News|break Namibiareliefweb.int/sites/reliefweb.int/files/resources/1DF38DA69D46BA0... · News|break • Issue 6 • March/April 2010 Namibia MDG 6: Combating HIV/AIDS, Malaria and

News|break • Issue 6 • March/April 2010

Namibia

MDG 6: Combating HIV/AIDS, Malaria and other diseases • Page 1

According to the verified data presented at the meeting, in total there were 13 332 TB cases reported for the period 1 January to 31 December 2009, as compared to 13 737 cases reported during the same period in 2008, representing a 3% decline from 2008 (Table 1). The Khomas region remains the worst affected with more than one-third (35.5%) of all TB cases reported in this region (Figure 1). This shows that the country is experiencing a gradual but consistent decline in TB cases notified. Additionally, since 2005, the treatment success rate increased from 64% to 82%, nearly reaching the WHO target of 85%.

Intensifying Efforts to Fight Drug Resistant Tuberculosis (DR-TB)

Source: MoHSS: National Tuberculosis and Leprosy Control Programme, Annual Report 2008/2009

News|breakIssue 6 • March/April 2010MDG 6: COMBATING HIV/AIDS,

MALARIA AND OTHER DISEASES

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Table 1: Comparison of Number and Type of TB cases reported for 2008 and 2009

2008 2009TB Notified cases 13 737 13 332New smear positive cases 4928 4608TB cases with known HIV status 9188 (67%) 9849 (74%)HIV positive TB cases 5425 (59%) 5676 (58%)HIV positive TB patients on CPT 5289 (98%) 5192 (92%)HIV positive TB patients on ART 2019 (37%) 1995 (35%)Treatment success rate new ss+ve 83% (2007) 82% (2008)MDR 201 236XDR 20 19Poly-resistant 47 80Unconfirmed on 2nd line medicines - 24DR TB All types 268 359Source: MoHSS: National Tuberculosis and Leprosy Control Programme, Annual Report 2008/2009

Figure 1: Number of Tuberculosis Cases (all forms) Reported by Region, Namibia, 2009

The Emergence of Drug-Resistant Tuberculosis (DR-TB) Despite this positive trend, preliminary data from 2009, indicates that the emergence of Drug-Resistance Tuberculosis (DR-TB) is on the increase and posing a significant challenge. DR-TB is a recent phenomenon in Namibia. In 2009, a total of 359 cases of all types of DR-TB were reported. These included 236 Multi-Drug Resistant TB (MDR-TB) cases, 80 Poly-Resistant TB cases (PR-TB) and 49 Extensively Drug Resistant Tuberculosis (XDR-TB) cases (Table 1).

Tuberculosis (TB), the country’s second biggest killer, following HIV/AIDS is stabilizing according to the Ministry of Health and Social Services (MoHSS), following a TB review meeting held from 16-18 February 2010 in Swakopmund, Erongo region. This was disclosed at a meeting that brought together 40 regional and district TB control focal persons from all 13 regions to review and audit all Drug Resistant TB cases reported for 2009, establish trends and compile the 2009 TB Annual Report.

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MDG 6: Combating HIV/AIDS, Malaria and other diseases • Page 2News|break • Issue 6 • March/April 2010

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Figure 2: Regional distribution of DR-TB cases in 2009


The Emergence of Drug-Resistant Tuberculosis (DR-TB) (continued)

MDR-TB represents a significant threat to development both globally and in Namibia due to its impact on the fiscus (treatment of drug resistant TB is extremely expensive) and on people’s health.

XDR-TB is even more difficult (some are impossible) to treat than other forms of DR-TB, since even second line medicines do not work in these patients. In Namibia there have been 39 confirmed cases since 2007; 25 of whom are deceased.

