PMTCT Operations Research

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PMTCT Operations Research

• Grace John-Stewart

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Assignment To decrease infant HIV in 2 years
using NVP

• Group 1
• Women with HIV Ideal clinic flow and procedures
• Group 2
• MCH Clinic Managers Ideal clinic flow and
  procedures
• Group 3
• National Planners Target percent to reduce, how
  to evaluate progress
• Group 4
• WHO/UNAIDS Expert Group Prioritize countries for
  intensive strategies, how to evaluate progress

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What medical interventions have resulted in
global benefit?
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Smallpox eradication
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Childhood vaccinationGAVI milestones

• By 2010 or sooner all countries will have routine
  immunization coverage at 90 nationally with at
  least 80 coverage in every district.
• By 2007, all countries with adequate delivery
  systems will have introduced hepatitis B vaccine.
• By 2005, 50 of the poorest countries with high
  disease burdens and adequate delivery systems
  will have introduced Hib vaccine.
• By 2008, the world will be certified polio-free.
• By 2005, the vaccine efficacy and burden of
  disease will be known for all regions for
  rotavirus and pneumococcal vaccine, and
  mechanisms identified to make the vaccines
  available to the poorest countries.

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Incremental steps

• Research to develop vaccine
• Program expansion to deliver vaccine
• National and international commitment
• Public and private sector
• Funding and expert support to accomplish targets
• Expert groups develop targets
• Implementers facilitate expansion and monitoring

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Common themes

• Define epidemiology
• Target high-prevalence areas
• Set specific goals for reduction
• Adapt strategies for different health care systems

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UN General Assembly Goals for PMTCT 2001

• Decrease HIV-1 infected infants by 20 by 2005
• Decrease HIV-1 infected infants by 50 by 2010
• 4-component strategy
• Prevent HIV-1 (all/women)
• Prevent unintended pregnancy
• Prevent transmission MTCT
• Provide care and support for infected
  women/families

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Interventions

• Randomized clinical trial
• Short-course antiretrovirals decrease MTCT
• Nevirapine
• One dose to mother
• One dose to baby

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How would you set up a program to implement this
regimen?
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Steps

• Access pregnant women
• Offer HIV testing
• HIV test
• NVP
• Mother
• Baby

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Improvement of coverage of MTCT
programs Temmerman, AIDS 2003171239-42
1,161 should have received NVP

• lt10 of mother/infant pairs who should have
  received NVP received NVP

6000 deliveries 4740 no ANC (80)
NVP 106 (30)
HIV-1 348 (14)

• Tested 2,483 (97)

Counseled 2, 516 (71)

Attended clinic 3,564
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Target areas
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Estimated number of children (lt15 years) newly
infected with HIV during 2005
Western Central Europe 200 lt 400
Eastern Europe Central Asia 3 700 2 600 6
400
North America 500 lt1 000
East Asia 2 300 840 6 300
North Africa Middle East 8 900 2 600 30 000
Caribbean 3 800 2 000 8 000
South South-East Asia 44 000 25 000 83
000
Sub-Saharan Africa 630 000 560 000 740 000
Latin America 7 700 5 600 14 000
Oceania 1 100 230 4 800
Total 700 000 (630 000 820 000)
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HIV Testing
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Mass administration of NVPMarseilles, Lancet
1999354803-9 Stringer, Lancet 19993581611-12

• Cost-effective
• Minimal risk of drug toxicity
• Controversial
• Concerns regarding loss of benefits of VCT

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PMTCT Western Kenyavant Hoog JAIDS
200540344-349

• Original
• Counseling/testing separate locations
• 34 wks NVP
• 77 received counseling
• 80 tested
• 55 learned HIV status
• 57 NVP uptake
• 15 effectiveness
• (31 target population, 47 efficacy)

• Revised
• Counseling/testing
• same location
• NVP 2nd trimester
• 92 received counseling
• 83 tested
• 68 learned HIV status
• 70 NVP uptake
• 23 effectiveness
• (48 target population, 47 efficacy)

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When to give NVP?
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What about women who come to delivery without
accessing prenatal care?
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• 16 US Centers MIRIAD
• 91,707 women in labor
• 7,381 no HIV status documented
• 5,744 (78) approached
• 4,849 (84) agreed
• 34 HIV positive
• 100 sensitivity, 99.5 specificity
• Recommend routine opt-out testing at delivery

JAMA 2004292219-223
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Integrating prevention of mother-to-child HIV
transmission into routine antenatal care the key
to program expansion in CameroonWelty JAIDS
2005 40(4)486-93

• 115 health facilities in 6 provinces
• Diverse staff (TBAs, midwives, nurses,
  nurse-aides)
• 68,635 women, 92 HIV tested
• 97.9 of HIV positive women received post-test
  NVP counseling
• Consistent training and programmatic support

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Making things happen

• Program optimization
• Policy to drive funding and personnel resources

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Case Study Elizabeth Glaser Pediatric AIDS
Foundation

• Motivation
• Research
• Call to Action
• Advocacy