Lessons learned Integrating PMTCT, HIV Care and ART Track 1.0 ART Program Meeting September 25, 2007 Dr Lulu Oguda Senior Medical Officer Elizabeth Glaser

Lessons learned Integrating PMTCT, HIV Care and ART

Track 1.0 ART Program MeetingSeptember 25, 2007

Dr Lulu Oguda

Senior Medical Officer

Elizabeth Glaser Pediatric AIDS Foundation

EGPAF PMTCT Program ResultsCumulative data, 2000 – June 2007

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

Eligiblew omen

Counseled Tested Results HIV+ WomenARV

Infant ARV

Project HEART: Patient Enrollment1

269,649

226,227

189,820

167,401

134,426117,996

96,37079,706

41,88531,337

15,039

142,249

20,84936,712

45,56157,882 68,536

86,69697,870

117,203

0

50,000

100,000

150,000

200,000

250,000

300,000

Q1-05 Q2-05 Q3-05 Q4-05 Q1-06 Q2-06 Q3-06 Q4-06 Q1-07 Q2-07

Cumulative Number on HIV Care

Cumulative Number on ART

30

36

56

73

92

94

119

144

163

183

1. CUMULATIVE data by June 30, 2007

2. Boxed numbers indicate the number of active sites each quarter

PMTCT and C&T sites: Project HEART Countries

Country #PMTCT sites only

# only C&T sites

# sites with both services

Total # sites

CI 72 36 37 145

Moz 14 4 15 33

SA 19 3 30 52

Tz 285 11 27 323

ZA 148 14 32 194

EGPAF Approach to Integrating PMTCT, HIV Care and ART

• Practice differs across countries• In most instances, HIV +ve pregnant women identified through ANC

and referred for PMTCT.• Number of women identified though HIV Care and the ART clinics

not well documented.• Estimated pregnancy rate in ART clinics in Zambia in 2006 = 4 /per

woman-year.• Pregnant women in HIV Care and on ART sent to nearest health

facility offering ANC• Adaptation of ART and other meds done as appropriate in ART

clinics• SA and CI offer both clinical screening and urine tests for pregnancy

[if clinically indicated] in ART clinics• Preconception care and counseling not routinely offered at the sites• CI, SA and TZ and ZA have established coding system that allow for

linking of mother-infant data from ANC/PMTCT to C&T

PMTCT Addendum A Indicators

Number of (see below) Identified as HIV+ Through PMTCT Enrolled in Care and Treatment Program – Pregnant Women– Pregnant Girls (14 and younger)– Non-Pregnant Women (15 and older)– Adult Men (15 and older)– Female Children (0-14 years old)– Male Children (0-14 years old)Number of (see below) Identified as HIV+ Through PMTCT

Receiving HAART– Pregnant Women (15 and older)– Pregnant Girls (14 and younger)– Non-Pregnant Women (15 and older)– Adult Men (15 and older)– Female Children (0-14 years old)– Male Children (0-14 years old)

Number of HIV+ pregnant women initiating ART : Project HEART countries

[PMTCT Reported Data]

Country 2005 2006 Q1 2007

Cote d’Ivoire 10 111 68

Mozambique 5 195 196

South Africa 64 183 205

Tanzania 43 528 449

Zambia NA 238 1010

Number of HIV-exposed infants initiating Cotrimoxazole prophylaxis at 6 weeks

of age : Project HEART countries [PMTCT Reported Data]

Country 2005 2006 Q1 2007


Mozambique 183 1612 878


Tanzania 779 942 512

Zambia NA 3040 1523

Number of HIV exposed infants tested for HIV : Project HEART countries


Country 2005 2006 Q1 2007


Mozambique NA 48 28


Tanzania 209 314 131

Zambia NA 476 871

Number of HIV + infants identifiedProject HEART countries


Country 2005 2006 Q1 2007


Mozambique NA 10 16


Tanzania 25 54 20

Zambia NA 131 276

Models of Integrated Service Delivery: Tanzania

• Specific project seeking to expand care and identification for children through increased identification of infants and strengthened linkages between PMTCT and C&T through:– PITC– Training – Active referral of HIV-positive children to CTC– Active follow-up of HIV-exposed children in community for 2y

with CTX prophylaxis• Implementation began in April 2007 at 2 hospitals –

Huruma and Mawenzi• Baseline data gathering and sensitization done• PITC introduced at RCH, general OPD clinics and IPD