The emergence of MDR-TB and XDR-TB, are principally a result of inadequate or poorly administered treatment or failure by patients to take the medicines as recommended. Dr Farai Mavhunga, Chief Medical Officer (CMO) for the National TB and Leprosy Control Programme in the MoHSS explains, “DR-TB develops due to failure by patients to complete the full course of treatment as prescribed; or due to erratic ingestion of medicines by the patient; or due to inadequate prescription. Both health workers and patients can contribute to the development and spread of DR-TB. Patients who have DR-TB can spread this form of TB to others if appropriate measures to prevent this transmission are not put in place. This transmission can take place at home, at work, in prisons, in schools, in health facilities; or in any other indoor setting where infected patients come into contact with other people.” It is therefore important that health facilities in particular adhere to the infection control practices recommended by the MoHSS in the Tuberculosis Infection Control Guidelines.

The cost of second and third-line anti-TB medicines, used for the treatment of MDR-TB and XDR-TB is extremely high, while at the same time the cure in such cases is not guaranteed. In 2009, the MoHSS spent N$12 million (US$ 1.56 million) for all anti tuberculosis medicines, of this amount N$8.8million (US$1.3 million), approximately 73% was for the treatment of DR-TB patients. This does not include expenses incurred for hospitalization and other related costs.

As a result of the rigorous treatment requirements and expenses, World Health Organization, Representative Dr Magda Robalo urged partners saying, “We need to continuously monitor and ensure that the standards of patient care are high in all health facilities. Satisfactory TB treatment outcomes can only be achieved through concerted efforts by government, public and private health care providers, families and communities who must all be involved in the process leading to the diagnosis of the disease and successful treatment of the patients.”

TB Dot Promoter, Priskilla with MDR-TB patient at Grootfontein Hospital in the Otjozondjupa Region.

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On the move against DR-TB in Namibia Namibia has put in place a number of measures to curtail further development and spread of DR-TB. Dr Farai Mavhunga, Chief Medical Officer (CMO) for the MoHSS National TB and Leprosy Control Programme said, “To address this situation, a National TB and Leprosy Programme has been operational since Independence. The Tuberculosis Infection Control Guidelines has been rolled out to assist health workers and other staff in high risk settings towards

preventing the spread of TB. Moreover, modifications and special installations are being made in facilities to help minimise the spread of TB within health facilities. Also, we have a committee at national level that provides technical guidance to health facilities on the management of each diagnosed case. With the support of WHO and partners, the MoHSS is finalizing the second Medium-Term Plan (MTP II) for TB and Leprosy. Under the MTP II, TB patients with HIV infection have access to free antiretroviral treatment and patients with MDR-TB and XDR-TB have free access to very expensive alternative anti-TB medicines, which is not the case in many countries.”

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MoHSS, National TB and Leprosy Control Programme, CMO, Dr Farai Mavhunga, informs UN staff and partners about the measures taken by the country to control all types of TB on World TB Day.

A DOT point in Walvis Bay to enable TB patients easier access to treatment and support within their community.

Community Mobilisation

Given that TB is mainly a community and social problem and not simply a medical issue, the MoHSS is implementing the WHO recommended Directly Observed Treatment Strategy (DOTS) which includes free medication and treatment at all government hospitals for a six-month course of medication. In tandem with the DOTS strategy, there is also the Community Based Directly Observed Treatment Short-Course Strategy (CB-DOTS). Under the CB-DOT-strategy patients are provided with support to take their medicines everyday under the direct supervision of a health worker or a treatment supporter such as a DOT promoter. In the absence of these strategies there is the risk of high defaulter rates, posing a risk for further spread of the disease and an increase of resistant cases.

The fight to control TB cannot be won by health care providers alone and requires multi-sectoral interventions. WHO Disease Prevention and Control Officer Dr Desta Tiruneh noted that social mobilization and community support are important saying, “It must be a joint effort by health providers, leaders and the communities. Individuals, families and communities should be mobilized to contribute to this effort.”

WHO Representative Dr Robalo, commended MoHSS for the rigorous implementation of the STOP-TB Strategy, including implementation of the DOTS and CB-DOTS to significantly improve case detection and treatment outcomes towards achieving universal access.


