PREVENTION OF MOTHER
TO CHILD TRANSMISSION: A
PANACEA FOR AN HIV – FREE
GENERATION
INCREASING PREVENTION OF
MOTHER TO CHILD
TRANSMISSION SERVICE
UPTAKE THROUGH
INTEGRATED HEALTH CARE
DELIVERY SYSTEM
-Dr. Adeyanju A. O
Global impact of the HIV epidemic
on children
• 14 percent (370,000 of 2.7 million) of new global
HIV/AIDS infections
• 14 percent (270,000 of 2.0 million) of HIV/AIDS deaths
annually
• 6 percent (2.0 million of 33.0 million) of the persons living
with HIV
Over 90% of children acquire HIV through mother-tochild transmission (MTCT)
Source: UNAIDS/WHO/UNICEF – Towards Universal Access 2008
NATIONAL HIV PREVALENCE TREND 1991 – 2010
HIV ESTIMATES BY END OF 2010
 No
requiring ART- 1,512,720
- Adult-1,300,000
- Children-212,720
 New
infections - 281,180
-Adult-126,260
-Children-154,920
 Total
AIDS orphans - 2,229,883
Nigeria and Global HIV Burden



Nigeria now has the second highest number of
people living with HIV in the world after South
Africa.
Nigeria, with about 2.98million PLWHIV,
accounts for about 9% of the global HIV
burden.
Home to 30% of the global PMTCT Gap
burden
The Global PMTCT
Gap
4/9/2015
UNICEF Mid-Year Review Meeting July,
2011
8
Mother To Child Transmission of
HIV can occur
•In-utero [5-10%]
•Labour/delivery [10-20%]
•Postpartum [5-20%]
Background



HIV prevalence (ANC): 4.1%
HIV positive persons: 3.15million (1.83m
female)
HIV+ pregnant women(annual): 229,480
Children <15 years living with HIV: 331,150
Transmission rates (at 6 weeks): from 2.34% (HAART) to
15.6% (no intervention)*
58% of pregnant women attend ANC at least once; 45%
attend at least 4 times
35% of births occur in health facilities, 62% occur at home.
National PMTCT Programme
Goal
 To contribute to improved maternal health and child survival
through accelerated provision of comprehensive PMTCT services
Targets
 At least 50% reduction in HIV incidence among 15-49yr old women
by 2015
 At least 90% of all pregnant women have access to quality HIV
counseling and testing by 2015
 At least 90% reduction in unmet need for Family Planning among
women with HIV by 2015
National PMTCT Targets

At least 90% of all HIV positive pregnant women and their
breastfeeding babies access more efficacious ARV prophylaxis
by 2015

At least 90% of HIV exposed infants have access to early infant
diagnosis services by 2015

