1. IAPSM Conference 2004 Greetings from For every child Health, Education, Equality, Protection ADVANCE HUMANITY

2. IAPSM Conference 2004 Prevention of Parent- to- Child Transmission ( PPTCT) ( generally known as “ PMTCT”) Dr. Bir Singh Project Officer, PPTCT UNICEF, New Delhi

3. IAPSM Conference 2004

4. Expanding Disease Burden 1986 to 2002

5. IAPSM Conference 2004 Known modes of HIV transmission, 2002

6. IAPSM Conference 2004 No. of Children 0-14 Years with HIV= 1,70,000 ( UNAIDS, 2002) No.of Children with AIDS =2,333 ( NACO, January, 2004)

7. IAPSM Conference 2004 Percent women aged 15-49 who know all three modes of vertical transmission of HIV/AIDS MICS-2000

8. IAPSM Conference 2004 Percent women aged 15-49 who have heard of HIV/AIDS MICS-2000

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10. Mother-Infant HIV Transmission in Hypothetical Cohort of 100 Children of HIV+ Mothers Early antenatal Late antenatal Early postpartum Late postpartum 36 wks6 months Labor & Delivery 100 98 23 80 15 75 5 70 uninfected 5 95 Children at Risk Children Infected 30 infected

11. IAPSM Conference 2004 Risk factors for postnatal transmission: Maternal immune status Leroy et al 2002

12. IAPSM Conference 2004 WHO/UNFPA/UNICEF/UNAIDS

13. IAPSM Conference 2004 Prevention of Parent-To-Child Transmission of HIV in India

14. The Rationale for PPTCT

15. IAPSM Conference 2004 Rationale for PPTCT in India 27 million pregnancies per year 108,000 infected pregnancies Annual Cohort of 32,000 infected newborns 0.4% prevalence 30% transmission 25,000-50,000 deaths within 2-5 years

16. PMTCT Feasibility Study AZT: March 2000 - August 2001 zTotal new ANC attendance:192,474 zNo. of pregnant mothers counseled:171,471(89.1%) zNo. of pregnant mothers accepted HIV tests :103,681(60.5%) zNo. of pregnant mothers detected HIV positive :1,724 (1.7%) zNo. delivered with AZT:726 (42.1%) zNo. of PCR samples at 48 hrs. tested:427 zNo. of samples tested (+) positive:34/427 (8.0%) zNo. of additional tested (+) at 2 months: 9 (adding a 2% transmission rate) zNo. of women who opted for breastfeeding (620:135(22%)

17. PMTCT Feasibility Study NVP: October 2001 - June 2002 zTotal new ANC attendance:71,149 zNo. of pregnant mothers counseled:61,901(87%) zNo. of pregnant mothers accepted HIV tests :56,913(92%) zNo. of women detected HIV positive - ANC: 958 (1.68%) zNo. of women detected HIV positive - Labour:140(3.33%) zNo. of women who picked up their test result :35,629 (62.6%) zNo. of (+) women who picked up their test result: 674 (70.4%) zNo. of husbands who accepted to be tested:1,291 (33.4%) zNo. of mother-baby pairs who received NVP:470 (72.3%) 384 (56.97%) / 86 (68.57%) zNo. of mothers who opted for breastfeeding :335 (51.5%) zNo. of babies exclusively breastfed at 4 months :168 (50%) zNo. of PCR (+) at 2 months::21/270(7.8%)

18. Anti-retroviral Protocols Feasibility Study Phase 1: modified CDC-Thailand Regimen zAZT 300 mg BD from 36 weeks onward zAZT 300 mg / 3 hours during labour zNo AZT to the baby Feasibility Study Phase 2: modified HIVNET 012 zNVP 200 mg single dose to mother at onset of labour zNVP 2 mg/kg single dose to newborn within 72 hours During the 2 phases: “informed choice on infant feeding”

19. IAPSM Conference 2004 Some Lessons Learnt: Reduced transmission of HIV from mother to infant

20. IAPSM Conference 2004 Some Lessons Learnt: Increased knowledge about how to prevent HIV/AIDS

21. IAPSM Conference 2004 PPTCT: Goals & Objectives Goals: zReduced HIV prevalence among pregnant women age 15-49 to below 3% in the 6 high prevalence States and below 1% in other States by 2005 zReduced the transmission rate of MTCT of HIV to below 20% by 2005 and below 10% by 2010

22. PPTCT 1) Scaling up Expected outputs zAn operational network of health facilities providing quality PPTCT services established zPPTCT used as an opportunity to strengthen MCH services. 2) District Models Expected outputs z A comprehensive, integrated and sustainable distrit- based PPTCT programme z Pre and in-service training modules for care providers to integrate youth friendly services Key results: Operational network of health facilities for PPTCT established A National Policy for PPTCT Replicable district PPTCT models Partnerships and resources mobilized for scaled up 3) Learning for Policy Development Expected outputs zA Feasibility Study of “PPTCT Plus” zStudies on HIV and infant feeding