Models of Integrated Service Delivery: Tanzania

Quantitative Summary – Huruma & Mawenzi Apr-Jun 2007

#

peds

tested

In PITC

# HIV

expose

#HIV

infected

# in HIV care

#

Mother

tested

#

Mother

positive

# Mother

in HIV

Care

572 36 43 47 22 3 3

Models of Integrated Service Delivery: Swaziland

• KSII PHU – • Initiated as partnership with ICAP and AED• Busiest primary care facility in Manzini. Referral facility

for 15 clinics. One of the 3 initial sites where EGPAF began support for PMTCT in 2004

• Counseling and Testing offered to all and referral to RFM hospital for ART[RFM = Raleigh Fitkin Memorial]

• C&T services began to be offered in Feb 2007. Reasons included:– Referral were ineffective– Self-selection of pregnant women– Change in counselors at the different ART site


• KSII first site to provide one-stop shop’ PMTCT service in Swaziland.

• Luyengo clinic introduced the services of a physician-led ART team in PMTCT clinic fortnightly in 2007

• Pigg’s Peak PHU began HIV Care and ART services in 2004 and introduced PMTCT in 2006. ART physician supervises the PMTCT clinic enhancing clinical care


Data Summary Jan-June 2007

709

215184

775

18396

1441

14811757 26 21

0

200

400

600

800

1000

1200

1400

1600

Number ofpregnantwomen

testing HIV+

CD4 cellcount done

Individualsstarted onCTX (care)

Pregnantwomen

started onHAART

Data Summary Jan- June 2007

KSII PHU

LUYENGO CLINIC

PIGG'S PEAK PHU

Issues to Address

• Indicators to capture integration between PMTCT, HIV care and ART not well developed.

• ‘Artificial’ divide between services → HIV Care, ART & PMTCT and RH services– Funding streams– Data reporting mechanisms – Emphasis on specialization not realistic where the NO and MO =

GP perform most tasks• History of ANC Care in HIV Care and ART clinics

– Traditionally housed in MCH/RCH unit of the facility– PMTCT generally provided at PHC level, ART at secondary or

tertiary centers– ANC care not provided as part of HIV Care & Treatment

package

Issues to Address

• Host government policies and clinical guidelines– Incomplete guidelines on preconception care, prenatal care in

ART or HIV palliative care clinic.– Unclear until what point PMTCT clinic should provide

longitudinal follow-up of the mother-infant pair

• Infant diagnosis– Dependency on DNA PCR– Presumptive diagnosis and use of Ab tests– Symptomatic infants not routinely offered Ab test– Aggregate number includes infants tested at other sites and

referred for care. – Difficult to ascertain transmission rates from the data available.

Issues to Address

• Different data sources for individual patients – Medical records, Registers etc

• Data source and reporting mechanism may not be at the same site or within the same service

• Linkage of data between HIV-exposed infants in HIV Care and mothers from PMTCT poor due to paucity of data

EGPAF Strategies for Integration

To optimize outcomes for patients 1. Link women and children identified in PMTCT to longitudinal C&T

1. a. Infant and Child Diagnosis2. b. Increase Infant and Child C&T

2. Link women in C&T to PMTCT

1. Increase # women receiving PMTCT from C&T

3. Strengthen Family Focus of C&T and PMTCT

• CoC Task Force established in 2006, framework created• CoC TWG appointed in 2007


Proposed Indicators: Care & Treatment

• Number of HIV positive women enrolled in HIV care and/or treatment that were referred from a PMTCT program

• Number of HIV-exposed children less than 2 years old enrolled in HIV care and/or treatment who were referred from a PMTCT program

• Number of HIV-exposed infants in C&T that have received an HIV Test

• Number of women in HIV care and/or treatment newly identified as pregnant and enrolled in ANC providing PMTCT services


Proposed Indicators: PMTCT

• Number of HIV positive women referred from PMTCT program and enrolled in HIV care and/or treatment programs

• Number of HIV positive women referred from PMTCT program that have been clinically staged for HIV illness

• Number of HIV positive women referred from PMTCT program that have had a CD4 assessment

• Number of HIV-exposed infants less than 8 weeks old identified by PMTCT program and enrolled in care and/or treatment programs

• Number of HIV-exposed infants identified by PMTCT program initiating Cotrimoxazole prophylaxis


Indicator Pilot StudiesPhase I

– October 2007 – Analysis of Data Sources – Mozambique, Zimbabwe

Phase II– Early 2008 – Propose denominators and refine indicators, based on Phase I– Pilot Implementation of refined indicators– 8 Countries 2008

Phase III– Mid 2008 – All EGPAF-Supported Countries

Documents

Lessons learned Integrating PMTCT, HIV Care and ART Track 1.0 ART Program Meeting September 25, 2007 Dr Lulu Oguda Senior Medical Officer Elizabeth Glaser