Increasing Coverage & Quality of PMTCT Services Beyond 2010

Place holder for PhotoIncreasing Coverage &

Quality of PMTCT Services Beyond 2010

Laura Guay MDElizabeth Glaser Pediatric AIDS Foundation

June 17, 2010

Photo Credit: Nigel Barker LLC

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WE HAVE ONLY JUST BEGUN….

• Goal: Elimination of pediatric HIV • Universal access and uptake of services• Cost effective, efficient, integrated services

• Call To Action was a major springboard for the rapid expansion of PMTCT programs throughout Africa

• and C&T programs!• and HIV research!

• Great progress, but still a long way to go; many challenges remain

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HIV Testing of Pregnant Women

2004 2005 2006 2007 20080%

5%

10%

15%

20%

25%

7%

7%

13%

15%

21%Percentage of pregnant women receiving an HIV test in low- and middle-income coun-tries

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Provision of ARVs for PMTCT

WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2009

2004 2005 2006 2007 20080%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

10%

15%

24%

34%

45%

6%

12%

18%20%

32%

Pregnant women living with HIV receiving ARVsInfants born to pregnant women living with HIV receiving ARVs

68% of HIV-exposed infants

not receiving PMTCT drugs

55% of pregnant womennot receiving PMTCT

drugs

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PEARL Study

Stringer et al. Cote D’Ivoire, South Africa, Zambia, Cameroon

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Attend ANC clinic 92%

Counseled & tested for HIV, CD4 75%

Get ARVs (pre- & perinatal)

50%

100 HIV+ mothers

92

68

34

Enter into program

8

32

66

No ARV (25% MTCT): 16.5 infected

Missed - no PMTCT

Most Critical Thing for PMTCT is Number of Women Completing Cascade

Overall ProgramEffectiveness(early MTCT)

sdNVP +ART: 19.5% tx

AZT/sdNVP: 17.5% tx

HAART: 17.1% tx

P. Barker, WHO Mtg Nov 2008

sdNVP alone: 22.5% tx

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Attend ANC clinic 95%

Counseled & tested for HIV, CD4 95%

Get ARVs (pre- & perinatal)

95%

100 HIV+ mothers

95

90

86

Enter into program

5

10

14

No ARV (25% MTCT): 3.5 infected

Missed - no PMTCT

Overall ProgramEffectiveness(early MTCT)

sdNVP +ART: 10.4% tx

AZT/sdNVP: 6.1% tx

HAART: 5.2% tx

P. Barker, WHO Mtg Nov 2008

sdNVP alone: 17.3% tx

Change Cascade Efficiency

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Long and bumpy roads lead to great places

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Where do we go from here?

• The CTA laid the first stones in the path to elimination of pediatric HIV

• Completing the path requires GLOBAL action

• Mobilization of resources to expand PMTCT programs:– Effective HIV prevention!

– PMTCT = MNCH

– Contributes to multiple MDGs

– Embodies a woman- and family-centered approach

– Supports health system strengthening

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Prevention of HIV in women, especially young women

Prevention of unintended pregnancies in HIV-infected women

Prevention of transmission from an HIV infected woman to her infant

Support for HIV infected women, their infant, and family

Component

1

Component

2

Component

3

Component

4

WHO’s 4-Component Strategy for MTCT Prevention

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Requirements for Achieving Scale-up

• Global advocacy

• Strong government leadership and prioritization of PMTCT in the country’s HIV/AIDS plan

• Public health approach to PMTCT– Ensure universal access to high-quality PMTCT services

• Provision of PMTCT in all health services that offer HIV/AIDS care and treatment

• Universal access to treatment for all eligible HIV-infected pregnant women

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• Decentralize PMTCT to district and sub-district levels– Build capacities for leadership, management, planning and

budgeting, M&E

• Strengthen MCH capacity (staff, infrastructure)

• Supportive national policies on level of health facilities/workers allowed to provide PMTCT services

• Greater coordination and collaboration among implementing agencies, international organizations & government entities

Requirements for Achieving Scale-up

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Program-Level Activities

• Country-level integration of PMTCT, HIV care & treatment, MNCH, FP programs

• Increase reach of PMTCT programs:– Focus resources on women outside the “cascade”

• Prioritize the inclusion of male partners, family members & community in PMTCT service delivery

• Address stigma within health workforce

• Facility program ownership with feedback of program results to support QA/QI activities

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Implementation Research

• Optimal strategies for cost-effective implementation of PMTCT programs and maximal retention along the PMTCT cascade

• Models of integration of MNCH, PMTCT, and comprehensive care and treatment services to optimize maternal, infant and child health and survival

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Conclusion

HIV CSTMCHPMTCT

2009 WHO Guidelines for PMTCT: Framework for Elimination• Blurs the lines between MCH, PMTCT, and HIV CST

• Complexity requires renewed intensity, integration, and innovation

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Tunaweza

Together, We Can … Eliminate Pediatric HIVPhoto Credit: Nigel Barker LLC

DISCLAIMER: This program was made possible through support provided by the Office of HIV/AIDS, Global Bureau Center for Population, Health and Nutrition, of the United States Agency for International Development (USAID), through the President’s Emergency Plan for AIDS Relief, as part of the Elizabeth Glaser Pediatric AIDS Foundation's International Family AIDS Initiatives (“Call To Action Project”/ Cooperative Agreement No. GPH-A-00-02-00011-00). Private donors also supported costs of activities in many countries. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.