IAPSM Conference 2004
Greetings from
For every childHealth, Education, Equality, ProtectionADVANCE HUMANITY
IAPSM Conference 2004
Prevention of Parent- to- Child Transmission
( PPTCT) ( generally known as “ PMTCT”)
Dr. Bir SinghProject Officer, PPTCT
UNICEF, New Delhi
IAPSM Conference 2004 < 5 % high risk groups> 1 % antenatal women
HIV Prevalencereaches over 5%amongst high risk
group inMaharashtra and
Manipur
1.74 m infectedFirst case of HIV
detected inChennai
1986 1990 1994
> 5 % high risk groups
4.58 m. Indians living with HIV
3.5 m. infected
1998 2001 2002
4.01 m. infected 4.58 m. infected
IAPSM Conference 2004
Expanding Disease Burden1986 to 2002
00.2
1.75
3.53.7 3.86
3.974.58
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
No
. e
sti
ma
ted
as
HIV
in
fec
ted
(i
n m
illi
on
s)
1986 1990 1994 1998 1999 2000 2001 2002
IAPSM Conference 2004
Known modes of HIV transmission, 2002
7.24
2.61 2.992.87
84.29
Sexual IDUs Blood & blood proucts Perinatal Unidentified
IAPSM Conference 2004
No. of Children 0-14 Years with HIV= 1,70,000 ( UNAIDS, 2002)
No.of Children with AIDS =2,333 ( NACO, January, 2004)
IAPSM Conference 2004
Percent women aged 15-49 who know all threemodes of vertical transmission of HIV/AIDS
13.3
13
40.6
34.4
31.4
40.8
36.642.2
46.9
46.8
14
12.8
11.5
30.8
19
37.821.1
39.6 36.1
6.8
17.7
23.4
36.9
58.1
21
15
21.1
50.2
29.9
17.2
26.2
31.1
Per cent
< 2020 - 2930 - 3940 & above
MICS-2000
IAPSM Conference 2004
Percent women aged 15-49 who have heard of HIV/AIDS
21.6
26.2
65.8
76.1
59.7
84.7
8774.5
87.7
70.6
23.8
27.3
23.9
48.7
32
7441.3
54.3 74
12.7
35.4
43
56.3
88.3
43.4
31.1
59.2
92.8
54.7
41.1
54.8
63.9
Per cent
< 3030 - 4950 - 6970 & above
MICS-2000
IAPSM Conference 2004
M T C T in 1 0 0 H I V + M o th e rs- T h e m a j o r ity o f c h ild re n d o n o t g e tin fe c te d e v e n w h e n w e d o n o th in g
01 02 0
3 04 0
5 0
6 07 0
8 09 0
10 0# un infe cte d
# infec te d duringB F fo r 2 y rs
# infec te d duringde liv ery
# infants in fe cte ddurin gpreg nan cy
6 3
u n in fe c te d
1 5
1 5
7
IAPSM Conference 2004
Mother-Infant HIV Transmission in Hypothetical Cohort of 100 Children of HIV+ Mothers
Early antenatal
Late antenatal
Early postpartum
Late postpartum
36 wks 6 monthsLabor & Delivery
100 98
2 3
80
15
75
5
70 uninfected
5
95Childrenat Risk
ChildrenInfected 30 infected
IAPSM Conference 2004
Risk factors for postnatal transmission: Maternal immune status
HI V transmission from 6 w - 24 mo in
West Africa by maternal baseline CD4
14
1.40
5
10
15
CD4 < 500 CD4 >= 500
Cum
ulat
ive
HIV
tran
smis
sion
(%
)
Leroy et al 2002
IAPSM Conference 2004
PPTCT :The “Four Component” Strategy
Preventionof HIV inYoungPeople
Preventionof HIVinfection inwomen ofchild bearingage
PreventionofUnintendedpregnanciesin HIVpositivewomen
Prevention oftransmissionfrom a HIVinfectedwoman to herinfant
Care & Supportfor the motherand her family
IV II I III
WHO/UNFPA/UNICEF/UNAIDS
IAPSM Conference 2004
Prevention of Parent-To-Child Transmission of HIV in India
The Rationale for PPTCT
IAPSM Conference 2004
Rationale for PPTCT in India
27 million pregnancies per year
108,000 infected pregnancies
Annual Cohort of 32,000 infected newborns
