Clinton Foundation HIV/AIDS Initiative: Global Prevention of Mother-to-Child Transmission of HIV

1. Clinton Foundation HIV/AIDS Initiative: Global Prevention of Mother-to-Child Transmission of HIV

2. 0.5 0.4 2.4 2.3 20- 45% <2% Best No interventions Eight Years into PMTCT Efforts in Resource – Poor Regions: New Infections Deaths Impact of current PMTCT efforts Net Impact HIV + • 20% of women in developing countries receive PMTCT services • The quality of services are varied • Resulting in an annual increase in the number of children living with HIV • Net result = failure of the current efforts

3. Current PMTCT and CHAIs Hopes: • Prenatal Care (includes treatment and prophylaxis • Safe Delivery • Postpartum/ Early Infant Care • Improved outcomes for both mother and child • Identifying/ Testing of all HIV+ Pregnant Women <28 weeks before birth 18 months after birth Most women give birth in the home- births are assisted by untrained individuals • EID system rare, majority of children LTF; most women mixed feed, primarily breastfeeding • Sd-NVP with only 40-50% efficacy; no linkages to c&t; most women attend only 1 ANC • Current Failure • Focus on prevention of HIV transmission and less on mothers health – resulting in orphans. No strong linkages to continued care • Less than 20% of pregnant women are tested • Early infant testing at 4-8 weeks, 6 months after weaning and Serology at 12-18 mos. Counsel mothers on importance of Exclusive feeding and support her choice, if EFF, provide water treatment supplies and formula Support women (through CHWs, transport etc) to give birth in facilities- train staff on non-invasive procedures and Intra-partum testing • Our Vision • Support Gov’ts to provide the highest possible standard of care at a minimum; HAART preferred; min. is WHO 2006 recommended.; increase uptake of all ANC visits • Support governments in building systems that will support both HIV and MCH programs - child survival, family planning nutrition, malaria • Reach and test all pregnant women. Huge opportunity for primary prevention

4. CHAI’s Goal: • To demonstrate that a dramatic reduction of mother-to-child-transmission of HIV is achievable in resource-limited settings, by significantly increasing access to care and quality of PMTCT services • The program will target the two main challenges in the provision of PMTCT services: • The need to provide high quality services • The need to reach all pregnant women • The program will serve as a vehicle to demonstrate that the proposed interventions can • Dramatically reduce transmission of HIV from mothers to their children • Be brought to scale

5. CHAI Approach: • CHAI is working with all partner governments and local implementing partners to ensure that all HIV+ pregnant women and their infants have access to a full cascade of quality PMTCT services at all stages of transmission risk • This cascade is defined by the following stages: • 1. Identification/Testing of all HIV+ Pregnant Women* • 2. Prenatal Care and Treatment • 3. Delivery • 4. Post-Partum/Early Infant Care and Treatment • 5. Referral and Continued Care for Mother-Infant Pair • *w/in program catchment area

6. Identification/Testing of all HIV Positive Pregnant Women: • In order to reduce HIV transmission to infants, pregnant women must be identified as early as possible. Once in ANC, availability of counseling, testing and education are key to identifying HIV positive women and preventing primary infections in uninfected women • Current Situation: • While most ANC sites provide testing, not all pregnant women attend ANC • Staff are overburdened and counseling is not always a priority • Goals: • To locate all pregnant women in catchment and encourage them (through education/community outreach) to attend ANC • Thru network of community outreach and mobilization increase awareness • Ensure that pre-test, “opt-out” and post-test counseling and testing are offered to all pregnant women, regardless of when they present to ANC (or during delivery) • Bolster HR – task shifting with lay counselors

