & AIDS, QA units
Implementation of the training programme Quarterly progress review meetings Information management and updating the DHIS Development and monitoring of conditional grant
business plans – DORA Ensure adequate resources for the MTEF period
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Proposed PMTCT - MTEF Budget
Province 2007/08 2008/09 2009/10 2010/11
EC11,933
m 43.871 m 50.381 m 56.593m FS 7,721m 28,386m 32,598m 36,617m GP 10,921m 40,150m 46,108m 51,794 mKZN 7,320m 26,911m 30,905m 34,716m LP 9,466m 34,801m 39,965m 44,893 mMP 2,757m 10,136m 11,640m 13,075 mNC 4,293m 15,783m 18,125m 20,360m NW 6,721m 24,709 m 28,376m 31,875 mWC 15,415m 56,672m 65,082 m 73,107m
Total76,547
m 281,420m
323,180m
363,030m
Current budget (projections) 3.8%
84,946m
101,695m
107,797m
Projected shortfall -196,474m
-221,485 m
-255,233m
Approved Addit. Budget 350,000m
650,000m
1,100,000m
PMTCT new proposal vs. additional budget 56.1% 34.0% 23.2%PMTCT new proposal vs. Total HIV and AIDS budget 10.9% 9.9% 9.1%
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RESOURCE IMPLICATIONS Items to consider for 2007/08 (the next six
weeks) Printing and distribution
Guidelines, IEC, Training manual, facility register, support visit tool
Training of trainers Stakeholder meetings Budgets available from NDOH
Provinces to submit business plans to the DG by 14 March 2008
Service points identified Patient target numbers 12 month plans
Indicating starting date
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Progress HODs have been briefed
Detail of policy and guideline discussed with provincial HAST managers
Approaches to implementation discussed with provinces
Developing provincial business plans NHC Council briefed
Commitment to support implementation of the policy and guideline
Local municipalities keen to contribute
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Conclusion The new policy and guidelines for PMTCT has been
approved National operational plan to be informed by
provincial business plans Some provinces may be more ready than others All nine provinces should have started by end of May
2008 NHLS to ensure support to implementation NDOH to ensure allocation of budgets during the
adjustment bid process Monitoring and evaluation essential
Pharmacovigilance Resistance surveillance Conclusion of current programme evaluation