23. IAPSM Conference 2004. The PPTCT Intervention Package 1. Ante-Natal Care 2.Group Education / Pre-Test Counselling 4. Post-Test Counselling 5. Institutional Delivery 6. Administration of Nevirapine to the woman during labour 3. HIV Testing

24. IAPSM Conference 2004 7.Administration to the BABY of SINGLE DOSE of Suspension Nevirapine ( 2 mg./ Kg.) between 24-72 hours 8. Counselling of mother for Infant Feeding Options 9. Care & Support 10. Follow -up The PPTCT Intervention Package…

25. 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

26. IAPSM Conference 2004 Nevirapine Administration Mother: Screened for contraindications Single Dose Tablet of 200 mg. during First stage of Labour Baby: Monitored for First 24 Hours Screened for Contraindications Single Dose of suspension 24 to 72 hours Nevirapine Courtesy : Donation from CIPLA

27. IAPSM Conference 2004 Training in PPTCT “ Cascade Effect” Centres of Excellence ( CEs) Medical Colleges District Hospitals & Maternity Homes

28. IAPSM Conference 2004 PPTCT Team Consists of : Obs-Gynaecologist -1 : Pediatrician - 1 : Microbiologist - 1 : Counsellor - 1 : Senior Staff Nurse -1 Trained for 5 Days : Structured,Module based Training

29. IAPSM Conference 2004 SACS /NACOUNICEF CE Teams from Medical Colleges Trained SACS PPTCT Center at M C Established Teams from District & Maternity Hospitals Trained PPTCT Centre at DH & MH established Request for Training Teams Funds TRAINING PROCESS 29 M &E QA Sensitization

30. IAPSM Conference 2004 Scaling Up Strategy: Training Component 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 - 2003-2004 Phase 1- 2002 Phase 2 - 2002 Phase 3 - 2002-2003 Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs

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32. Monitoring and Evaluation Quality assurance of services UNICEF’ s Role in PPTCT Research Training Drugs Counseling Data Dissemination of results Study design PPTCT “Plus” District Models Infant Feeding

33. IAPSM Conference 2004 UNICEF Support to PPTCT

34. Infant Feeding and HIV: Current recommendations Informed Choice through COUNSELLING

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36. Global recommendations on IYCF when HIV-negative or unknown HIV status zEarly initiation with exclusive breastfeeding for 6 months zAppropriate complementary feeding with continued breastfeeding up to 2 years or beyond zAppropriate feeding in exceptionally difficult circumstances (HIV, emergencies, LBW, sickness, malnutrition)

37. IAPSM Conference 2004 Recommendations on feeding by HIV-positive mothers: WHO consultation Oct.2000 zWhen replacement feeding is “AFASS”,i.e. A cceptable, Feasible, Affordable, Sustainable and Safe, avoidance of all breastfeeding is recommended. Otherwise EBF is recommended for the first (6) months of life with early zand abrupt cessation…weaning.  Counselling should include information about the risks and benefits of various infant feeding options, and guidance in selecting the most suitable option

38. IAPSM Conference 2004 Reducing risk of HIV transmission through breastfeeding zShorter duration – 6 months zExclusive breastfeeding during 1 st 6 months zSafe sex practices of mother during lactation period to prevent infection or re-infection zGood lactation management (attachment, positioning, frequency) to avoid mastitis zNo feeding from cracked nipple zARVs?

39. IAPSM Conference 2004 BF transmission of HIV: Ghent meta-analysis (Read et al, 2002). - Early cessation can reduce BF transmission with about 60% Cumulative rates of late postnatal HIV infection (> 4 wks)

40. IAPSM Conference 2004 Early cessation is possible but: zEarly, rapid cessation is possible (Uganda, Zambia, Botswana) zProblems encountered ybreast engorgement; mastitis; babies crying, trouble sleeping, appetite loss, diarrhea; financial constraints with replacement feeding; family objections ymore problems when cessation < 6 months (Botswana) zTrained counselors were able to help mothers overcome problems zProvision of replacement feeds, family support facilitated process zImpact on HIV transmission, survival not yet known

41. IAPSM Conference 2004 Key Findings: Data : January to September 2003 Overall prevalence rate in ANCs : 2.1% VCCT acceptance rate : 61.5% Intervention uptake : 87.6%

42. IAPSM Conference 2004 PPTCT: Challenges,Issues,Concerns zHow to maintain QA while going to scale? (Training, Counselling). “ Counsellors based programme”. zPPTCT only for institutional deliveries? ( Out -reach, District Model) zCompletion of the ‘PPTCT package’ with Primary Prevention and continuum of care: zInfant Feeding dilemma zIntegration into the National Reproductive & Child Health programme. zStigma, Discrimination, Attitude of health care providersCommunication Strategy, Male Involvment

43. IAPSM Conference 2004