PMTCT overview: current-scale up efforts and challenges in operations

and implementation

Dr Angela MushaviNational PMTCT and Pediatric HIV Care

and Treatment Coordinator: ZimIAS 2011, Rome: Italy

17/07/2011

Outline of PresentationBackground and epidemiology of HIV in

ZimbabwePMTCT Program performance in 2010Current scale-up efforts and challenges with

implementationAnd so wither Zimbabwe?

Background of ZimbabwePopulation: ~12 millionAdult HIV prevalence: 13.7% ANC sero-prevalence : 16.1%An estimated 1,1 mil

Zimbabweans are HIV positive*

Of these, 151, 749 are children 0-14 years*

New pediatric HIV infections are estimated at 14,976* (90% from MTCT)

1,090 patients dying weekly due to AIDS Source: DHS 2005/6 & MOHCW HIV estimates 2009*

Background of Zimbabwe94% of pregnant women received ANC (ZDHS 05/06)

68% of pregnant women delivered in Health Institutions (ZDHS 05/06) MNCH indices of Zimbabwe

398,889 expected pregnancies in 2010; of these, 47,494 are to HIV infected pregnant women

In the last 10 years, MMR has increased555/1000,000: ZDHS 2005/6 725/100,000: MOHCW 2007 Maternal and Perinatal Mortality StudyHIV/AIDS is leading contributor to high MMR (26%)

21% of the Under 5 Mortality Rate (<5MR) is attributed to HIV/AIDS (MIMS 2009)

National PMTCT ProgramPMTCT started as a 3 site pilot in 1999PMTCT program rolled-out in 2002Initially using only SD NVP for both the HIV infected

mothers and their HIV exposed infantsPiloted the use of more efficacious regimens (MER)

as per 2006 WHO Guidelines in 2007Roll-out of MER only started in 2009 Zimbabwe has officially adopted the 2010 WHO

guidelines (Option A) and roll-out is in progress

Current geographic coverage of PMTCT

Total # of health facilities: 1643 Total # of ANC providing PMTCT: 1560 (95%)

Comprehensive PMTCT 1200 (77%) (Both on site HIV testing & ARV prophylaxis) Minimum PMTCT sites 360(No on-site HIV testing but have ARV prophylaxis) 883 sites (57%) of all ANC sites in the 62 districts offer MER while

366 sites (23%) collect DBS for HIV DNA PCR (EID)

Comprehensive PMTCT sites

2007 2008 2009 20100

200

400

600

800

1000

1200

1400

710920 940

1200

Year

No

of s

ites

Estimated pregnancies versus actual seen in ANC

2009 20100

50000

100000

150000

200000

250000

300000

350000

400000

450000

500000

450 000

398 264

270 527

325 476

229 104

295 629

Expected Pregnancies Pregnant women booked for first ANC visitPregnant women HIV tested in ANC

Maternal and Infant ARV prophylaxis

2009 20100

10000

20000

30000

40000

50000

60000

50069 47494

29692 (59%)

39782 (84%)

23042 (46%)

35256 (74%)

ANC Women HIV positiveHIV positive pregnant women received ARV prophylaxisHIV exposed infants who received ARV prophylaxis

Year

Preg

nant

wom

en/I

nfan

t

Importance of partner support

Women HIV tested in ANC Women recived ARV in ANC Infants received ARV0%

20%

40%

60%

80%

100%

92% 94%

80%78%76%

50%

Comparison of Partner Supported and Non-Partner Supported Sites Zimbabwe MOHCW 2009 Data

EGPAF NO PARTNER

CTX prophylaxis to HEI

2007 2008 2009 20100

5000

10000

15000

20000

25000

30000

8225 (14%)

12626 (24%)

17171 (34%)

24996 (53%)

Exposed infants given cotrimoxazole

Exposed infants given cotrimoxazole

DNA PCR for Early Infant Diagnosis of HIV

YEAR Positive Negative TOTAL

2007 77 (31%) 245 322

2008 581 ( 38%) 1585 2 169

2009 901 (25%) 3597 4 498

2010 2373 ( 17%) 14159 16 532

PMTCT: Achievements

Strong PMTCT partnership forum (PPF) that supports scale-up

Transitioning to more efficacious regimens for PMTCT (moving to Option A)

Revised IMAI/IMPAC curriculum with on-going training and support supervision of staff

HIV DNA PCR for early infant diagnosis of HIV (EID) available since 2007

Support from government, donors and partners to provide resources for PMTCT scale-up; including GFATM and the National AIDS Trust Fund (AIDS levy)

Achievements of the PMTCT program

Elimination campaign officially launched in January of 2011

Strengthened efforts towards SRH/HIV integration targeting Prongs 1 and 2

Receiving increasing funding commitments from MOHCW through NAC, GFATM, EGPAF and other donors to scale-up towards elimination of new Pediatric HIV infections

Deploying Point of Care CD4 machines

Point of Care (POC) CD4 machines Evaluation of Point of Care CD4 machines: end 2009-2010

No significant difference between POC and laboratory based CD4 machines

Nurses able to operate as well as lab scientists

• MOHCW has given official go-ahead to procure and deploy these devices

• Roll out and evaluation of the machines under field conditions on-going

PMTCT: ChallengesSome progress yes; but much more needed to increase quality

and coverage towards universal access. In fact, much more needed to attain elimination of Pediatric HIV by 2015

Community mobilization and demand generation: some effort but how much is enough? Stigma and discrimination? Low male participation

Late booking, user fees and home deliveries: a missed opportunity for PMTCT

Lack of tracking of mother-infant pairs in PMTCT; and slow scale-up of EID and early treatment of HIV positive infants

M&E; including revision of tools and data quality and issues

PMTCT: ChallengesChallenge with human resources for health (HRH):

• High staff attrition rates; with constant need to train and retrain (IMAI/IMPAC)

• No official task sharing policies/strategies• Few health care workers trained in the revised 2010 WHO

guidelines for: Infant feeding in the context of HIVPMTCTAntiretroviral treatment

Challenges: PMTCTProcurement, supply chain management for PMTCT in the face

of an under-resourced health care system• Inadequate resources for ARVs, EID and other lab

support(e.g. HR, CD4 machines and consumables)• Shortages of other commodities: Cotrimoxazole, HIV Test

kits and essential equipment for the delivery of quality and comprehensive ANC and MCH services

• Minimal integration of PMTCT within the broader sexual and reproductive & maternal newborn and child health agenda: critical to helping us attain MDGs 4, 5 and 6 by 2015

And so do we give up? A most emphatic no!Understanding these challenges allows us to

design innovative and creative solutionsAnd with support from government,

multilateral and bilateral agencies including PEPFAR, GFATM, and others, we will truly reach the goal of elimination of new HIV infections in children by 2015