Figure 3: TB Patients with Known HIV Status: 2005-2009

TB and HIV infection

TB is the world’s biggest killer of people living with HIV. Equally, the TB epidemic in most parts of the world is driven by the HIV epidemic. In Namibia, 74% of TB patients are HIV infected. The percentage of TB patients tested for HIV has increased from 16% in 2005 to 74% in 2009 (Figure 3). The target is to have all TB patients tested for HIV and vice versa. Those patients who are HIV positive can then receive comprehensive care for both TB and HIV.

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World Tuberculosis (TB) Day 2010 Commemorated “Health Workers on the Move Against TB”

Deputy Health Minister Petrina Haingura, in a statement made on behalf of H.E. President Hifikepunye Pohamba, praised the concerted efforts of doctors, nurses, health workers, NGOs and volunteers in the fight against TB.

US Ambassador, Ms Dennise Mathieu commited to help strengthen primary health systems in the fight against TB.

World Tuberculosis (TB) Day, 2010, was commemorated in Namibia under the global theme, “Innovation” with the slogan “On the Move Against Tuberculosis.” The commemoration served to acknowledge the achievements of health workers, TB lifestyle ambassadors, Community-Based Directly Observed Treatment Short-Course Strategy (CB-DOTS) promoters who continue to sacrifice themselves and find new ways to stop TB. This year’s World TB celebration was commemorated in Otjozondjupa Region in the Grootfontein District, one of the regions with the highest concentration of Multi-Drug Resistant TB (MDR-TB) cases. Of the 2318 TB cases, 39 have MDR-TB.

Delegates attending the commemoration included the Deputy Minister of Health and Social Services (MoHSS), Petrina Haingura, Honourable Governor, Mr Freddie Kavetuna for Otjozondjupa Region, US Ambassador, Ms Dennise Mathieu, WHO Represen-tative, Dr Magda Robalo, MoHSS Director of Special Programmes, Ms Ella Shihepo, traditional leaders and NGO partners from Red Cross Society, Namibia Business Coalition on AIDS (NABCOA), Advanced Community Health Care Services (CoHeNa), Health Unlimited and Penduka among others.

Speaking at the event, Deputy Minister Petrina Haingura on behalf of His Excellency, President Hifikepunye Pohamba, acknowledged the efforts made by TB ambassadors and promoters who volunteer their time to spread the message about TB treatment and prevention as well as DOT supporters who provide direct support and supervision to patients on treatment.

Given the high rate of DR-TB, WHO Representative Dr Magda Robalo reiterated saying, “The theme and the slogan of World TB Day 2010 responds directly to the need to accelerate our efforts towards greater community involvement and increased research with a view to ensuring better and more accurate diagnostic methods and access to treatment, including treatment of drug-resistant cases. WHO will continue to assist the MoHSS through support to research for the development of new diagnostic tools and medicines to speed up case identification and shorten the duration of treatment. In

doing so, we hope that our efforts will enable Namibia to realize the Millennium Development Goal Six target, which is to combat priority diseases such as HIV/AIDS and TB.”

The co-infection of TB and HIV is increasing the risk of DR-TB. The United States of America Ambassador, Ms Dennise Mathieu stated; “The US Embassy remains committed to work with the MoHSS and partners in the fight against TB and HIV/AIDS, and to help strengthen primary health systems in Namibia. We’ll work with you to improve surveillance; to enhance facilities; to ensure TB treatment adherence through Community-Based Directly Observed Therapy (CB-DOTS); and to strengthen the Programmatic Management of Drug Resistant Tuberculosis (DR-TB).”

In addition to the commemoration of World TB Day in Grootfontein, the MoHSS and Penduka with support from other partners commemorated the event with a TB Car Convoy in Windhoek. WHO hosted a UN and Partners Brown Bag lunch to stimulate discussions about the status of TB in Namibia.

This year marks the halfway point for the Global Plan to Stop TB 2006 – 2015. World TB Day, 24 March is the day on which Robert Koch discovered the micro-organism that causes TB in 1882. The overall aim of the commemoration is to raise awareness about the global TB epidemic and to encourage all people to intensify efforts to control the disease.


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Volunteers illustrating how HIV can be transmitted through Multiple Concurrent Partnerships (MCPs) using a game. In Namibia as in most parts of the world, TB is driven by the HIV epidemic.

