AIHA’s Pilot Project in Odessa: A Comprehensive MTCT Prevention and Intervention Program Zoya Shabarova American International Health Alliance zoya@shabarova.nl

AIHA Strategic Framework to Prevent Mother-to-Child-Transmission of HIV in Odessa “Plus-pMTCT-Plus” First “Plus”: prevention of HIV among women of reproductive age and family planning for women with HIV pMTCT: Prevention of mother-to-child transmission of HIV End “Plus”: Follow up care and support for families

Ukrainian Context for MTCT Strategy Prenatal HIV screening is widely available Prenatal, perinatal and postnatal coverage is almost universal High percentage of HIV+ women are IDUs; high percentage of infants are born addicted to drugs Replacement feeding can be carried out by HIV infected mothers without major risks and obstacles Because numbers of identified HIV infected women is still limited, it is still affordable to provide pMTCT interventions The current, relatively low number of MTCT cases provides a window of opportunity to prepare the health care system to cope with the emerging problem

AIHA MTCT Pilot Project Goals Reduce the incidence of HIV in women of reproductive age, increase the early identification of HIV+ pregnant women (Plus-pMTCT) Prevention of MTCT during pregnancy, delivery and postpartum (pMTCT) Provide follow up care and support to infants, mothers and families to ensure that children born to HIV+ mothers grow up in a sustainable, nurturing environment (pMTCT-Plus) Prevent occupational exposure to HIV among healthcare workers Create a model that is adaptable to other sites and a teaching laboratory to facilitate dissemination and replication (scaling up)

MTCT Project Strategic Partners in Odessa Odessa Oblast Clinical Hospital Odessa State Medical University Odessa Oblast AIDS Center Odessa Oblast and Odessa City Health Administrations Boulder Community Hospital University of Colorado’s Health Sciences Center Children’s Hospital of Denver International Donors Organizations and NGOs (MSF, UNICEF, PATH, Odessa PLWA NGOs)

Coordination of USAID Donor and Inter-Donor Efforts in Odessa USAID Donors JHPIEGO Family Planning Trainings including counseling component 1997-8, Odessa Oblast Hospital AIHA Consultation Training and Pre- and Post- HIV Testing Counseling workshop, May 2002, Kiev. Attended by all AIHA Women Wellness Centers (WWC) and PHCs including OOH PATH VCT training, 2002-2003, Odessa Inter-Donor MSF: Provide Nevirapine, infant formula, C-section delivery kits for OOH and develop laboratory capacity; cooperation on Satellite Clinic development at OOH UNICEF: Developed training materials on pMTCT in collaboration with OSMU and OOH

Main Components of AIHA’s Odessa Pilot Project Develop a comprehensive strategy and establish widespread community support for key components. Creation of a “center of excellence” at a designated healthcare facility (OOH). Restructuring of health care delivery system: effective communication and referral system between health institutions, effective allocation of limited resources. Development and implementation of relevant, evidence-based practical guides, informational brochures, and patient charts among others. Training of healthcare professionals. Assure high quality of care at designated health care facility (OOH). Provision (including substantial donations) of essential medical equipment and supplies. Coordination of activities with other donor organizations (MSF, UNICEF, PATH) and Odessa PLWA NGOs.

Project Milestones (1) A catalogue of reference documents was developed (practical guides for healthcare workers, patient’s charts, and patient education materials). A clinical training program was initiated in Denver in April 2002. MTCT supplies and equipment were delivered to the Odessa Oblast Hospital. A case management Monitoring and Evaluation PMTCT database was developed (in MS Access), data entry is in progress; preliminary results are available. A MTCT training course curriculum for Odessa HCWs was developed. Odessa Oblast Health Administration issued an order requesting HCWs from all women's consultations to participate in the MTCT training course (May 2002). Odessa Oblast Health Administration issued an order in May 2002 that all HIV-positive pregnant be referred for prenatal care and for delivery to OOH.