0.4% prevalence
30% transmission
25,000-50,000 deaths within 2-5 years
PMTCT Feasibility Study AZT: March 2000 - August 2001
Total new ANC attendance : 192,474 No. of pregnant mothers counseled : 171,471 (89.1%)
No. of pregnant mothers accepted HIV tests : 103,681 (60.5%) No. of pregnant mothers detected HIV positive : 1,724 (1.7%) No. delivered with AZT : 726 (42.1%) No. of PCR samples at 48 hrs. tested : 427 No. of samples tested (+) positive : 34/427 (8.0%) No. of additional tested (+) at 2 months : 9
(adding a 2% transmission rate)
No. of women who opted for breastfeeding (620 : 135 (22%)
PMTCT Feasibility Study NVP: October 2001 - June 2002
Total new ANC attendance : 71,149 No. of pregnant mothers counseled : 61,901 (87%) No. of pregnant mothers accepted HIV tests : 56,913 (92%) No. of women detected HIV positive - ANC : 958 (1.68%) No. of women detected HIV positive - Labour : 140 (3.33%) No. of women who picked up their test result : 35,629 (62.6%) No. of (+) women who picked up their test result : 674 (70.4%) No. of husbands who accepted to be tested : 1,291 (33.4%) No. of mother-baby pairs who received NVP : 470 (72.3%)
384 (56.97%) / 86 (68.57%) No. of mothers who opted for breastfeeding : 335 (51.5%) No. of babies exclusively breastfed at 4 months : 168 (50%) No. of PCR (+) at 2 months: : 21/270 (7.8%)
Anti-retroviral ProtocolsFeasibility Study Phase 1: modified CDC-Thailand
Regimen
AZT 300 mg BD from 36 weeks onward
AZT 300 mg / 3 hours during labour
No AZT to the babyFeasibility Study Phase 2: modified HIVNET 012
NVP 200 mg single dose to mother at onset of labour
NVP 2 mg/kg single dose to newborn within 72 hours
During the 2 phases: “informed choice on infant feeding”
IAPSM Conference 2004
33
80
10
20
30
40
%
No ARV With ARV
who acquired HIVProportion of infants of HIV (+) mothers
Some Lessons Learnt:Reduced transmission of HIV from mother to infant
IAPSM Conference 2004
Some Lessons Learnt:Increased knowledge about how to prevent HIV/AIDS
50.335.7
85.187.8
0
50
100
Before counselling After counselling
Proportion of women who know how to avoid:
acquiring HIV/AIDS
transmitting HIV/AIDS to baby
IAPSM Conference 2004
PPTCT: Goals & Objectives
Goals:Reduced HIV prevalence among pregnant
women age 15-49 to below 3% in the 6 high prevalence States and below 1% in other States by 2005
Reduced the transmission rate of MTCT of HIV to below 20% by 2005 and below 10% by 2010
PPTCT
1) Scaling up
Expected outputs An operational
network of health facilities providing quality PPTCT services established
PPTCT used as an opportunity to strengthen MCH services.
2) District Models
Expected outputs A comprehensive,
integrated and sustainable distrit- based PPTCT programme
Pre and in-service training modules for care providers to integrate youth friendly services
Key results:
• Operational network of health facilities for PPTCT established• A National Policy for PPTCT • Replicable district PPTCT models• Partnerships and resources mobilized for scaled up
3) Learning for Policy Development
Expected outputs A Feasibility
Study of “PPTCT Plus”
Studies on HIV and infant feeding
IAPSM Conference 2004
.