The Police and the National Defense Force leads a procession for World TB Day commemorations in Grootfontein.

WHO Representative, Dr Magda Robalo with MoHSS Deputy Minister Petrina Haingura at the Grootfontein TB Day event.

Musicians Exit and Mushe who volunteer as TB Lifestyle Ambassadors performed at the 2010 World TB Day national event in Grootfontein district.

The MoHSS and Penduka with support from other partners commemorated TB Day with a Car Convoy in Windhoek so as to mobilise greater involvement of communities and increase awareness.

Namibia TB Commemoration

A proud day for TB patients who have successfully completed treatment with their DOT promoters, receive a hamper of food items to reward them.


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United States of America, Ambassador Ms Dennise Mathieu with the Honourable Deputy Prime Minister, Dr Libertina Amathila unveil the inauguration plaque of the Resource Centre.

Inauguration of TB/HIV Resource Centre for School of Nursing & Public Health Faculty at University of Namibia (UNAM)

On 15 March 2010, the University of Namibia (UNAM) with support from USAID inaugurated a TB and HIV/AIDS Resource Centre to provide students with the latest information and resources on TB and HIV/AIDS. The Resource Centre comes in response to the high rates of TB and HIV co-infection and the need to equip future healthcare workers with the latest knowledge required to combat these diseases. In 2009, of the 13 332 TB cases, nearly 60% tested HIV positive. The Resource Centre is targeted for postgraduate students, especially for those who are from rural areas who, when coming to UNAM for studies have no access to books, videos and internet facilities to help them in their research.

Honourable Deputy Prime Minister, Dr Libertina Amathila, WHO Representative, Dr Magda Robalo and Dean of School of Nursing and Public Health, Dr Lischen Haoses-Gorases take in the view of the new library equipped with the latest textbooks, computers and internet connectivity which will enable students to keep abreast of the latest information on HIV/AIDS and TB.

Speaking at the inauguration, the Honourable Deputy Prime Minister, Dr Libertina Amathila said; “The MoHSS with the support from USAID has taken a bold stand to embark on this initiative, it is indeed a gesture of friendship and partnership towards building our future healthcare workforce to be able to put an end to TB.”

United States of America, Ambassador Ms Dennise Mathieu said, “I am so excited about the opening of this new resource centre. The centre will contain academic journals, computers with which to access electronic and internet resources, and a library of relevant Government publications. This will be a place where students, faculty members and health professionals can go to keep abreast of the latest information on public health in general, and on TB and HIV/AIDS in particular. And I certainly hope the first class of medical students will make use of this centre as well. After all, in addition to the books and computers mentioned before, the most valuable resource at this centre will be the students who come here for information. It is an honor to be able to invest in those who will be at the forefront of Namibia’s health system for years to come.’’

The Resource Centre was furnished with support from partners such as Koninklijke Nederlandse Centrale Vereniging tot bestrijding der Tuberculose (KNCV) [Dutch Tuberculosis Foundation], International Training and Education Centre for Health (I-TECH) Washington, assisted by the Centre for Disease Control (CDC) donated computers, printers and books to the Resource Centre.


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Along with the unveiling of the “Wipe Out Malaria” Campaign, MoHSS Honourable Minister Dr Richard Nchabi Kamwi launched the Malaria Communications and Advocacy Strategy to sustain the initiative.

On Friday, 23 April, the Ministry of Health and Social Services (MoHSS), with support from WHO and other partners, commemorated World Malaria Day 2010 (April 25) with the launch of a national elimination campaign titled “Wipe Out Malaria” and the unveiling of a logo to unite and scale-up Namibia’s malaria elimination efforts over the coming years in Oshikango, Ohangwena Region. World Malaria Day was observed under the global theme, “Counting Malaria Out,” calling on all countries to deliver effective, affordable protection and treatment to all people at risk of malaria.

Ministry of Health and Social Services launches Malaria Elimination Campaign on World Malaria Day 2010

The Honourable Minister Dr Richard Nchabi Kamwi with dignitaries from the Ohangwena region unveil the national elimination “Wipe Out Malaria” logo.