At least 90% of pregnant women requiring ART for their own
health receive life long ART by 2015
Score Board after nearly One Decade of
Implementation
HIV+ pregnant women:
Coverage of ARV/ART for PMTCT:
Estimated HIV incidence (modelled):
Contraceptive prevalence:
Unmet need for FP:
ANC at least 1 visit:
Median duration of BF:
MTCT rate in 2009:
New child infections 2009:
Nigeria South Africa
210,000
210,000
22%
88%
0.39%
1.68%
20%
62%
20%
14%
58%
92%
19 m
16 m
32%
19%
64,700
40,500
Sources: WHO Universal access report 2010, Nigeria DHS 2008, South Africa DHS 2003,
UNAIDS analysis
4/9/2015
UNICEF Mid-Year Review Meeting July,
2011
13
Problems peculiar to Developing
Countries
• High fertility rate
• Lack of access to good antenatal
and delivery care and support
• Absence of antiretroviral
drugs/therapy
Historical Background
• Over the years prolongation of life with
availability of better treatment options among
HIV patients have been achieved.
• PMTCT has become an effective part of
Obstetric practice in HIV/AIDS care
• Emerging issues then include:
– Integration of HIV prevention and care into
other RH programmes
• Contraception, Fertility desires, options and
management is an important component.
Previous Policy
• Initially, the Centers for Disease Control
and Prevention (CDC - 1985)
encouraged HIV-infected women to defer
pregnancy because of poor prognoses
associated with HIV infection and the risk
of perinatal transmission
Previous Policy
• In 1987, the American College of Obstetrics and Gynecology
(ACOG) advised physicians to encourage women infected with HIV
NOT to become pregnant, and to inform pregnant HIV-infected
women of termination options.
• The Ethics Committee of the American
Society for Reproductive Medicine
suggested in 1994 that physicians “counsel
couples about the consequences of using
potentially infected sperm and discuss the
options of donor sperm, adoption, or not
having children.
A ray of HOPE
• The introduction of potent ARV (HAART) in the last decades has
changed both the decisions & discussions about HIV infection
generally.
• People infected with human
immunodeficiency virus (HIV) are living
longer and experiencing improved health.
• Also, physicians now view HIV infection as a
manageable chronic illness and encourage
patients to maintain normal lives
Current Situation
• In 2001, the CDC amended its previous
recommendations, stating that HIV-infected
pregnant women should receive information
about all reproductive options and that
reproductive counseling should be
nondirective and supportive of the patient’s
decision.
• Currently ACOG now states that “assisted
reproductive technologies should not be denied to
HIV-infected couples solely on the basis of their
positive HIV serostatus.”
Conception issues
• Women with HIV are similar to non-HIV infected
women in what influences their desire to get
pregnant
• Among those desiring children,
• 69% of women
• 59% of men
Desired to have children in the future
• Women’s desire for children is more affected by
personal health status vs. men’s
Sowell RL et al. AIDS Care. 2002;14(2):181191
Importance of getting pregnant
• 83.2% (74.7% M; 90.7% F) believed it is very
important to have own biological child.
• Reasons:
– Low parity (57.5% parity ≤ 2)
– To continue family name
– Availability of better treatment
– Having a HIV negative baby from
previous pregnancy
– Less stigmatisation
PRECONCEPTION CARE
• A specialized form of care for women of
reproductive age group before the onset of
pregnancy, to detect ,treat or counsel them
about preexisting medical and social conditions
that may militate against safe motherhood and
the delivery of a healthy offspring.
• It is a component of comprehensive maternity
care– PrCC, ANC, IntraPC, and PNC
• AIM: TO IMPROVE THE PROSPECT OF SAFE
MOTHERHOOD
Objectives of Preconception Care
• Avoidance of maternal exposure to
teratogens during fetal organogenesis
• Checking basic measurements e.g BP,
Weight before conception
• Introduction of intending mothers to social
and medical interventions at a time they
can have maximal effect on the outcome
of pregnancy
National PMTCT Programme
Goal
– To contribute to improved maternal health and child survival
through accelerated provision of comprehensive PMTCT
services
Targets
– At least 50% reduction in HIV incidence among 15-49yr old
women by 2015
– At least 90% of all pregnant women have access to quality
HIV counseling and testing by 2015
– At least 90% reduction in unmet need for Family Planning
among women with HIV by 2015
General Principles

Combination regimens are more effective than single or
double drug regimens.

Combination Highly Active Antiretroviral Therapy is
standard of care for treatment of maternal HIV infection
and prevention of mother to child transmission of HIV.

Pregnancy in the HIV positive woman is an indication for
prophylactic ART irrespective of CD4 count, viral load or
clinical stage of the disease.

All efforts should be made to ensure that all HIV positive
pregnant women have access to ART.
General Principles (II)


All patients placed on ART should be monitored clinically,
biochemically and immunologically.
Pre-treatment evaluation should include:







Complete history and physical examination.
Checking laboratory parameters (FBC/ESR, FBS, LFT, E&U, Serum lipids, CD4
count and viral load).
WHO clinical and immunological staging of the client.
Ensuring availability of supportive measures (nutritional and psychosocial).
Patient-specific adherence strategy
If facility for CD4count is not available, the client should be referred or
client’s specimen sent to the nearest centre with such facility.
Where the patient is on AZT only for prophylaxis, the minimum tests
to be done will include HB /PCV, CD4 count and urinalysis.
Specific PMTCT Interventions
• HCT- HIV Counseling and Testing
• Modification of Obstetrics practices
• Administration of ARV prophylaxis to
mother-child pair
•HIV and Infant Feeding Counselling
• Care and Support for HIV positive women and
their families (PMTCT plus).
PMTCT Strategies

Primary prevention of HIV infection in women of reproductive
age group and their partners.

