Application of M

1
Application of ME to Technical ProgramsPMTCT

• N. Shaffer, MD
• PMTCT Team Leader, HHS/CDC/GAP
• SI/ME Field Officer Orientation
• Atlanta, August 10, 2004

2
Summary Main Themes

• ME essential part of PMTCT program activity
• Needs to occur at facility level, national and
  international levels
• Needs to be simple combine several different
  approaches
• Challenge and opportunity for human capacity
  development and systems building
• Needs to be unified, coordinated

3
Major Questions for PMTCT ME

• How broad is the coverage of services for
  pregnant women?
• How good is the uptake of services being provided
  for HIV women?
• How effective is the program in preventing infant
  infections?
• Special challenges of evaluating infant infection
  status and program effectiveness

4
Perinatal HIV Transmission

• Primary route of HIV infection in infants and
  children
• Transmission rates vary globally from
• 15 - 40 in absence of antiretrovirals
• 1- 15 range with antiretrovirals
• Nearly a doubling of transmission rates in
  breastfeeding settings
• Worldwide, 2,000 infants become infected each
  day or 720,000 per year
• Most in Africa

5
Baseline Assessment ANC HIV Prevalence, PMTCT
Initiative
6
Objectives of PMTCT Initiative

• Reach up to 1 million women annually in focus
  countries
• Reduce mother-to-child HIV transmission by up
  to 40 among women treated

WHO/P. Virot
7
PMTCT Program Goals

• UNGASS Indicators
• 2005 50 of women have access to PMTCT
• 2010 80 of women have access to PMTCT
• 2010 50 decrease in perinatal transmission
• Presidents Initiative focus countries
• Reach 1 million women annually
• 40 decrease in perinatal transmission
• within 5 yrs

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PMTCT Burden in Focus Countries

• 1.2 million HIV women delivering / year
• Approx 420,000 infant infections / year (35 of
  HIV-exposed)
• Goal
• Reach 1 million women annually (gt80)
• Prevent 168,000 infant infections (40)

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How Does PMTCT Relate to 2-7-10?

• PMTCT presents direct opportunity (and
  challenge) in general population to contribute to
  all 3 program goals
• Treatment
• 2M pregnant women eligible for ARV over 5 years
• Plus 2M husbands, 1.5M infants
• Prevention
• Can prevent 500K-1M infant infections over 5
  years
• Primary prevention for HIV- women and discordant
  couples
• Care
• Care for gt10M HIV-infected family members and
  AIDS orphans

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PMTCT Indicators - EPAR

• service outlets with PMTCT
• faith-based service outlets with PMTCT
• women provided with PMTCT services
• women provided with ARV prophylaxis for PTMCT
• people trained in PMTCT services
• --------------------------------------------------
  ---------
• service outlets with PMTCT

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Key Background Data

• Number of women
• women delivering each year
• delivering in facility
• delivering in faith-based facility
• delivering at home
• and HIV-positive deliveries per year
• Facilities
• facilities/ faith-based facilities
• facilities providing PMTCT and PMTCT services
  ANC and LD

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Baseline Assessment Nigeria

• Population 115 million HIV prevalence 5.8
• 4.37 million births/year
• 64 pregnant women register for ANC
• 37 pregnant women deliver at health facilities
• 260,000 HIV positive pregnant women deliver/yr
• 100,000 infant HIV infections/yr
• 23,000 MCH facilities (14,000 public, 9,000
  private)
• Public (50 tertiary, 750 secondary,13,200
  primary)
• Global Fund 70m for national ARV PMTC-PLUS
• National PMTCT- PLUS Program
• Began Sept. 2002 at 8 major tertiary care
  facilities
• Plan to expand to 12 additional facilities
  bi-annually

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USG PMTCT STRATEGY

• Core Interventions
• Routine ANC CT
• Simplified pre-test, rapid same-day results
• Short-course ARV (NVP, AZT)
• Introduce longer treatments and combination /
  HAART treatment where feasible, and when woman
  eligible
• Infant feeding counseling
• Program support for safe, feasible alternatives

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PMTCT Cascade
Pregnant
ANC
Pre-test counseling
Test accepted
Results given
ARV initiated
ARV completed
Safer infant feeding
Infections averted
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Elements of PMTCT Program Logic Model
Activities