This year’s World Malaria Day in Namibia targeted decision makers and influential stakeholders from all sectors to support the national goal and to become advocates for elimination within their relative spheres of influence.

Malaria deaths have dropped by 90% between 2001 and 2008. The number of malaria cases treated at hospitals has also fallen by 77% from 41 100 to 5200, during the same period. The number of recorded malaria deaths has also fallen from 1700 in 2001, to 170 deaths in 2008. The country has exceeded the targets set out in the Abuja Declaration to cut malaria deaths by 50 percent by 2010.

The Honourable Minister of Health and Social Services (MoHSS), Dr Richard Nchabi Kamwi officially unveiled the logo of the elimination campaign. In his keynote speech, Minister Kamwi noted that Namibia is making progress: “The Wipe Out Malaria campaign serves to help Namibia sustain and accelerate efforts to eradicate malaria. The campaign will promote four key malaria prevention and control measures, namely, nightly use of insecticide treated nets (ITNs), intermittent preventive malaria treatment for pregnant

women, indoor residual spraying (IRS) as well as prompt and appropriate treatment for all malaria infections.” He said people should be made aware that malaria is a disease that should be kicked out of the country and that people should adhere to the four proven malaria control actions.

Minister Kamwi thanked the Global Fund to fight AIDS, TB and Malaria for funding Government’s efforts to control malaria since 2005. The funding helped to improve mosquito-control programmes, the distribution of bed nets, rapid testing for malaria at almost all health facilities and the acquisition of effective medicines.

Adding further, Dr. Kamwi called upon the private sector to take up the malaria elimination challenge together with the MoHSS: “I call upon you all here – both old and new partners – to join the Government as it embarks on a new phase which will focus on eliminating malaria. Malaria places a significant burden on the health and well-being of Namibians, simultaneously robbing the nation of countless hours of productivity each year.”


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WHO Disease Prevention and Control Officer and Officer-in-Charge, Dr Desta Tiruneh commended Namibia for the progress made with declining infection and death rates showing that the elimination of malaria is possible.

Mayor of Heloa Nafidi town of Ohangwena Region, Mr. P. Carolissen, stressed the need for the community to use mosquito nets correctly.

Honourable Minister Kamwi with learners from Omutaku Primary School who recited a poem about malaria.

The commemoration was attended by officials from WHO, Red Cross Society, The Global Fund, Society for Family Health and a representative of the Queen of Oukwanyama.

Emphasizing further the goals of the campaign, WHO Disease Prevention and Control and Officer-in-Charge, Dr Desta Tiruneh stressed, “Elimination is an ambitious effort but the evidence of declining infection and death rates in Namibia also suggest that it is within reach. Its achievement requires active participation of all stakeholders and every Namibian, including neighbouring malaria endemic countries.”

Governor of the Ohangwena Region, Usko Nghaamwa, said the public should treat malaria with seriousness and a sense of urgency, since it has the potential to cripple the country. “The battle against malaria cannot be attained without the use of insecticide treated nets. The gathering here today will hopefully instill positive influence on how our people perceive malaria and how they should protect themselves from mosquito bites.”

To reach these ambitious goals, the MoHSS, supported by its partners, is investing in the National Elimination Strategy to reduce local malaria transmission to zero. In Namibia, malaria control is coordinated by the MoHSS National Vector-borne Diseases Control Programme, with local activities implemented by regional health offices.

Namibia is one of four African countries whose transmission of malaria has declined significantly to lead national and international experts to recommend that the country make the transition from a control towards an elimination programme over the next 5 – 10 years. As such, Namibia is a key member of a sub-regional group of countries that are aiming to eliminate malaria within their borders. Other countries engaged in this initiative are Angola, Botswana, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe. The sub-regional grouping is currently chaired by the Honourable Minister of Health and Social Services (MoHSS), Dr Kamwi.


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Dr John Govere orientates an IRS team preparing to spray homes in Otjozondjupa region as a measure to control malaria.

WHO Support Malaria Spraying in Northern Namibia

Malaria continues to be a major public health problem in Namibia, ranking fourth among the top ten diseases in the country. Malaria, considered endemic in Caprivi, Kavango, Kunene, Ohangwena, Omusati, Oshana, Oshikoto, and part of Otjozondjupa and Omaheke regions, affects more than 60% of the population.

The epidemiological situation in Namibia is changing from a high to low malaria burden. According to records of the Ministry of Health and Social Services (MoHSS) Health Information System (HIS), more than 400 000 malaria cases (clinical and laboratory confirmed) and more than 1000 deaths were reported annually before 2005. Since then, there has been a decreasing trend in transmission, resulting in 102 381 and 119 711 malaria cases being reported in 2007 and 2008 respectively.

Namibia is making progress against the Abuja Declaration - signed in 2000 - to cut malaria deaths by 50%; the number of recorded malaria deaths has fallen from 1700 in 2001, to 170 deaths in 2008 – a reduction of 90%, far surpassing the Abuja targets. Namibia now aims to wipe out malaria completely.

To this end, WHO supervised Indoor Residual Spraying (IRS) activities from 13-24 November 2009 in Otjozondjupa and

Kavango regions. The mission aimed to assess areas in need of strengthening and provide support in finalising the MoHSS’s National Vector Control Guidelines.

The mission led by Dr John Govere, WHO Entomologist, assessed the storage and logistical capacity of the National Medical Store where insecticides and other IRS supplies and equipment are stored. The mission found that the MoHSS was well stocked and the storage of insecticides and other IRS commodities adhered to WHO recommendations.

Additionally, the IRS spraying teams visited villages, clinics, hospitals and farmsteads in Kavango and Otjozondjupa Regions with the district malaria spraying teams.

Throughtout the period 13-24 November 2009, the spraying teams were able to spray, on average, 40 rooms per day.


Namibia

On average, the spraying teams were able to spray 40 rooms per day.

Indoor Residual Spraying (IRS)

IRS is the application of long-acting chemical insecticides on the walls and roofs of all houses and domestic animal shelters in a given area, in order to kill the adult vector mosquitoes that land and rest on these surfaces. The primary effects of IRS towards curtailing malaria transmission are:

• to reduce the life span of vector mosquitoes so that they can no longer transmit malaria parasites from one person to another, and

• to reduce the density of the vector mosquitoes. In some situations, IRS can lead to the elimination of locally important malaria vectors.

Some insecticides also repel mosquitoes and by so doing reduce the number of mosquitoes entering the sprayed room, and thus human-vector contact.

WHO’s Malaria Programme

WHO’s Malaria Programme recommends the following four primary interventions that must be scaled-up in countries to effectively respond to malaria, towards achieving the Millennium Development Goals (MDGs) for malaria by 2015 and other health targets:

• Timely diagnosis of malaria cases and treatment with effective medicines;

• Distribution of insecticide-treated nets (ITNs) to achieve full coverage of populations at risk of malaria;

• Indoor residual spraying (IRS) where appropriate as a major means of malaria vector control to reduce and eliminate malaria transmission including, where indicated, the use of DDT; and

• Prevention of malaria during pregnancy through administration of intermittent preventative treatment (IPTp).

Scaling-up access and achieving high coverage of these effective interventions, particularly to populations who are at the highest risk of malaria and sustaining their implementation, remain major challenges for achieving current global malaria control goals.

Based on the mission, the WHO technical team recommended the following:

• Improved supervision of the IRS teams to ensure that timing of operations is on schedule and that there is a high quality of spraying of individual housing units and coverage is high,

• A Supervisory Checklist should be developed to assist supervisors in the collection of baseline data and planning of IRS spraying campaigns during the period October to January,

• Community sensitisation campaigns should be conducted well in advance of the IRS activities to raise awareness and facilitate community mobilisation, acceptance and participation in IRS campaigns, and

• In view of the malaria elimination agenda in Namibia, malaria baseline surveys on vector density, distribution, biting and resting behaviour, infectivity rate and susceptibility must be conducted.

