of Mother to Child Transmission of HIV · 2015 formed based on global consensus that world can eliminate MTCT HIV infections by 2015 •2012-2015: Framework launched and implemented

Kenya’s progress towards elimination

of Mother to Child Transmission of HIV

Presenters:

Mildred Mudany1,MBCHB, MMED-

Paeds, PhD.

Anthony Gichangi,MSc, PhD

Isaac Malonza, MD

Kenya Background

Total population is approx. 45M ( was 38M at

census 2009)

Adult HIV prevalence 5.6% (KAIS 2012)

Total number of people living with HIV

1,192,000 (KAIS 2012)

Number of pregnancies per year: 1,500,000

HIV prevalence among WRA dropped from

8.5% in 2007 to 6.9% (KAIS 2012)

Est. HIV+ pregnant women as at 2015 are

79,475

>800,000 people receiving ART

(10% children)

3

PMTCT PROGRAM in Kenya

PMTCT services started in a few pilot sites in the late 1990s and Currently,

the services are provided in the whole country

• Now estimated sites 4,500

Evolution of regimen:

• Started with single dose nevirapine till 2009

(No longer recommended)

• Option A and B recommendation since 2010

(No longer recommended)

• HAART for all pregnant and breastfeeding women July 2014

(CURRENT RECOMMENDATION)

TWG meets on quarterly basis co chaired with DRH with representation

from technical teams , partners, CSOs and PLHIV networks , Selected MOH

from counties

Hosts the eMTCT and Beyond Zero campaign agenda in NASCOP,

4

Four prongs of PMTCT

5

Prevent MTCT of HIV

Among Infected Women

Provide Care & Treatment

for

HIV infected

Women/Families

Prevent HIV in women

Of reproductive age

PreventUnintended Pregnancies

Scale up of PMTCT Sites and Services in

Kenya (2005-2013)

6

19439 34795 50659 59601 58591 70399 67276 60000 53629

0

1000

2000

3000

4000

5000

6000

0

200000

400000

600000

800000

1000000

1200000

1400000

2005 2006 2007 2008 2009 2010 2011 2012 2013

TotalWomentested HIVpositivepregnantwomengivenARVs PMTCTsitesYEAR

Wo

me

n te

ste

d / H

IV p

ositiv

e

pre

gna

nt w

om

en g

iven A

RV

sP

MT

CT

Site

s

Milestones of PMTCT in Kenya

7

• 3rd edition of national guidelines

efficacious regimen introduced

• Expansion of PMTCT sites

• PMTCT pilot projects in

Nairobi, Karatina &

Homabay

• National PMTCT program launched

• 1st edition of National Guidelines

• Small scale implementation of

PMTCT

• Technical Working Group

(NASCOP & Department of

Reproductive Health (DRH))

• 4th edition of

National guidelines

5th Edition Guidelines

Option B+ where

feasible

• ART Rapid Advice-

HAART for all

positive pregnant

women

• Adoption of short course

efficacious regimen

• 2nd Edition:

• Opt out approach for HIV testing introduced

countrywide

• Routine PCR testing for EID launched

1999 2000 2002 2006 20092010-

112012 2013 2014

Evolution of PMTCT guidelines

8

1st Edition

2002

2nd Edition

2005

3rd Edition

2009

4th Edition

2011

(WHO option A)*

5th Edition

2012

Triple ARVs

Mother SD

Nevirapine,

SD Nevirapine AZT from 28 weeks,

SD NVP

AZT+3TC at labor,

AZT, 3TC x7 days

days postpartum

AZT from 14 weeks ,

SD NVP, AZT, 3TC at

labor, AZT, 3TC x1

week postpartum,

HAART for pregnant

women who qualify

Triple ARVs

AZT or TDF/3TC/NVP

or EFV

From 14 weeks to cover

pregnancy, BF and for

life

Baby No drugs AZT x6 weeks NVP stat, 3TC x 7

days, AZT x 6weeks

AZT until 1 week after

cessation of breast

feeding, NVP for 6 wks

if mum on HAART

Children <18 months

infected give ART

NVP or AZT for 6

weeks

Feeding

Option

Exclusive b/feeding for 6 months or replacement

feeding if meeting AFASS criteria

Exclusive breastfeeding

for 6 months, introduce

complementary foods

and continue breast

feeding for at least 1

year

Exclusive breastfeeding

for 6 months, introduce

complementary foods

but continue

breastfeeding for 1 year

Evolution of our efforts in EMTCT

9

• 2012: EMTCT

Framework for 2012-

2015 formed based on

global consensus that

world can eliminate

MTCT HIV infections by

2015

• 2012-2015: Framework

launched and

implemented in the

context of devolution

• July-July 2016: Review

conducted with ~700 from

across counties

• 2016: Based on

recommendations,

DRAFT Strategic

Framework for 2016-

2021 drawn

• September 2016:

>1000 county

representatives

reviewing draft,

validating, and setting

targets

• 2019: Pre-exlimination

targets met

• 2021: Elimination

targets met

Where have we

been?Where are

we now?