7. Prenatal Care and Treatment: • Current Situation: The majority of sites offering PMTCT are only providing, at most, Sd-NVP at delivery. • 1. Treatment: • Evidence has indicated that early treatment for those who are eligible results in • quality and quantity of life-years as well as reduces HIV transmission to infant. • Eligibility is based on staging, which includes CD4 and clinical • Goals: • CD4 and clinical evaluation to be obtained at time of positive HIV test results, and results returned to mother as quickly as possible • Facilitating transport • Raise CD4 threshold (for treatment with HAART) to 350 • 2. Prophylaxis: • Evidence suggests that the more aggressive the regimen, the lower the rate of • HIV transmission to the infant. • Goal: • Where possible, HAART for all. At minimum, the 2006 WHO recommendations • Developing M&E strategies to quickly evaluate successes to move national policy

8. Delivery: • Evidence indicates that prolonged labor, premature rupture of membranes and invasive procedures during delivery is associated with increase risk of HIV transmission to the infant. Furthermore, many women present for the first time in labor and HIV status is not known. • Current Situation: • Majority of women deliver at home • If attended, usually by untrained birth attendants • Rarely are women offered HIV testing in labor • Goals: • With the assistance of Community Health Workers, mobilize communities and assist women into health facilities for “safe” deliveries (non-invasive procedures whenever possible); support transport • Ensure that all MCH staff are trained on intra-partum testing for mothers • whose status is unknown • 3. Ensure that all staff are trained and have job aides available to reinforce “safe” delivery practices

9. Postpartum/Early Infant Care and Treatment: • Infant testing/Treatment: • Early infant diagnosis is key to improving the long-term health of HIV positive infants. Current WHO recommendation is to obtain at DNA-PCR test at 4-8 weeks of life and Serology at 18 mos • Desired standard of treatment (and WHO recommended) is ARV prophylaxis with Sd-NVP + AZT for 7 – 28 days and Cotrim from six weeks of age until HIV status determined 6 weeks post-weaning • Current Situation: Many women in developing countries will breastfeed their children up to 24 months of life and availability and uptake of infant testing is generally low • Goals: • Obtain PCR DNA at 6 weeks of age, 6 weeks post-weaning and serology at 18 mos. If the child is not breastfeeding, the serology can be obtained earlier.

10. Postpartum/Early Infant Care and Treatment (cont’d): • Infant Feeding: • Whether formula or breastmilk, the most important aspect here is exclusivity. • Current Situation: • The vast majority of women in our program countries breastfeed, in part because of cultural significance and in part because they do not have the resources required (financial and water treatment) to formula feed. Many will mixed feed. • Goals • Promote Mother’s Choice- and where agreed to by Gov partners, provide formula, water treatment supplies and support for mothers that choose Exclusive Formula Feeding (EFF) • Ensure proper counseling for mothers and staff on the risks and benefits of both methods (breast and replacement), and ensure close monitoring for exclusive feeding • Work with all partners to develop clear guidelines and support for complimentary feeds

11. Referral and Continued Care for Mother-Infant Pair: • In order to ensure continued health for both the HIV infected woman and child, all need to be linked to post-delivery care • Current Situation: weak to non-existent systems in place to ensure smooth transition into long term care • Goals: • At each point of the cascade, community mobilization to reduce stigma and other identified cultural barriers to access • All HIV infected women and children will be referred post-delivery for appropriate follow up; CHWs to ensure and assist in follow-thru

12. CHAI Global PMTCT Country Partners and Site Descriptions:

13. India’s Perinatal Prevention of Mother-to-Child Transmission of HIV (PPTCT): • Objectives • Universal coverage – the program aimed to reduce transmission of HIV infection to under 5% by 2011 in program districts • Increase capacity of government and nongovernmental agencies and scope of services provided • Pilot the most effective prevention strategy - HAART for all HIV-positive pregnant women from 28 weeks weaning • Strengthen infrastructure and human resource capacity of PPTCT centers and delivery rooms • Expand training and utilization of various community health workers, to accompany HIV-positive mothers and navigate through Reproductive and Child Health and ART services to ensure patient follow-up. • Address stigma by partnering with BCC-focused NGOs to enhance IEC through schools, village meetings, CHWs and PLHA organizations

14. CHAI/India: Back of the Envelope Cost Calculations: