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Greetings from. For every child Health, Education, Equality, Protection ADVANCE HUMANITY. Prevention of Parent- to- Child Transmission ( PPTCT). ( generally known as “ PMTCT”). Dr. Bir Singh Project Officer, PPTCT UNICEF, New Delhi. Expanding Disease Burden 1986 to 2002.

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

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

  3. IAPSM Conference 2004

  4. Expanding Disease Burden 1986 to 2002 IAPSM Conference 2004

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

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

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

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

  9. IAPSM Conference 2004

  10. Mother-Infant HIV Transmission in Hypothetical Cohort of 100 Children of HIV+ Mothers Children Infected 2 3 5 5 30 infected 15 Children at Risk 98 80 75 70 uninfected 95 100 Early antenatal Late postpartum Late antenatal Early postpartum 36 wks 6 months Labor & Delivery IAPSM Conference 2004

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

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

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

  14. The Rationale for PPTCT

  15. 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 IAPSM Conference 2004

  16. PMTCT Feasibility Study AZT: March 2000 - August 2001 • Total new ANC attendance : 192,474 • No. of pregnant mothers counseled : 171,471 (89.1%) • No. of pregnant mothers accepted HIV tests : 103,681 (60.5%) • No. of pregnant mothers detected HIV positive : 1,724 (1.7%) • No. delivered with AZT : 726 (42.1%) • No. of PCR samples at 48 hrs. tested : 427 • No. of samples tested (+) positive : 34/427 (8.0%) • No. of additional tested (+) at 2 months : 9 (adding a 2% transmission rate) • No. of women who opted for breastfeeding (620 : 135 (22%)

  17. PMTCT Feasibility Study NVP: October 2001 - June 2002 • Total new ANC attendance : 71,149 • No. of pregnant mothers counseled : 61,901 (87%) • No. of pregnant mothers accepted HIV tests : 56,913 (92%) • No. of women detected HIV positive - ANC : 958 (1.68%) • No. of women detected HIV positive - Labour : 140 (3.33%) • No. of women who picked up their test result : 35,629 (62.6%) • No. of (+) women who picked up their test result : 674 (70.4%) • No. of husbands who accepted to be tested : 1,291 (33.4%) • No. of mother-baby pairs who received NVP : 470 (72.3%) 384 (56.97%) / 86 (68.57%) • No. of mothers who opted for breastfeeding : 335 (51.5%) • No. of babies exclusively breastfed at 4 months : 168 (50%) • No. of PCR (+) at 2 months: : 21/270 (7.8%)

  18. Anti-retroviral Protocols Feasibility Study Phase 1: modified CDC-Thailand Regimen • AZT 300 mg BD from 36 weeks onward • AZT 300 mg / 3 hours during labour • No AZT to the baby Feasibility Study Phase 2: modified HIVNET 012 • NVP 200 mg single dose to mother at onset of labour • NVP 2 mg/kg single dose to newborn within 72 hours During the 2 phases: “informed choice on infant feeding”

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

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

  21. PPTCT: Goals & Objectives Goals: • Reduced 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 • Reduced the transmission rate of MTCT of HIV to below 20% by 2005 and below 10% by 2010 IAPSM Conference 2004

  22. 1) Scaling up Expected outputs An operational network of health facilities providing quality PPTCT services established PPTCT used as an opportunity to strengthen MCH services. 2) District Models Expected outputs A comprehensive, integrated and sustainable distrit- based PPTCT programme Pre and in-service training modules for care providers to integrate youth friendly services PPTCT • 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 • A Feasibility Study of “PPTCT Plus” • Studies on HIV and infant feeding

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

  24. The PPTCT Intervention Package… 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 IAPSM Conference 2004

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

  26. 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 IAPSM Conference 2004

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

  28. 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 IAPSM Conference 2004

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

  30. Scaling Up Strategy: Training Component 11 Centers of Excellence ~ 780 Health Facilities Phase 1- 2002 74 Medical Colleges High Prevalence States Phase 2 - 2002 Phase 3 - 2002-2003 159 District Hospitals/ Maternity Hospitals High Prevalence States 79 Medical Colleges Low Prevalence States Phase 4 - 2003-2004 450+ District Hospitals/ Maternity Hospitals Low Prevalence States IAPSM Conference 2004 Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs

  31. IAPSM Conference 2004

  32. UNICEF’ s Role in PPTCT Monitoring and Evaluation Quality assurance of services Research Infant Feeding Study design Counseling PPTCT “Plus” Data Training District Models Dissemination of results Drugs IAPSM Conference 2004

  33. UNICEF Support to PPTCT IAPSM Conference 2004

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

  35. IAPSM Conference 2004

  36. Global recommendations on IYCF when HIV-negative or unknown HIV status • Early initiation with exclusive breastfeeding for 6 months • Appropriate complementary feeding with continued breastfeeding up to 2 years or beyond • Appropriate feeding in exceptionally difficult circumstances (HIV, emergencies, LBW, sickness, malnutrition) IAPSM Conference 2004

  37. Recommendations on feeding by HIV-positive mothers: WHO consultation Oct.2000 • When replacement feeding is “AFASS” ,i.e. Acceptable, Feasible, Affordable, Sustainable and Safe, avoidance of all breastfeeding is recommended. Otherwise EBF is recommended for the first (6) months of life with early • and 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 IAPSM Conference 2004

  38. Reducing risk of HIV transmission through breastfeeding • Shorter duration – 6 months • Exclusive breastfeeding during 1st 6 months • Safe sex practices of mother during lactation period to prevent infection or re-infection • Good lactation management (attachment, positioning, frequency) to avoid mastitis • No feeding from cracked nipple • ARVs? IAPSM Conference 2004

  39. 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) IAPSM Conference 2004

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

  41. Key Findings: Data : January to September2003 Overall prevalence rate in ANCs : 2.1% VCCT acceptance rate : 61.5% Intervention uptake : 87.6% IAPSM Conference 2004

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

  43. Thank You IAPSM Conference 2004

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