Project Milestones (2) Five abstracts based on project results were published in the XIV International AIDS Conference abstract book, six articles were published in the special volume containing the extended versions of the abstracts and five posters were presented. MOH decided to use Odessa PMTCT M&E database as the basis for the development of national MTCT M&E database. UNICEF asked AIHA to demonstrate the PMTCT M&E database during the UNICEF sponsored PMTCT Study Tour for CARK policy makers. Satellite Clinic was opened for HIV+ people at the OOH in June 2003 (in collaboration with MSF). The Odessa PMTCT Training center was opened in June 2003. In September , based on WHO/GTZ mission assessment visit, Odessa PMTCT Training center was chosen by as the element of WHO Knowledge Hub, focused on PMTCT. Two abstract were published in Abstract book of 2nd IAS conference on HIV pathogenesis and treatment and two posters were presented at the conference in Paris. Odessa model was the element of the PMTCT review in Ukraine conducted by WHO, UNICEF, Ukrainian MOH and international organizations. Two Odessa experts participated in this review in Kiev and Dnepropetrovsk.

Project Monitoring and Evaluation Purpose of M&E: to ensure that implementation is progressing as planned, to examine activities and determine the degree of achievement in meeting set objectives Two types of results: Replicable management tools (practical guides, information brochures, charts, etc.) Clinical

MTCT Practical Guides Purpose: Provide improved practice guidelines for OB/GYNS, neonatalogists, pediatricians, family physicians, nurses, midwives, social workers and lab technicians on various aspects of treating HIV+ patients. Family Planning for Women with HIV Prevention and Treatment of STIs Treatment of STIs in HIV+ Pregnant Women Infection Control Practices Voluntary Counseling and Testing in Prenatal Care Prenatal Care for HIV+ Women Prevention of MTCT During Delivery Infant Feeding for Babies Born to HIV+ Women Pediatric Care for Infants Born to HIV+ Mothers Primary Health Care for HIV+ Patients PMTCT among women who are IDUs

Other MTCT Products for Dissemination 1. Questionnaires Purpose: Assess knowledge of HIV/AIDS and MTCT of healthcare workers in maternity houses and pediatric settings. Questionnaires have also been developed for parents and guardians of children born to HIV infected mothers and for HIV+ pregnant women. 2. Information Packages Purpose: Disseminate information among women of reproductive age and HIV+ women on HIV prevention, pregnancy and HIV testing, HIV, newborn and infant Care. 3. Patient Charts Purpose: Collect and maintain information about HIV infected women and Infants.

Monitoring of Clinical Results Within “Plus-PMTCT-Plus” approach, PMTCT can be considered as a cascade of program intervention to stop the transmission of HIV from mother to child, integrated into the MCH and PHC schedule (UNAIDS, 1999; UNICEF, UNAIDS, WHO, 2001). The MCH schedule provides a basis for monitoring and evaluating the PMTCT project clinical results. Cascade of interventions is based on the best available evidence, adapted to regional situation.

Main M&E Indicators MTCT rate in OOH. Number of HIV positive women who was registered for prenatal care before the 2 trimester of pregnancy (delivery at OOH). Number of HIV positive pregnant women who had PMTCT counseling at OOH. Number of cases where the HIV positive status was known before delivery in OOH. Number of HIV positive pregnancies appropriately treated for PMTCT at OOH. Number of HIV positive deliveries appropriately handled for PMTCT at OOH. Number of babies, exposed to HIV, appropriately treated for PMTCT at OOH. Number of HIV positive women and their babies who received family oriented follow up care at OOH Satellite Clinic. Number of health care professionals, trained for PMTCT, in Odessa region.

Selected PMTCT Project Preliminary Data

Future Directions Replication of Odessa PMTCT Model in other regions in Ukraine and the NIS Development of comprehensive model of care and treatment to women with HIV and HIV infected children Further development of the Odessa PMTCT Training Center as “Teaching Laboratory” on PMTCT for the NIS region