Prevention of unintended pregnancies among HIV positive
women.

Prevention of HIV transmission from HIV infected mothers to
their unborn babies and infants.

Care and support for HIV infected women, their infants and
family members.
INTEGRATED HEALTH
CARE DELIVERY SYSTEM




Integration-stems from the Latin verb integer
i.e to complete
Integrated-=organic part of a whole or reunited
part of a whole
Used to express the bringing together or merging of
elements or components that were formerly separate
It is a desire to understand the relationship of elements
that constitute the entirety
INTEGRATED SERVICE
DELIVERY

“The management and delivery of health
services so that clients receive a continuum
of preventive and curative services ,
according to their needs over time and
across different levels of the health system.”

Referrals and Linkages

We need a comprehensive , integrated
approach to service delivery. We need to
fight fragmentation—
Dr Margaret Chan
WHO Director General (2007)
INTEGRATED HEALTH
SERVICES:






A package of preventive and curative health interventions for a particular population
group.
Refers to multi-purpose service delivery points i.e a range of services for a catchment
population is provided at one location.
Achieving continuity of care over time i.e a life long care for chronic condition or a
continuum of care between more specific stages in a person’s life cycle e.g ANC,PNC,
Newborn and child care.
Refer to the vertical integration of different levels of services. There is a well functioning
procedures for referrals up and down the levels of the system, and between public and
private providers.
Refer to integrated policy- making and management which is organized to bring
decisions and support functions across different parts of the health service.
Mean working across sectors. It occurs when there are institutionalized mechanisms to
enable cross-sectional funding, regulation and service delivery. E.g working with
education services to develop effective school health promotion campaigns
--NB: identify the most appropriate sector(s) to deal with a particular health issue and
establish linkages with them.
Comprehensive HIV/AIDS Service
Provision of HIV prevention, treatment, care and support
services through
 VCCT--HCT
 PMTCT
 HOME BASED CARE
 CLINICAL CARE
 LABORATORY SUPPORT
 SUPPORT GROUP
 OVC
Specific PMTCT Interventions
• HCT- HIV Counseling and Testing
• HIV and Infant Feeding Counselling
• Modification of Obstetrics practices
• Administration of ARV prophylaxis to
mother-child pair
• Care and Support for HIV positive women and
their families (PMTCT plus).
Essential commodites for
PMTCT Programme








HIV test Kits/reagents
IEC materials
Consumables
Antiretroviral drugs
Drugs for opportunistic infections
Starter packs for PEP
Family planning commodities
National PMTCT Guidelines
Essential commodities for
PMTCT Programme-- continue



Registers and forms for Monitoring and
Evaluation
Items for Universal precautions
Supplies for cervical screening
ADULT HIV COUNSELLING AND TESTING NUMBERS JAN
-OCT 12
1800
1582
1600
1400
1200
1108
1000
910
801
800
HCT
642
600
400
579
488
308
372
200
118
0
Jan 12
Feb 12
Mar 12
April 12
May 12
June 12
July 12
Aug 12
Sep 12
Oct 12
Prevention of Mother To Child
Transmision Jan- Oct 12
1200
1091
1000
871
800
600
865
725
599
784
691
636
587
622
PMTCT
400
200
0
Jan 12 Feb
12
Mar April May June July Aug Sept Oct
12
12
12
12
12
12
12
12
Adult New on Care Jan-Oct12
120
110
100
79
77
80
70
59
57
60
59
55
CARE
47
40
37
20
0
Jan12
Feb12
Mar12
April12
May12
June12
July12
Aug12
Sept12
Oct12
Adult New on ART Jan-Oct 12
60
51
50
47
40
40
30
45
40
38
36
34
31
29
ART
20
10
0
Jan12
Feb12
Mar12
April12
May12
Jun12
July12
Aug12
Sept12
Oct12
OYO STATE
5 State Hospitals
 27 General Hospitals
 351 Primary Health Centers
 166 Primary Health Clinics
 113 Rural Health Centers or Posts
Most of the PLWHA can be reached if all these
are involved in their treatment, care and support


