Lessons learned Integrating PMTCT, HIV Care and ART Track 1.0 ART Program Meeting September 25, 2007 Dr Lulu Oguda Senior Medical Officer Elizabeth Glaser Pediatric AIDS Foundation

EGPAF PMTCT Program Results Cumulative data, 2000 – June 2007

Project HEART: Patient Enrollment CUMULATIVE data by June 30, Boxed numbers indicate the number of active sites each quarter

PMTCT and C&T sites: Project HEART Countries Country#PMTCT sites only # only C&T sites # sites with both services Total # sites CI Moz SA Tz ZA

EGPAF Approach to Integrating PMTCT, HIV Care and ART Practice differs across countries In most instances, HIV +ve pregnant women identified through ANC and referred for PMTCT. Number of women identified though HIV Care and the ART clinics not well documented. Estimated pregnancy rate in ART clinics in Zambia in 2006 = 4 /per woman-year. Pregnant women in HIV Care and on ART sent to nearest health facility offering ANC Adaptation of ART and other meds done as appropriate in ART clinics SA and CI offer both clinical screening and urine tests for pregnancy [if clinically indicated] in ART clinics Preconception care and counseling not routinely offered at the sites CI, SA and TZ and ZA have established coding system that allow for linking of mother-infant data from ANC/PMTCT to C&T

PMTCT Addendum A Indicators Number of (see below) Identified as HIV+ Through PMTCT Enrolled in Care and Treatment Program –Pregnant Women –Pregnant Girls (14 and younger) –Non-Pregnant Women (15 and older) –Adult Men (15 and older) –Female Children (0-14 years old) –Male Children (0-14 years old) Number of (see below) Identified as HIV+ Through PMTCT Receiving HAART –Pregnant Women (15 and older) –Pregnant Girls (14 and younger) –Non-Pregnant Women (15 and older) –Adult Men (15 and older) –Female Children (0-14 years old) –Male Children (0-14 years old)

Number of HIV+ pregnant women initiating ART : Project HEART countries [PMTCT Reported Data] Country Q Cote d’Ivoire Mozambique South Africa Tanzania ZambiaNA

Number of HIV-exposed infants initiating Cotrimoxazole prophylaxis at 6 weeks of age : Project HEART countries [PMTCT Reported Data] Country Q Cote d’Ivoire Mozambique South Africa Tanzania ZambiaNA

Number of HIV exposed infants tested for HIV : Project HEART countries [PMTCT Reported Data] Country Q Cote d’Ivoire MozambiqueNA4828 South Africa Tanzania ZambiaNA476871

Number of HIV + infants identified Project HEART countries [PMTCT Reported Data] Country Q Cote d’Ivoire MozambiqueNA1016 South Africa Tanzania ZambiaNA131276

Models of Integrated Service Delivery: Tanzania Specific project seeking to expand care and identification for children through increased identification of infants and strengthened linkages between PMTCT and C&T through: –PITC –Training –Active referral of HIV-positive children to CTC –Active follow-up of HIV-exposed children in community for 2y with CTX prophylaxis Implementation began in April 2007 at 2 hospitals – Huruma and Mawenzi Baseline data gathering and sensitization done PITC introduced at RCH, general OPD clinics and IPD

Models of Integrated Service Delivery: Tanzania Quantitative Summary – Huruma & Mawenzi Apr-Jun 2007 # peds tested In PITC # HIV expose #HIV infected # in HIV care # Mother tested # Mother positive # Mother in HIV Care

Models of Integrated Service Delivery: Swaziland KSII PHU – Initiated as partnership with ICAP and AED Busiest primary care facility in Manzini. Referral facility for 15 clinics. One of the 3 initial sites where EGPAF began support for PMTCT in 2004 Counseling and Testing offered to all and referral to RFM hospital for ART [RFM = Raleigh Fitkin Memorial] C&T services began to be offered in Feb Reasons included: –Referral were ineffective –Self-selection of pregnant women –Change in counselors at the different ART site

Models of Integrated Service Delivery: Swaziland KSII first site to provide one-stop shop’ PMTCT service in Swaziland. Luyengo clinic introduced the services of a physician-led ART team in PMTCT clinic fortnightly in 2007 Pigg’s Peak PHU began HIV Care and ART services in 2004 and introduced PMTCT in ART physician supervises the PMTCT clinic enhancing clinical care

Models of Integrated Service Delivery: Swaziland Data Summary Jan-June 2007

Issues to Address Indicators to capture integration between PMTCT, HIV care and ART not well developed. ‘Artificial’ divide between services → HIV Care, ART & PMTCT and RH services –Funding streams –Data reporting mechanisms –Emphasis on specialization not realistic where the NO and MO = GP perform most tasks History of ANC Care in HIV Care and ART clinics –Traditionally housed in MCH/RCH unit of the facility –PMTCT generally provided at PHC level, ART at secondary or tertiary centers –ANC care not provided as part of HIV Care & Treatment package

Issues to Address Host government policies and clinical guidelines –Incomplete guidelines on preconception care, prenatal care in ART or HIV palliative care clinic. –Unclear until what point PMTCT clinic should provide longitudinal follow-up of the mother-infant pair Infant diagnosis –Dependency on DNA PCR –Presumptive diagnosis and use of Ab tests –Symptomatic infants not routinely offered Ab test –Aggregate number includes infants tested at other sites and referred for care. –Difficult to ascertain transmission rates from the data available.

Issues to Address Different data sources for individual patients – Medical records, Registers etc Data source and reporting mechanism may not be at the same site or within the same service Linkage of data between HIV-exposed infants in HIV Care and mothers from PMTCT poor due to paucity of data

EGPAF Strategies for Integration To optimize outcomes for patients 1.Link women and children identified in PMTCT to longitudinal C&T 1.a. Infant and Child Diagnosis 2.b. Increase Infant and Child C&T 2.Link women in C&T to PMTCT 1.Increase # women receiving PMTCT from C&T 3.Strengthen Family Focus of C&T and PMTCT CoC Task Force established in 2006, framework created CoC TWG appointed in 2007

EGPAF Strategies for Integration Proposed Indicators: Care & Treatment Number of HIV positive women enrolled in HIV care and/or treatment that were referred from a PMTCT program Number of HIV-exposed children less than 2 years old enrolled in HIV care and/or treatment who were referred from a PMTCT program Number of HIV-exposed infants in C&T that have received an HIV Test Number of women in HIV care and/or treatment newly identified as pregnant and enrolled in ANC providing PMTCT services

EGPAF Strategies for Integration Proposed Indicators: PMTCT Number of HIV positive women referred from PMTCT program and enrolled in HIV care and/or treatment programs Number of HIV positive women referred from PMTCT program that have been clinically staged for HIV illness Number of HIV positive women referred from PMTCT program that have had a CD4 assessment Number of HIV-exposed infants less than 8 weeks old identified by PMTCT program and enrolled in care and/or treatment programs Number of HIV-exposed infants identified by PMTCT program initiating Cotrimoxazole prophylaxis

EGPAF Strategies for Integration Indicator Pilot Studies Phase I –October 2007 –Analysis of Data Sources –Mozambique, Zimbabwe Phase II –Early 2008 –Propose denominators and refine indicators, based on Phase I –Pilot Implementation of refined indicators –8 Countries 2008 Phase III –Mid 2008 –All EGPAF-Supported Countries