1. PREVENTION OF MOTHER TO CHILD TRANSMISSIONOF HIV IN INDIA: ISSUES AND CHALLENGES Dr. S.K CHATURVEDI UNICEF DR. KANUPRIYA CHATURVEDI

2. LESSON OBJECTIVES TO HAVE AN UNDERSTANDING OF THE SERVICES RELATED TO PREVENTION MOTHER TO CHILD TRANMISSION OF HIV( PMTCT) TO APPRECIATE THE ISSUES AND CHALLENGES TO UNDERSTAND THE SCALING UP OF SERVICES TO IDENTIFY KEY ACTIONS POINTS RELATED TO SCALING UP

3. Global HIV/AIDS IN 2004 Effect on Children 39.4 -40.0 million people are living with HIV/AIDS 2.2 million are children under 15 years 6,40,000 children were newly infected with HIV in 2004 5,10,000 children died of HIV in 2004

4. NEW CHALLENGES …. NEW OPPORTUNITIES HIV +U5MR

5. Adult HIV Prevalence High Prevalence States

6. INDIA : MCH PROFILE Total Population 1027 M Crude Birth Rate 25/1000 Sex Ratio (F:M) 933 Annual Pregnancies 27 M ANC Coverage 65.4 % Institutional Deliveries [12.1% to 79.3%]35.6 % Deliveries attended by skilled birth attendants42.3 %

7. Feasibility studies PPTCT Feasibility Study AZT: March 2000 - August 2001 –AZT 300 mg BD from 36 weeks onward –AZT 300 mg / 3 hours during labour –No AZT to the baby PPTCT Feasibility Study NVP: October 2001 - June 2002 –NVP 200 mg single dose to mother at onset of labour –NVP 2 mg/kg single dose to newborn within 72 hours

8. Some Lessons Learnt: Reduced transmission of HIV from mother to infant

9. LESSONS LEARNT

11. Unicef role in PPTCT

12. . PPTCT Intervention Package 1. Ante-Natal Care 2.Group Education / Pre-Test Counselling 4. Post-Test Counselling 5. Institutional Delivery : Safe Birthing Practices 6. Administration of Nevirapine to the woman during labour 3. HIV Testing : after Informed Consent

13. 7.Administration to the BABY of SINGLE DOSE of Suspension Nevirapine ( 2 mg./ Kg.) within first 72 hours 8. Counselling of mother for Infant Feeding Options 9. Care & Support 10. Follow -up PPTCT Intervention Package… PPTCT Plus

14. Nevirapine Administration Mother: Screened for contraindications Single Dose Tablet of 200 mg. during First stage of Labour Baby: Single Dose of suspension within first 72 hours Nevirapine Courtesy : Donation from CIPLA

15. Enrollment Procedure ANC Group Education Offered HIV test Post-Test Counseling HIV Test Pre-Test Counseling Enrollment: AZT/NVP HIV +HIV - Primary Prevention One-To-One

16. Rationale for PPTCT in India 27 million pregnancies per year* 1,89,000 infected pregnancies per year Cohort of 56,700 infected newborns per year 0.7% prevalence** 30% transmission *Derived from population estimates (SRS) AND Crude Birth rate, adding 10% pregnancy wastage **Weighted average of estimates numbers of rural and urban HIV prevalence amongst women15-19 years

17. 11 Centers of Excellence 74 Medical Colleges High Prevalence States 159 District Hospitals/ Maternity Hospitals High Prevalence States 450+ District Hospitals/ Maternity Hospitals Low Prevalence States 79 Medical Colleges Low Prevalence States Phase 4 - 2004-2005 Phase 1- 2002 Phase 2 - 2002 Phase 3 - 2003-2004 Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs SCALE UP STRATEGY

18. S. No. Activities Numbers % 1. Total No. of New ANC Registrations in 288 PPTCT Centers11,34,839 2. Total No. of women counseled9,40,85382.9 3. Total No. of women accepted HIV test8,29,16488.13 4. No. of women found HIV positive8,8391.07 5. No. of women who collected their HIV results6,81,61082.2 6. No. of women who received post test counseling6,43,33677.5 7. No. of HIV positive women who collected their results6,98779 8. No.of Spouses/ partners of HIV positive women counseled4,78154 9. No. of spouses/partners of HIV positive women accepted HIV test4,53394.8 10. No. of Husbands / partners detected HIV positive3,75982.9 11. No. of women coming directly in labour without ANC Reg.2,11,518 India: PPTCT Performance: Analysis of Jan-Dec 2004 (Data Source: NACO, 04 August, 2005 )

19. S. No. Activities Numbers % 12. No. of women counseled who arrived in labour without ANC 1,25,51259.3 13. No. of women who accepted HIV test1,08,28886.24 14. No. of women detected HIV positive1,8721.73 15. Total HIV Tests Done in PPTCT Centers for pregnant women 9,37,452 16. Cummulative HIV Positivity Rate among Pregnant women 1.14% (8839+1872)= 10,711/937452 17. Total no. of mother-baby pairs received NVP4,45141.56 18. No. of mother-baby pairs received NVP who were registered for ANC 3,223 19. No. of mother-baby pairs received NVP who came directly in labour 1,228 20. Total pregnant women availing PPTCT Services counseling onwards…(Booked 9,40,853+ Unbooked 1,25,512 ) 10,66,365 * Uttaranchal, Bihar, West Bengal, Delhi, Chandigarh

20. Increase in Facility based coverage However Nevirapine uptake is static at 40-42%

21. Current level of PPTCT coverage PPTCT services are available in all states at tertiary and secondary levels and currently 14 per cent of all pregnant women currently access such services. However, in 2004, only 3.94 per cent of all pregnant women received HIV counselling and testing and 2.35 per cent of the HIV-positive pregnant women received ARV prophylaxis.