The PPTCT Intervention Package
1. Ante-Natal Care
2.Group Education / Pre-Test Counselling
4. Post-Test Counselling
5. Institutional Delivery
6. Administration of Nevirapine to the woman during labour
3. HIV Testing
IAPSM Conference 2004
7.Administration to the BABY of SINGLE DOSE of Suspension Nevirapine ( 2 mg./ Kg.) between 24-72 hours
8. Counselling of mother for Infant Feeding Options
9. Care & Support
10. Follow -up
The PPTCT Intervention Package…
Enrollment Procedure
ANC GroupEducation
OfferedHIV test
Post-TestCounseling
HIV Test
Pre-TestCounseling
Enrollment:AZT/NVP
HIV + HIV -
Primary Prevention
One-To-One
One-To-One
IAPSM Conference 2004
Nevirapine Administration
Mother:Screened for contraindications
Single Dose Tablet of 200 mg.during First stage of Labour
Baby:Monitored for First 24 HoursScreened for ContraindicationsSingle Dose of suspension 24 to 72 hours
Nevirapine Courtesy : Donation from CIPLA
IAPSM Conference 2004
Training in PPTCT
“Cascade Effect”
Centres of Excellence ( CEs)
Medical Colleges
District Hospitals & Maternity Homes
IAPSM Conference 2004
PPTCT Team
Consists of : Obs-Gynaecologist -1
: Pediatrician - 1
: Microbiologist - 1
: Counsellor - 1
: Senior Staff Nurse -1
Trained for 5 Days : Structured ,Module based Training
IAPSM Conference 2004
SACS /NACO UNICEF
CE
Teams from Medical Colleges Trained
SACS
PPTCT Centerat M C Established
Teams from District& Maternity Hospitals
Trained
PPTCT Centre
at DH & MHestablished
Requestfor Training
Teams
Funds
TRAINING PROCESS
29
M &EQA
Sensitization
IAPSM Conference 2004
Scaling Up Strategy: Training Component
11 Centers of Excellence
74 Medical CollegesHigh Prevalence States
159 District Hospitals/Maternity Hospitals
High Prevalence States
450+ District Hospitals/Maternity Hospitals
Low Prevalence States
79 Medical CollegesLow Prevalence States
Phase 4 - 2003-2004
Phase 1- 2002
Phase 2 - 2002 Phase 3 - 2002-2003
Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs
IAPSM Conference 2004
Prevention of Parent to Child Transmission (PPTCT) of HIV in India
Status of PPTCT Services as of 31 October 2003
Medical Colleges District/ other hospitalsStateNumber ofInstitutions
trained
Numberprovidingservices
Number ofinstitutions
trained
Numberprovidingservices
Total trained
Andhra Pradesh 14 14 23 23 37Karnataka 18 18 22 22 40Maharashtra 30 30 25 25 55Manipur 01 01 08 05 06Nagaland - - 08 08 08Tamil Nadu 19 19 31 31 50Mumbai 05 05 18 14 19Delhi 04 03 06 05 08Gujarat 10 - - - 10Goa 01 01 - - 01Kerala 06 - - - 06Pondicherry 01 - 01 01 02J & K 01 - - - 01H.P. 02 - - - 02West Bengal 09 - - - 09Chandigarh 01 - - - 03Punjab 06 - - - 06Haryana 02 - - - 02MP 05 - - - 05Assam 03 - - - 03Rajasthan 06 - - - 06Bihar 03 - - - 03Sikkim 01 - - - 01Total 149 91 142 134 291
Between 01 November and 31st December, 2003, 10 more teams have been trained. Total now , the number is301.
IAPSM Conference 2004
Monitoring and Evaluation
Quality assurance of
services
UNICEF’ s Role in PPTCT
Research
Training
Drugs
Counseling
Data
Disseminationof results
Studydesign
PPTCT“Plus”
DistrictModels
Infant Feeding
IAPSM Conference 2004
1. Capacity building - which includes training
2. Quality assurance : Monitoring inputs provided through training,counseling and Anti-Retro Viral( Nevirapine).
3. Monitoring and evaluation- Supporting NACO in Data collection, compilation and
analysis- Dissemination of results
4. Research: which focuses on:
District Integrated Approach: Linking Institution based PPTCTservices with primary prevention among young women and withcommunity based services for care and support
Infant feeding - to support development on a India specific Policy PPTCT Plus
UNICEF Support to PPTCT
Infant Feeding and HIV:Current recommendations
Informed Choice through COUNSELLING
IAPSM Conference 2004
IAPSM Conference 2004
Global recommendations on IYCF when HIV-negative or unknown HIV status
Early initiation with exclusive breastfeeding Early initiation with exclusive breastfeeding for 6 monthsfor 6 months
Appropriate complementary feeding with Appropriate complementary feeding with continued breastfeeding up to 2 years or continued breastfeeding up to 2 years or beyondbeyond
Appropriate feeding in exceptionally Appropriate feeding in exceptionally difficult circumstances (HIV, emergencies, difficult circumstances (HIV, emergencies, LBW, sickness, malnutrition)LBW, sickness, malnutrition)
IAPSM Conference 2004
Recommendations on feeding by HIV-positive mothers: WHO consultation Oct.2000
When replacement feeding is “AFASS” ,i.e. Acceptable, Feasible, Affordable, Sustainable and Safe, avoidance of all breastfeeding is recommended. Otherwise EBF is recommended for the first (6) months of life with early
and abrupt cessation…weaning.
Counselling should include information about the risks and benefits of various infant feeding options, and guidance in selecting the most suitable option
IAPSM Conference 2004
Reducing risk of HIV transmission through breastfeeding
Shorter duration – 6 months Shorter duration – 6 months Exclusive breastfeeding during 1Exclusive breastfeeding during 1stst 6 months 6 months Safe sex practices of mother during Safe sex practices of mother during
lactation period to prevent infection or re-lactation period to prevent infection or re-infectioninfection
Good lactation management (attachment, Good lactation management (attachment, positioning, frequency) to avoid mastitispositioning, frequency) to avoid mastitis
No feeding from cracked nippleNo feeding from cracked nipple ARVs?ARVs?
IAPSM Conference 2004
BF transmission of HIV: Ghent meta-analysis (Read et al, 2002). - Early cessation can reduce BF transmission with about 60%
4
9
16
0
5
10
15
20
4 w to 6 mo up to 12 mo up to 18 m
Cumulative rates of late postnatal HIV infection (> 4 wks)
IAPSM Conference 2004
Early cessation is possible but:
Early, rapid cessation is possible (Uganda, Zambia, Botswana)
Problems encountered breast engorgement; mastitis; babies crying, trouble
sleeping, appetite loss, diarrhea; financial constraints with replacement feeding; family objections
more problems when cessation < 6 months (Botswana) Trained counselors were able to help mothers
overcome problems
Provision of replacement feeds, family support facilitated process
Impact on HIV transmission, survival not yet known
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Key Findings:Data : January to September 2003
Overall prevalence rate in ANCs : 2.1%
VCCT acceptance rate : 61.5%
Intervention uptake : 87.6%
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PPTCT: Challenges,Issues,Concerns
How to maintain QA while going to scale? (Training, Counselling). “ Counsellors based programme”.
PPTCT only for institutional deliveries? ( Out -reach, District Model)
Completion of the ‘PPTCT package’ with Primary Prevention and continuum of care:
Infant Feeding dilemma Integration into the National Reproductive & Child
Health programme.Stigma, Discrimination, Attitude of health care
providersCommunication Strategy, Male Involvment
IAPSM Conference 2004