Core Monitoring Indicators
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Elements of PMTCT Program Logic Model
Guidelines development Program planning,
monitoring and evaluation
Supervision management in service delivery
sites Commodities (test kits, medicines,
etc) Laboratory testing Training
staff Physical infrastructure improvement Commun
ity mobilization outreach Operations research
Services to all pregnant women (ANC, HIV
education testing, partner HIV
testing) Services to HIV- women (counseling,
prevention) Services to HIV women (HIV
counseling med care, ARV for PMTCT, infant
feeding, ARV treatment and care) Services to
children born to HIV women (PCP prophylaxis, HIV
diagnosis treatment and care)
USG initiative country program evaluations Review
monitoring data Modeling estimates of
impact Special studies
Activities
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Elements of PMTCT Program Logic Model
Activities
Core Monitoring Indicators
of sites meeting program standards
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Where are we with PMTCT?

• Wide range in national programs and capacity
• HIV-infected pregnant women receiving
• 2003 2004 target
• CT lt1 - 40 4 - 70 median (lt10)
  median gt10
• Any ARV lt1 - 12 3 - 40
• (HIV) median lt5 median gt5

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Thailands National PMTCT ProgramUptake of
Interventions, 2001-2003
Newborns Receiving ARV
Mothers Receiving ARV
80 85
65 70
85 90
70 75
90 95
75 80
gt 95
gt 80
20
Thailands National PMTCT ProgramUptake of
Interventions, 2001-2003
VCT
ARV
21
PMTCT in Botswana

• PMTCT program started 1999
• National rollout 2001 (first national PMTCT
  program in Africa)
• Low uptake of testing and interventions
• In 2002 40 of pregnant women tested
• In 2002 only half of known HIV women received
  PMTCT interventions
• USG assistance has helped improve program
  monitoring and program

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Percent of women who were tested for HIV by the
end of pregnancy-related care Francistown,
Botswana -- 2002-2004
Routine testing
PMTCT counselors started
ARV program
PMTCT survey
Links to care workshop
BOTUSA PMTCT project
23
Estimated infections averted by national PMTCT
program Botswana 2002-2004
24
National Facility-Based PMTCT-MSCDC Reference
System

• Standardize data collection and monitoring
• Provide monitoring information to identify
  progress and challenges and improve PMTCT
  services
• Facilitate standard reporting of national and
  international PMTCT indicators
• Flexible to allow country-specific adaptations
• Support PMTCT program and reporting requirements
  of the Presidents Emergency Plan

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PMTCT-MS Overview

• PMTCT service data recorded in registers kept in
  ANC and LD wards
• Additional columns added to standard registers
• Monthly summary forms tally registers to report
  number of women and children receiving PMTCT
  services
• Monthly summary forms reported and entered into
  computer
• Reports and graphs generated to provide feedback
  to program managers and health care workers

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PMTCT-MS Components

• Registers (ANC and LD)
• Monthly summary forms
• PMTCT-MS Epi Info Database
• Reports and graphs
• Support materials sample protocols, checklists,
  training materials, job aids

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Data Collection and Reporting Procedure
Health Facility
ANC Register
Maternity (LD) Register
ANC Monthly Form
Maternity (LD) Monthly Form
Send Forms
District / Regional Office
Feedback
National Office
Data Entry
Forward flow Feedback
Analysis
Feedback
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Key Approaches for PMTCT ME

• Mapping and line listing of PMTCT facilities and
  services
• Standardized facility-based monitoring systems
• ANC surveillance (UAT) and expanded surveillance
  to include PMTCT
• Special studies on program effectiveness

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PMTCT Targeted Evaluations

• Intrinsic part of program monitoring and
• improvement
• How to improve uptake and coverage?
• How to provide more effective regimens?
• How to access male partners and provide
  family-centered approach?
• How to best link PMTCT with care and Tx?
• How to evaluate effectiveness?

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PMTCT ME - Conclusions

• Reporting on PMTCT indicators is complex, but
  essential
• Special opportunity to coordinate among partners
  and build national capacity
• Uniquely situated within MCH services
• Challenge to meet international reporting
  requirements and strengthen HMIS
• SI and ME officers can play key role
• Supporting national PMTCT ME effort
• Coordinating unified USG monitoring effort
• Helping to support special evaluation studies
• Providing feedback to PMTCT program managers and
  implementing partners