22. Gaps Inadequate expansion of PPTCT services beyond the large delivery units The low proportion of women identified to be HIV infected that receive the nevirapine prophylaxis (40-42%) or ART where eligible. Insufficient linkages with HIV are and support services, and unclear application of CD4 testing policies for pregnant women. The focus on identifying infected women and the little attention given to HIV uninfected Decentralised management and coordination is up to state level and there are limited structures at sub-state level Prioritisation of high prevalence states and facilities with high delivery numbers and not high volume antenatal units No clear of the contribution from private sectors as the monitoring system does not currently include them

23. Conclusions from India 2004 Data when projected to a population base Every year in India: : Total number of pregnant women : 270,00,000 ( 27m) : Pool of HIV infected pregnant women: 1,89,000 ( 0.7 % prevalence, NACO-2004) : Pool of HIV infected babies : 56,700 ( @ 30% transmission) Only 3.94% of all (27 million) pregnant women are availing PPTCT services (Counseling onwards…) in 288 PPTCT centres (10,66,365 / 270,00,000) Only 2.35 % of pregnant women living with HIV are being covered with NVP (4,451/ 1,89,000) ( all-India) Reduction in proportion of infected babies on All –India basis : 668 / 56,700 = 1.17 %

24. For achieving the UNGASS goal of 2005, we need to protect a total of 11,340 (20 % of 56,700) babies in the country. For protecting 11,340 babies, we need to cover, 22,680 babies with NVP in the country. For covering 22,680 babies with NVP, we need to administer NVP to 74,844 pregnant mothers with HIV ( 22,680 x 3.3), i.e, 39.5 % of all HIV+ mothers in the country (74,844 / 1,89,000). For reaching these 74,844 HIV + pregnant women, we need to strategize differently for high prevalence states and other states

25. High prevalence States account for 21% of the pool of pregnancies from HIV positive women For UNGASS goal of 2005 for the HPS, we need to protect 7,882 babies from acquiring infection. For this, we need to administer NVP to 15,764 babies …likely to be born to 52,000 HIV + mothers. For reaching these 52,000 HIV+ pregnant women, we need to cover a total of 2,184,874 pregnant women. Of these, 841,750 are already being reached, an additional 13,43,124 pregnant women to be reached with PPTCT services. PPTCT coverage for High Prevalence States

26. Strategies for HP states are: 1.Scale up services to all CHCs and PHCs …. At least to 50 % by 2005/ 2006. 2.Provide PPTCT services through the private sector ….. At least to 50 % by 2005/ 2006 3.Improve quality of services in the existing centres to retain all women coming to these centres. 8,41,750 pregnant women in these states, the actual reach for Nevirapine administration is only 3,47,581 and we are losing 5,02,258 pregnant women despite “ reaching them”. 4.Care, Support and Treatment services for women and children to be a priority.

27. These states have a combined population of about 700 million. They being “low prevalence states” contribute about 17,300 infected babies (30 % of the total ) every year to the national pool of 56,700 HIV infected babies. If we need to achieve UNGASS goal for 2005 for these states, we need to protect 3,460 babies from acquiring HIV infection……For this to happen, 6,920 babies need to be administered NVP. For achieving this, we need to target 22,836 HIV+ pregnant women for NVP administration. For reaching these many women, we need to have 87,83,076 pregnant women availing PPTCT services (approx. 33 % of all 27 million ). Of these, 1,74,533 are already being reached, we need to reach an additional 87,00,000 pregnant women in these 28 states and UTs. PPTCT coverage for Other States

28. PPTCT Programme will be one of the Entry Points for ART ( Others are: VCCTCs T.B. DOTS Centres STD Clinics Blood Banks Networks of Positives )

29. Convergence of PPTCT with ART Programme Convergence in Counselling Convergence in Training Linkages for Care and Support

30. Issues and challenges Scaling up the access to PPTCT services Focus on quality Counseling services Streaming Patient Flow Emergency counseling and testing Operationalizing a “single window” system

31. Issues and challenges(contd). Strengthening referral links and services Increased focus and action on Prongs 1,2 and 4 Strategies for alternative delivery of Counseling and PPTCT services to be formulated in NE states

32. Broad Strategies Developing and implementing a costed population- based PPTCT scale-up plan with clear operational targets based on state level burden of disease estimates; Defining a minimum package of services to be provided at the different levels of care including standard operating procedures for strengthening linkages between PPTCT and ART services; Strengthening follow up services for HIV positive mothers and their children within a continuum of prevention and care, and Intensifying HIV/STI/RH preventive interventions for HIV negative pregnant women in the context of PPTCT

33. Key action points Decrease the loss to follow up in the existing PPTCT centers Strengthening the Emergency counseling and testing service at all PPTCT sites: Scale up PPTCT services to cover all public health care sites:

34. Action points (contd.) Public private partnerships Increasing access to quality counseling services to women in the reproductive age group and enhance institutional deliveries. Building capacity of all health care providers (up to grassroots level) in HIV /AIDS counseling and management of HIV /AIDS cases. Linking PPTCT programme to existing primary prevention and care and support programs for HIV /AIDS in the State and strengthening links with People Living with HIV /AIDS networks (PLHA) of all PPTCT service sites.

35. Tools for Scale Up 1.Standardized training packages for PPTCT team- (Gynaecologists, technician, pediatricians and staff nurse) and Counsellors 5 day training package for all team members 12 day training package for counselors that also includes infant feeding 2.Cadre of master trainers at state level 3.PPTCT indicators capturing process and outcomes 4.Data flow – Facility to national level 5.Communication strategy in place (Phase I being implemented, Phase II creatives being developed) 6.Testing supported by EQUAS