Antiretroviral Treatment of
Mothers: interrupting vertical
transmission
Dr Angela Mushavi
National PMTCT and Pediatric HIV Care and Treatment
Coordinator
Ministry of Health and Child Care, Zimbabwe
Antiretroviral Treatment in RLS
IAS, Melbourne
21/07/2014
Outline of Presentation
•
•
•
•
Background data for Zimbabwe
About the PMTCT Program
Choice of PMTCT regimen
The process of regimen selection for
PMTCT
• Transition to Option B+
• Summary
• Total population: 13mil (2012)
• PLHIV: 1,4mil; of whom 156, 718
are children 0-14years*
• Adult HIV prevalence 15%*
– ANC HIV prevalence 16.1%*
MTCT rate: 18% (Spectrum
2011); 8.8% from 2012 survey
• New pediatric HIV infections are
estimated at 6,843* (90% from
MTCT)
• Adult need for ART (2014)
955 922
• Peds needing ART (2012):
100 561
Sour11 & MOHCW HIV estimates 2012
The National PMTCT Program
• PMTCT started as a 3 site pilot in 1999
• PMTCT program rolled-out in 2002-to date 1560 sites
(95%) offer PMTCT services
• Initially using only single dose of Nevirapine
• Transitioned to 2006 WHO guidelines in 2009
• Implementing Option A of the 2010 WHO guidelines
since 2011
• February 2013: Stakeholders’ Consultation
recommends Option B+-fully adopted after country
WHO guideline adaptation process
• Roll-out ongoing since late 2013
Evolution of WHO PMTCT ARV
Recommendations
2006
2010
Launch
July 2013
PMTCT
2004
4 weeks AZT;
AZT+ 3TC, or
SD NVP
AZT from 28
wks + SD NVP
AZT from 28wks Option A
Option B or B+
+ sdNVP
(AZT +infant NVP) Moving to ART
+AZT/3TC 7days Option B
for all PW/BF
(triple ARVs)
ART
2001
No
recommendation
CD4 <200
CD4 <200
CD4 <350
Move towards: more effective ARV drugs, extending coverage
throughout MTCT risk period, and ART for the mother’s health
CD4 <500
Choosing a PMTCT Regimen: B or B+
• WHO PMTCT Programmatic Update released in April 2012
• MOHCC convened Stakeholder Consultation on B/B+ Feb
2013
• Consultation attended by Dr Chirwa from Malawi MOH (B+)
and Dr Martha from EGPAF Rwanda-started on B; now moving
to B+
• Participants were unanimous in recommending Option B+
• These included the Director AIDS and TB Unit, Director Family
Health, D/Director SRH, program managers and officers from
the AIDS and TB Program, Nutrition, Directorate of Pharmacy,
Provincial and District staff, City Health Directorates,
Academics, PLWHIV, Civil society, donors and implementing
partners
Consolidated guidelines development
process
• Process led by National Medicines and Therapeutics Policy
Advisory Committee (NMTPAC)-responsible for Essential
Medicines List for Zimbabwe (EDLIZ) including ARVs
• Following attendance of the WHO 2013 Guideline
Dissemination Meeting in Pretoria, the AIDS and TB Unit and
NMTPAC constituted a WHO 2013 National Adaptation
Steering Committee (multidisciplinary including PLHIV)
• The Steering committee had 3 sub-committees
– Adult and Adolescent ART
– eMTCT and Pediatric HIV
– HIV Prevention including HTC
• Stakeholder consultations and consensus building workshops
• National guidelines produced and launched Nov 2013
Adapting WHO 2013 Guidelines on
PMTCT
• Option B+ is lifelong ART for HIV positive pregnant
and lactating women irrespective of clinical stage or
CD4 count
• Benefits of B+
• No need for CD4 count before starting B+
• No interruption of triple ART ‘’avoid a startstop-start-stop approach’’
• Simpler to implement
• One regimen for all-non-pregnant populations
and pregnant women
• Easier to harmonize with the treatment
program
• Covers future pregnancies esp with high fertility
Advantages of Option B+
• More paediatric HIV infections are averted-cost
saving
• Better health outcomes for the mother-through
earlier ART
• Prolonging the life of the mother improves the
chances of survival for her HIV exposed infant
(irrespective of HIV status)
• Benefits in the case of sero-dicordant couple (TasP)
Issues of to address
• Readiness and willingness to adhere to lifelong
ART throughout ANC, delivery and beyond
• Tracking of M-B pairs and keeping them in care
• Inconvenience of lifelong treatment
• What happens to HIV positive male partners of
women on Option B+??
• Costs associated with FDC-TDF/3TC/EFV
• Risks of ART-toxicity, resistance and drug
interactions
Policy questions for Option B+
• Review scope of practice of nurses to
allow ART initiation
• ART within MCH and not just at specific
OI/ART clinics to minimize delays and
missed opportunities
• ART decentralization for adults and
children, and moving to family centred
care
• Storage and distribution of ART drugs
Summary of Key Issues for Option B+
• Effectively integrating ART/PMTCT/MNCH at all
levels
• Preparing sites rapidly while retaining quality
• Adequate training/supervision to decentralize
ART
• Newly engaging communities to support
retention
• Adapting existing distribution systems to Option
B+
• Meeting new data needs including revision of
tools to become B+ compliant
Phasing of Implementation
Phased approach
• Preparation and two implementation phases
• Necessary to manage existing Option A stocks
• Timing of implementation dependent on site
readiness as determined at provincial level
• Timing of ART initiation generally based on
current status of ART delivery
i. Early sites: those already delivering ART (n~700)
ii. Late sites: those not yet delivering ART (n~860)
Option B+ Implementation Phasing
Preparation Phase: September 2013
Launch Event: November 2013
Early Implementation Phase
(500 sites By February 2014)
Interim Review and Program Adjustment
Late Implementation Phase
(All sites by November 2014)
Post-Rollout Review
Summary
• Option B+ adopted in Zimbabwe-rapid roll-out
to all sites by end 2014
• Benefits for women and children, towards
eMTCT by 2015
• Equity issues for male partners who test HIV
positive-proposed ‘’Option B+M’’; and for
women who opt-out of Option B+
• Pharmacovigilance critical
Acknowledgements
•
•
•
•
•
•
•
MOHCC and AIDS and TB Unit
Provincial and District Officers
NAC
Implementing partners
Multilateral agencies
Donors
CSOs and PLHIV