Where are

we going?

Entry into PMTCT

10

0%

20%

40%

60%

80%

100%

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

All pregnant women Attended ANC Tested HIV positive

Number Percent

Maternal and infant prophylaxis coverage:

2012-2015 ( Prong III)

11

56,355

76,074 69,81563,778

52,180

55,54452,383

59,253

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

2012 2013 2014 2015

Need for PMTCT HIV+ Pregnant Women Identified Maternal ARVs issued Infant Prophylaxis issued

MCH follow up of Mother-baby pair

12

Positivity of EID within 2 months

over the years

13

Series1

Series2Series3

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

1 2 3 4 5 6 7 8 9 10 11 1213

Series1 Series2 Series3

Lesson 1) PMTCT ART coverage scale up

is key in reducing MTCT rates

14

60%

68% 66%

75%

8% 8% 7% 6%

16% 14% 17%

8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2012 2013 2014 2015

ARV Prophylaxis Coverage Transmision rate at 1st PCR MTCT rate @ 18mo

Infant and Young Child Feeding

Exclusive breastfeeding & continued breastfeeding until 2 years reduces

infant and child mortality

ART protects breastfeeding for the HIV-exposed infant

Majority of HIV-exposed infant deaths occur due to poor adherence to

exclusive breastfeeding guidelines

15

Breastfeeding status

among children <6 months

Challenges to Infant and Young Child Feeding

16

Weak knowledge & attitude of

healthcare workers

Aggressive marketing of

breast milk replacements

Stigma in communities

Poor dissemination following

change in policies and

guidelines, fueling myths and

misinformation

Monitoring infant feeding

practices

Patient support system

1st Framework outcomes at a glance

2012-2015

17

Indicator 2012 2013 2014 20152015

Target

Unmet FP 27% 27% 17.5 % 17.5 % 0%

Need for PMTCT 85,714 79,475 79,475 79,475 43,500

HIV+ pregnant women identified 56,355 76,074

(96%)

69,815

(88%)

63,778

(81%)90% of need

#/% HIV+ pregnant women receiving

ARVs**

52,180

(59.9%)

55,544

(68%)

52,383

(66%)

59,253

(75%)90% of need

ART to Children 38% 43% 39% 54% 90%

MTCT Rates trend (18 months) 16% 14% 17%* 8.3%** <5%

Early Infant Diagnosis <2months 57,961 51,758 54,154 54,242 No target

*2013 Estimates **2015 Estimates currently under validation

APHIAPLUS KAMILI’s Accelerated Response on

HAART for HIV Positive Pregnant Women

18

3738 40 60

43 62 87 95 76 102 115 123 140 140 152 157 202 245

37 75 115 175 218280

367462

538640

755878

10181158

1310

1467

1669

1914

0

500

1000

1500

2000

2500

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

2013 2014

NO.O

FPOSITIVEPREG

NANTWOMEN

ONHAART

HIVPositivepregnantwomenstartedonHAART:Apr2013- Sep2014

EnrolledonHAART Cum.OnHAART

Increasing Access to PMTCT

Decentralization of PMTCT

services

• 75% of public health

facilities offer PMTCT

Integration of PMTCT into

MCH

Various models

Fully integrating ART into

MCH

Effective referral from MCH

to ART clinics

ART days in MCH

19

Improved lab coverage

• 72% of HIV+ pregnant women

have CD4 test at 1st ANC

(Impact evaluation study, 2010)

Increasing Access to PMTCT Services

Scale up of PMTCT sites to >80% of

Public Health Facilities and FBOs

Reaching high volume private facilities

Using Community Health Strategy

Roll out of Kenya Mentor Mothers

Program

Follow up of mother and baby using Mother

Baby Health Booklet

HEI Cohort Register

Revision of Data collection tools

20

21

Are we on course towards elimination of

MTCT of HIV and syphilis?