Successful IRS campaigns require high-level political commitment, dedicated human, logistic, transport, financial resources and adequate organisational and planning capacity. Training and motivation of temporary field personnel backed up by a core of full-time field officers and regular supervision are critical for effective delivery of IRS. In order to ensure timeliness, the campaign should be organised and completed in the shortest period of time, before the onset of transmission. Community awareness and compliance as well as acceptance of IRS, community education and communication should be an essential part of the campaign to ensure high coverage. Households should be well informed on and aware of the benefits of the campaign.

WHO Support Malaria Spraying in Northern Namibia (continued)


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Namibia Adopts WHO New HIV Recommendations to improve health, reduce infections and save lives

Namibia is working to roll-out the new WHO recommendations on treatment, prevention and infant feeding in the context of HIV, based on the latest scientific evidence. The new recommendations were released on the eve of World AIDS Day, 30 November 2009. WHO now recommends earlier initiation of antiretroviral therapy (ART) for adults and adolescents, the delivery of more patient-friendly antiretroviral drugs (ARVs), and prolonged use of ARVs to reduce the risk of mother-to-child transmission of HIV. For the first time, WHO recommends that HIV-positive mothers or their infants take ARVs while breastfeeding to prevent HIV transmission.

Preventing mother-to-child transmission (PMTCT) and improving child survival

In 2006, WHO recommended that ARVs be provided to HIV-positive pregnant women in the third trimester (beginning at 28 weeks) to prevent mother-to-child transmission of HIV. At that time, there was insufficient evidence on the protective effect of ARVs during breastfeeding. Since then, several clinical trials have shown the efficacy of ARVs in preventing transmission to the infant while breastfeeding. The 2009 recommendations promote the use of ARVs earlier in pregnancy, starting during the 14th week of gestation and continuing throughout the breastfeeding period until one week after cessation of breastfeeding.

WHO now recommends that breastfeeding continue until the infant is 12 months of age, provided the HIV-positive mother and the baby are taking the recommended ARV treatment. This will reduce the risk of HIV transmission and improve the infant’s chance of survival.

“With the new recommendations, we are sending a clear message that breastfeeding is the best option for every baby, even those born to HIV-positive mothers, when they have access to the recommended ARVs medications,” said Dr Ghirmay Andemichael, Maternal and Child Health Officer at WHO Namibia.

Benefits:

• An earlier start to antiretroviral treatment boosts the immune system and reduces the risks of HIV-related death and disease. It also lowers the risk of HIV and TB transmission,

• The new PMTCT recommendations have the potential to reduce mother-to-child transmission of HIV to less than 5%. Combined with improved infant feeding practices, the recommendations can help to improve child survival;

• Earlier treatment may also encourage more people to undergo HIV testing and counselling and learn their HIV status, and

• Initially a greater number of people will require treatment. However, the associated costs of earlier treatment may be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections.

New treatment recommendations

In 2006, WHO recommended that all patients start ART when their CD4 count (a measure of immune system strength) falls to 200 cells/mm3 or lower, at which point they typically show symptoms of HIV disease. Since then, studies and trials have clearly demonstrated that starting ART earlier reduces rates of death and disease. WHO is now recommending that ART be initiated at a higher CD4 threshold of 350 cells/mm3 for all HIV-positive patients, including pregnant women, regardless of the WHO clinical staging.

WHO also recommends that countries phase out the use of Stavudine, or d4T, because of its long-term, irreversible side-effects. Stavudine is still widely used in first-line therapy in developing countries as it is cheaper and widely available. Zidovudine (AZT) or Tenofovir (TDF) are recommended as less toxic and equally effective alternatives.

The 2009 recommendations outline an expanded role for laboratory monitoring to improve the quality of HIV treatment and care. They recommend greater access to CD4 testing and the use of viral load monitoring when necessary. However, access to ART must not be denied if these monitoring tests are not available.

“These new recommendations are based on the most up to date, available data,” said World Health Organization Representative Dr Magda Robalo, “Their widespread adoption and implementation will enable many more people in high-burden areas to live longer and healthier lives.”


