Charles S. Kiptemas, MBChB, MPH Director South Rift Valley HIV Care & Treatment Program Kenya Medical Research Institute/Walter Reed Project Track 1 Partners Meeting; Willard Intercontinental Washington, DC Track 1 Partners Meeting; Willard Intercontinental Hotel, Washington, DC August 11-12, 2008 Integration of ART Into MCH: Experience from Kericho District Hospital One Client: Multiple Needs

Kenya National PMTCT Goal By 2005:  50% of all pregnant women should access PMTCT services.  Reduce proportion of infants infected with HIV by 20%. By 2008:  80% of all pregnant women should access PMTCT services.  Reduce proportion of infants infected with HIV by 50%.

Models of Providing HIV Care to Pregnant Women HIV counseling, testing, staging (clinical and immunological), care and treatment including PMTCT at MCH, or HIV counseling, testing, staging (clinical and immunological), non ART care including PMTCT at MCH and referral for ART on/off site, or HIV counseling, testing, and PMTCT at MCH and referral for care and treatment on/off site.

Rationale for Integration Maternal-child health clinics are often the point of entry to care for HIV-infected women and children. In Kenya over 90% of pregnant women seek antenatal care at least once. PMTCT program has been successfully integrated within the MCH framework. Enhances follow up of the mothers and the exposed infants since they are served under one roof. To support accelerated scale-up of HIV prevention, care, and treatment in resource-constrained settings.

The South Rift Valley PMTCT Program Started in August 2001  As a collaboration effort between USMHRP and EGPAF To date approximately 200, 000 pregnant women have been counseled Because of the maturity of the PMTCT program at Kericho District Hospital (KDH), the hospital was selected to pioneer the integration of ART in MCH.

Implementation of ART in MCH HIV clinic for pregnant women started in MCH due to:  Loss to follow up,  Poor uptake of more efficacious regimens, and  Poor access to care and treatment. Run by clinical officers and nurses.  Runs 5 days a week.  Peer educators used to support the service. A file is opened for each patient.  HIV care and PMTCT counseling provided by the clinical officer.  Clinical Staging and blood for baseline evaluation that includes CD4 cell count done in MCH.  NVP for baby and mother given at first contact.

Implementation of ART In MCH, cont. HIV Care and PMTCT ARV prophylaxis initiated at next visit(s):  Prescriptions written in MCH and drugs dispensed from central pharmacy. Women encouraged to bring members of her family for HIV diagnosis. Mother and baby followed up in MCH till child is 18 months old:  Early HIV Infant Diagnosis by PCR done at 6 weeks.  Septrin prophylaxis provided to both infant and mother.

Recommendations for Initiating ARV Treatment in HIV Infected Pregnant Women WHO clinical stage CD4 testing not available CD4 testing available 1 Do not treat (Efficacious Prophylaxis) Treat if CD4 <350* cells/mm3 2 3 Treat 4 *. * CD4 >250/mm3 and <350/mm3 use PI based.

MCH Care of HIV Infected Pregnant Women: Kericho District Hospital (KDH) (Jan 05-June 08) Number of Clients

Uptake Of More Efficacious Regimen (KDH) (Jan 08- June 08) Number of Clients

Male Involvement: Kericho District Hospital (Aug 05-June 08) Number of Clients

Challenges & Issues Integrating ART into MCH with improved uptake of services in high volume sites is possible. Increased workload for the MCH/FP health care providers. -Task shifting: auxiliary staff, peer counsellors. Requirement of additional & training of health care providers. Additional services will require additional resources that may include clinic space and furniture, diagnostic test, and ARV drugs. Disclosure issues.

Anticipated Challenges/Issues Maintaining quality services against the many facility limitations and competing needs. Supervision, monitoring and evaluation. Early initiation of ARV's in pregnancy remains a challenge (roll out of dual therapy). Health worker buy-in/motivation critical. Supply chain management.

Acknowledgements Kenya Ministry of Health Dr. John Odondi KDH Staff Kenya Medical Research Institute/Walter Reed Project HIV Program Leonard Soo Fredrick Sawe United States Military HIV Research Program Dr. Tiffany Hamm Dr. Nelson Michael Ms. Lisa Reilly Dr. Doug Shaffer Sponsors Kenya Ministry of Health Kenya Medical Research Institute United States Military HIV Research Program Presidents Emergency Plan for AIDS Relief Asanteni na Karibuni Kericho, Kenya!

Women Presenting Below 38 Weeks Gestation With Less Advance Disease WHO clinical stage I or II with CD4 cell count > 350/mm3 OR WHO clinical stage I or II no CD4 cell count done –HB ≥7g/dl OR no clinical features of anaemia –AZT 300mg BD from 28 weeks At onset of labour –Administer Nevirapine 200mg and AZT 300mg stat and, Combivir one tab BID to mother. Post partum –Give Infant sd Nevirapine 2mg/kg within 72 hours of birth and AZT syrup 4 mg/kg BD for 4 weeks. –Give mother AZT300 mg / 3TC 150 BID for 7 days