22

Kirinyaga

Samburu

Nairobi

Baringo

Kakamega

Kiambu

West Pokot

Trans Nzoia

Kisii

Nyeri

Bomet

Homa Bay

Siaya

Nyamira

Migori

Kisumu

Nyandarua

Muranga

Narok

Turkana

Laikipia

Embu

Vihiga

Isiolo

Kericho

Kilifi

Tharaka

Taita Taveta

Busia

Uasin Gishu

Meru

Parking: small

improvements

(<50% reduction)

Forward gear:

large

improvements

(>50% reduction)

Reverse gear: reversions

(increases of any size)

Kitui

Machakos

Mombasa

Kwale

Marsabit

Garissa

Lamu

Mandera

Tana River

Wajir

Bungoma

Nakuru

Makueni

Nandi

Elgeyo

Marakwet

Kajiado

Changes in HIV infant infection rates (2013-2015)

We must all shift to green!

HAART uptake by County : July 2015

23

County NVP only AZT+SdNVP

Interrupted

HAART HAART Total % HAART

Homa Bay 0 0 4 73 77 95%

Kisii 0 0 0 7 7 100%

Kisumu 0 0 0 52 52 100%

Migori 0 0 0 67 67 100%

Nyamira 0 0 0 47 47 100%

Nyanza 0 0 4 246 250 98%

Bungoma 0 0 0 96 96 100%

Busia 0 0 0 24 24 100%

Kakamega 0 0 0 154 154 100%

Vihiga 0 0 0 48 48 100%

Western 0 0 0 322 322 100%

Overall 0 0 4 568 572 99%

HIV among Adolescents & Youth

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Total new HIV infections in 2015: 77,647

Adolescents & youth: 35,776 (46%)

13% of PMTCT pregnancies among

adolescents and youth

Adolescents and youth are especially

vulnerable

• Increasing incidence of HIV acquisition

• Lower likelihood of PMTCT completion

• Only age demographic with increasing

risk of HIV-associated mortality

Proportion of new infections by age group

54%46%

All otherages

Children new HIV infections 2015 status

25

6,613 New HIV infections

11 counties contribute

70.6%

15 counties contribute

21.1%

21 counties contribute 8.3%

Changes in HIV infant infection rates

(2013-2015)

26

Kirinyaga

Samburu

Nairobi

Baringo

Kakamega

Kiambu

West Pokot

Trans Nzoia

Kisii

Nyeri

Bomet

Homa Bay

Siaya

Nyamira

Migori

Kisumu

Nyandarua

Muranga

Narok

Turkana

Laikipia

Embu

Vihiga

Isiolo

Kericho

Kilifi

Tharaka

Taita Taveta

Busia

Uasin Gishu

Meru

Parking: small

improvements

(<50% reduction)

Forward gear: large

improvements

(>50% reduction)

Reverse gear: reversions

(increases of any size)

Kitui

Machakos

Mombasa

Kwale

Marsabit

Garissa

Lamu

Mandera

Tana River

Wajir

Bungoma

Nakuru

Makueni

Nandi

Elgeyo

Marakwet

Kajiado

27

12%

10%

6%5%

4%

0%

2%

4%

6%

8%

10%

12%

14%

2010 2011 2012 2013 2014

Kenya National EID Data % Positivi ty using DNA PCR at 6 weeks

% Positivity

% P

ositi

vity

usi

ng D

NA

PC

R a

t 6 w

eeks

Challenges

Service delivery• New PEPFAR Direction of

going where virus is…many

facilities left unsupported, new

rise in infections

• Late ANC attendance

• Retention on HAART

• Low male involvement

Poor record keeping

28

Projected MTCT rate

29

14.0%

17.0%

8.3% 7.7%6.9%

5.9%4.7%

4.0% 3.6%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

2013 2014 2015 2016 2017 2018 2019 2020 2021

MT

CT

rate “Business as usual”

reductions

Accelerated

progress reductions

Can you explain what happened in 2014 and 2015? What drove the

increase and the decrease?

Conclusion

Kenya has made significant progress in PMTCT

• MTCT rate now <5% at 6 weeks, 8.3% at 18mo

Need to increase review effect of new PEPFAR

direction on coverage

Strengthen strategies retention on HAART

Focus on the achievement of 90:90:90 UNAIDS

goals

Ultimate goal is to reduce MTCT to <5% and

keep mothers alive.

30