1. WABA GLOBAL FORUM II 23rd - 27th September, 2002. Arusha, Tanzania Topic: PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV By Dr. Augustine Massawe Department of Paediatrics Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania

2. BACKGROUND 4 MTCT of HIV is the major cause of HIV infection in children. Each year approximately 700,000 children are infected. 4 Without intervention, up to 40% of children born to HIV infected women will be infected. Infection can take place: 4 in utero 4 during labour and delivery 4 postpartum through breast milk Risk factors include: 4 Mode of delivery 4 Prolonged rupture of membranes for more than 4 hours 4 Some factors may be associated: -Episiotomy -Intrapartum haemorrhage -twin delivery,1st twin higher risk -Invasive foetal monitoring

3. RELEVANT STATISTICS IN AFRICA 4 Globally 1.3 million children under 15 years of age live with HIV/AIDS 4 Nearly 4 million children under 15 years old have died of disease since the epidemic began 4 Majority of these children were born to mothers infected with HIV acquiring the virus the during  pregnancy  delivery  breastfeeding

4. Relevant statistics#2 J SSA has 70% of the worlds HIV infected children, 80% of the deaths and 90% of AIDS orphans J 10% of children under 15 in some African are now orphans J More than 13 million children worldwide are single or double orphans of these 90% live in SSA J Comparing the under five mortality rate and IMR in Sub Sahara Africa to industrialized  Under five mortality rate in SSA is 173 while IMR is 107  Under five mortality industrialized countries was 37(1960) now is 6 (1999) with IMR of 6 in 1999

5. Estimated impact of AIDS on under-5 child mortality rates – Selected African countries, 2010 Source: US Bureau of the Census 250 200 150 100 50 0 per 1000 live births with AIDS 98036-E-25 – 1 December 1999 BotswanaKenyaMalawiTanzaniaZambiaZimbabwe without AIDS

6. HIV/AIDS EFFECT ON CHILD SURVIVE IN TANZANIA  HIV prevalence antenatal women 12%  MTCT Transmission rate 40%  72,000 babies every year added = 200 babies a day  25,200 through breastfeeding  Underfive mortality from 137 (1996) to 150 per 1000 live births (1999) (TRCHS)  Infant mortality 88 per 1000 live births 1996 to 99 per 1000 live births in 1999  Neonatal mortality increased from 28 per 1000 live births 1996 to 44 per 1000 live births 1999  20% paediatric admissions HIV+ve (2000)

7. MODE OF HIV INFECTION IN TANZANIA 4 Heterosexual 82% 4 Mother to child transmission 6% – 0 - 4 yrs 78.3% – 5 - 9 yrs 17.5% –10 - 14 yrs 4.2% 4 Blood transfusion 1%

8. Timing of Transmission  Intrauterine: one third(1/3)  Intrapartum (during labour and delivery)(two thirds2/3)  Post-natal through breastfeeding( 14%)

9. Factors associated with increased risk of MTCT in HIV

10. HIV & Infant Feeding Background: 4 HIV in breastmilk- 1985 4 Transmission 14% - 20% 4 Increased risk of transmission with longer duration of breast feeding 4 Mixed feeding carries higher risk than EBF

11. Prevention of Perinatal Transmission: Major issues Reduction of postnatal transmission Reduction of postnatal transmission breast feeding dilemma breast feeding dilemma exclusive breastfeedingexclusive breastfeeding mixed breastfeedingmixed breastfeeding prolonged breastfeedingprolonged breastfeeding mastitismastitis cracked nipplescracked nipples oral thrush in the babyoral thrush in the baby right to breastfeedright to breastfeed stigmastigma undisclosureundisclosure Care of uninfected children born of HIV-infected mothers Care of uninfected children born of HIV-infected mothers care of orphans care of orphans Prevention of pregnancy among HIV-infected women Prevention of pregnancy among HIV-infected women Prevention of HIV infection among women Prevention of HIV infection among women

12. PMTCT THROUGH BREASTFEEDING 4 Breast feeding in Tanzania 4 98% of women initiating breast feeding immediately after delivery 4 60% within one hour, 4 88% within 24 hours 4 95% continue to breastfeed 4 38.5% exclusively breastfeed for 4 months! 4 Medium period for breastfeeding is 22 months in Tanzania 4 59 hospitals are baby friendly.(128 hospitals trained)

13. PMTCT THROUGH BREASTFEEDING 4 Availability of infant formulae in the market Heavy workload for women 4 Lack of enough supportive policies and regulations 4 Inappropriate hospital routines or practices.

14. PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV Research Regime Reduction Petra 61% Thailand 50% Nevirapine 47% Mitra (Petra Arm A) + Infant up to 6 months HAART therapy from second trimester + ECS less than 2% HAART therapy - viral load 0- normal vaginal delivery

16. CONCLUSION u AZT+3TC started at the onset of labour and for one week postpartum to the mother and the child significantly reduced MTCT of HIV by 37%, in a breastfeeding population. u When started at 36 weeks of pregnancy until delivery and for one week postpartum to the mother and the child MTCT was significantly reduced by 50% in the same population. u When given during intrapartum only, AZT+3TC had no effect on prevention of MTCT of HIV. u No difference between the arms in infant mortality from birth to 6 weeks.

17. HIV test results of informed husband and partners who agreed to undergo the test following counselling EventNumberpercent Tested 2960.4 Refused 1939.6 HIV+ve 20 69 HIV-ve 9 31 Demonstrate a high rate of couple discordance

18. Infant feeding pattern of children born to HIV infected women in Dar es Salaam following counselling (N=267) Number % Breastfeeding25093.6 Never breastfed 176.4 Recurrence of Pregnancies subsequent to participation in PETRA Study 18/255(7.1%)

19. Source of the new pregnancy in those who conceived. Person Number percent Responsible same Husband 9 50% New Partner 316.7% Casual partner 6 33.3% Total 18 100%

20. HIV test results of informed husband and partners who agreed to undergo the test following counselling EventNumberpercent Tested 2960.4 Refused 1939.6 HIV+ve 20 69 HIV-ve 9 31 Demonstrate a high rate of couple discordance

21. PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV IN TANZANIA ELEMENTS OF PILOT PROJECTS Strengthening ANC Modification of obstetric practices VCT and ANC Short-course AZT Infant feeding counselling and support Follow-up Monitoring and evaluation

22. CURRENT PMTCT SITES IN TANZANIA MARCH 2002 PMTCT SITES: 1.MVH MOH:1.MVH 2.KCMC 2.KCMC 3.BUGANDO 3.BUGANDO 4.MBEYA 4.MBEYA 5.KAGERA 5.KAGERA :1.HAI AXIOS(NOG):1.HAI 2.KILOMBERO 2.KILOMBERO TANSWID/SAREC DSM** HAVARD:1.DSM(MUCHS)** TEMEKE* UNAIDS/WAF UNICEF-TEMEKE* PASADA:RCA DSM* :DODOMA* ANGLICAN CHURCH:DODOMA* TANGA* TANGA* KAGERA* KAGERA* GTZ:MBEYA** MDM SPAIN: COAST REGION MDM FRANCE: KAGERA

23. SITUATION ANALYSIS - FINDINGS - Limited awareness of MTCT - ANC attendance adequate, but full service package not always delivered - Variation in obstetric practices - VCT not widespread - Different HIV tests, costs - Counselling often lacks MTCT - AIDS training lacks MTCT, infant feeding - Importance of support services underestimated.

24. MAIN OBJECTIVE To reduce mother-to-child transmission of HIV-1 among the regular catchment population of the five hospitals by at least 50% when compared to pre-intervention levels.

25. INTERIM GOALS - Make available good quality antenatal care, voluntary and confidential counselling services to pregnant women. - Provide antiretroviral therapy, infant feeding counselling and support to HIV + pregnant women - Provide follow-up care to HIV + women and their children.

26. Constraints 4 Inadequate counselling skills 4 Involvement of male partners 4 Compliance to ARV 4 Limited space for counselling at health facility 4 Insufficient human resources 4 Low motivation of counsellors and other personnel 4 High defaulter rate and lost to follow up 4 Lack of community mobilisation strategy 4 Insufficient data collection and handling 4 Poor monitoring 4 Irregular supply of drugs and consumables.

27. ELEMENTS OF PMTCT Strengthening ANC VCT Modification of obstetric practices ARV Infant feeding counselling and support Follow-up Monitoring and evaluation.

28. Capacity Development and Support - Improve the knowledge and skills of the counsellors in all aspects of the PMTCT - Infant feeding counselling requires adequate knowledge, skills and time on part of the counsellors - In appropriate counselling influence mothers to make inappropriate choices on infant feeding. - Formal training on HIV counselling and breastfeeding to improve the knowledge and skills of the counsellors

30. S CALLING UP OF PMTCT ISSUES Areas requiring strengthening: Counselling, Personnel Follow-up Infant feeding, Care and support for mothers, children and the family - nutrition care, psychosocial support Communication strategy for PMTCT - stigma, male participation, community participation

31. LESSONS LEARNED 4 90% of women attend ANC 4 MCH Clinics 4 Voluntary Testing and Counselling: 90%accept to be tested but 1/3 missed this opportunity 4 Community involvement - Local leaders -Religious Leaders -Respected elderly e.g. in laws, grandparents, TBA What is their contribution e.g paying for test kit 4 Involvement of Male partner - support on prevention and care - Stigma - nutritional support 4 Care of Mother: during pregnancy, labour and delivery and postnatal 4 Care of the Child 4 professional counsellors/Lay Counsellors 4 Others NGOs in HIV programs 4 Family Planning

32. THANK YOU FOR LISTENING.