Meeting the needs of growing number of
PLWHA, their care givers and their family
members requires the collective effort of many
facilities and organizations

It also requires appropriate policies, supportive
social attitude and community support system
Number of Service Delivery Points Offering PMTCT Services
800
744
670
700
600
675
533
500
419
400
300
No of PMTCT Sites
230
200
100
0
2006
2007
2008
2009
2010
2011
COMMUNITY BASED PMTCT
Definition:
Is the provision of PMTCT services by formal or informal caregivers
outside the hospital or facility settings
•
•
•
What is the need:
Most deliveries in Nigeria and sub-Saharan Africa occur in homes,
churches etc; and attended by mothers, family relatives, TBA.
Studies in Nigeria have shown that home deliveries account for
about 80% of deliveries in Nigeria. Although about 60-80% attend
at least one ANC visit; only approximately 20-30% deliver in
Hospitals.
Community based PMTCT
•
There are low number of hospitals and maternity homes
•
Low coverage of PMTCT services (10%). Mostly in urban areas.
•
Predictors of home deliveries
–
Poor maternal education, multiparity, low socioeconomic status,
distance from health facility, political instability, industrial strikes,
poor attention at facilities etc
Components of a community based PMTCT









A strong facility based PMTCT
Cultural accepted health based education programs
Strong support group ( facility & community)
Lay counselors ( Peer)
Incorporation and training of retired midwives/nurses
Incorporation and training of TBA
Involvement of District , local government health Authorities
CT as an important entry point for PMTCT
Encourage the involvement of CBO, FBO, Traditional healers and
Leaders
Models for implementation
•
PMTCT facility networking to lower cadres of care (Network model)
•
Community programs using retired midwives, TBA
•
Community referral programs using Lay counselors, Chews,
•
PMTCT mobilization with retired midwives, TBA, Lay counselors,
Chews,
Potential areas for linkages
•
Health sector: Family planning; Safe motherhood, child survival,
TB, Malaria
•
Other developmental linkages: education, food and nutrition,
economic strengthening.
ART
PMTCT
HCT
Labs – CD4, FBC, Chemistry
FP
QC/QI
HUB & SPOKE MODEL
PHC
PHC
PHC
Secondary
Facility
eg
Community
Onikan Health centre
HCT
PMTCT
STI
CXT
BCK
DOTS
?ART refills
FP
Multivitamins
PHC
eg Irru
PHC
Prev. message
Treatment literacy
Treatment support
Adherence
Patient tracking
Comm. Based services
-IEC
-FP
-BCK
-Condoms
-DOTS
Out reaches
-BCC
-Treatment message
-HCT
-Advocacy
ART
PMTCT
HCT
Labs – CD4, FBC, Chemistry
FP
QC/QI
HUB & SPOKE MODEL
Mole
te,
Map
o
Ayey
e
Orier
u,
Ayey
e
Adeoyo Maternity
Hospital, yemetu
HCT
PMTCT
STI
CXT
BCK
DOTS
?ART refills
FP
Multivitamins
Odoona
Community
Oniya
nrin
Prev. message
Treatment literacy
Treatment support
Adherence
Patient tracking
Comm. Based services
-IEC
-FP
-BCK
-Condoms
-DOTS
Out reaches
-BCC
-Treatment message
-HCT
-Advocacy
CONCLUSION


Integrated health care service delivery will enhance and promote
decentralization of HIV care, support and services .
Comprehensive HIV/AIDS services at PHC level will bring services to
where people live and enhance their ability to access services and adhere to
care and treatment

It is a key to the successful expansion of HIV services(PMTCT inclusive) for
people living in the rural areas

It will assist in decongesting hospitals where such services are typically
delivered

However, training and mentoring of health care providers with recruitment of
staff are important in conjunction with a good referral systems and linkages
Strong political support at all levels with appropriate policies is of paramount
importance for the overall success of this laudable approach

CONCLUSION

There is therefore the need for all stake holders in the
country and at all level of government to maintain the
earlier momentum of interventions so as to sustain the
decline in prevalence earlier observed
THANK YOU………
………..WITH LOVE,
FROM MOTHER TO