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Challenges:

• The main challenge lies in increasing the availability of treatment in resource-limited countries. The expansion of ART and PMTCT services is currently hindered by weak infrastructure, limited human and financial resources, and poor integration of HIV-specific interventions within broader maternal and child health services,

• Encouraging more people to receive voluntary HIV testing and counselling before they have symptoms. Currently, many HIV-positive people are waiting too long to seek treatment, usually when their CD4 count falls below 200 cells/mm3;

• Global funding shortfalls for fighting AIDS could make it impossible for developing countries to implement the WHO treatment guidelines. The global economic downturn forced the Global Fund to Fight AIDS, Tuberculosis and Malaria, the world's largest funder, to cut disbursements by 10 percent in 2008, while the US President's Emergency Plan for AIDS Relief (PEPFAR) has flat-lined funding to many countries, limiting the growth of PEPFAR-funded treatment programmes, and

• Domestic funding for HIV/AIDS programmes from recipient countries have not been increased in most cases, creating critical challenges to the sustainability of ART programmes.

WHO, in collaboration with key partners, will provide technical support to countries to adapt, adopt and implement the revised guidelines. Implemented at a wide scale, WHO’s new recommendations will improve the health of people living with HIV, reduce the number of new HIV infections and save lives.

The Four-Pronged Strategy for PMTCT

The four-pronged strategy for PMTCT addresses a broad range of HIV-related prevention, care, and treatment and support needs of pregnant women, mothers, their children and families. This comprehensive approach includes the following:

1. Primary prevention of HIV infection among women, especially young womenAvoiding infection in parents-to-be will help to prevent HIV transmission to infants and young children, as well as help towards other prevention goals. HIV prevention needs to be directed at a broad range of women at risk and their partners. As primary HIV infection during pregnancy and breastfeeding poses an increased threat of MTCT, HIV prevention efforts should address the needs of pregnant and lactating women, especially in high prevalence areas. In addition, special effort should be made to prevent future infection among women diagnosed HIV-negative especially in antenatal care settings.

2. Prevention of unintended pregnancies among HIV-infected womenReproductive health (including family planning) services need to be strengthened so that all women, including those who are infected, can make informed decisions about their future reproductive life, including when to seek appropriate support and services to prevent unintended pregnancies. Most HIV-infected women in the developing world do not know their serostatus. Increased availability of counselling and testing services would enable them to obtain essential care and support services, including family planning and reproductive health services, in order that they can make informed decisions about their future reproductive lives.

3. Provision of specific interventions to reduce HIV transmission from HIV infected women to their infants For HIV-positive women who do become pregnant, WHO has identified a package of interventions for the PMTCT. It includes antiretroviral drug regimens for HIV-infected pregnant women and their newborn, safe obstetric practices and counselling and support for HIV-infected pregnant women on infant feeding options.

4. Provision of treatment, care and support for HIV-infected mothers, their infants and family Care and support must be fully integrated into ongoing efforts to improve maternal and child health services, and be tailored to the needs of women for safe and effective antenatal, obstetric and reproductive health services. This also includes sexual and reproductive health interventions for HIV-infected women and other care for HIV-infected women and for children born to HIV-infected mothers.

WHO Antiretroviral Therapy Guidelines

Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV

infection in infants

Available at: http://www.who.int/hiv/pub/mtct/advice/en/index.html

Rapid advice: infant feeding in the context of HIV

Available at:http://www.who.int/hiv/pub/paediatric/advice/en/index.html

For more information: WHO Country Office in Namibia • UN House 2nd Floor, 38 Stein Street, Klein Windhoek, P.O. Box 3444, Windhoek, Namibia Phone: +264-61-255-121/171 • Fax: +264-61-204-6202 • Email: [email protected] • Website: www.afro.who.int

Documents

News|break Namibiareliefweb.int/sites/reliefweb.int/files/resources/1DF38DA69D46BA0... · News|break • Issue 6 • March/April 2010 Namibia MDG 6: Combating HIV/AIDS, Malaria and