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Management & Leadership role of Pharmacists in HIV & MCH care – towards achieving Millenium Development Goals 4 PowerPoint Presentation
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Management & Leadership role of Pharmacists in HIV & MCH care – towards achieving Millenium Development Goals 4

Management & Leadership role of Pharmacists in HIV & MCH care – towards achieving Millenium Development Goals 4

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Management & Leadership role of Pharmacists in HIV & MCH care – towards achieving Millenium Development Goals 4

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  1. Management & Leadership role of Pharmacists in HIV & MCH care – towards achieving Millenium Development Goals 4, 5 & 6. Dr. Jaydeep Tank MD, DNB, DGO, FCPS, MICOG. FOGSI representative to the Consortium for Safe Abortion, FIGO Project on Unsafe Abortion, PMNCH – WHO (Geneva). Co Chair Reproductive Endocrinology Committee – Asia Oceania Federation of Obstetrics and Gynecology (AOFOG) Convener- Sub Committee on Unsafe Abortions – (AOFOG). Ex Chairman MTP committee (FOGSI) 2004 - 09. Member Advisory Committee for Operational Research on Safe abortion of the Ministry of Health and Family Welfare - Government of India Ashwini Maternity and Surgical Hospital, Center for Endoscopy and IVF Visiting Consultant for IVF- Akola, Jabalpur and Jalandar

  2. A classic—something that everybody wants to have read and nobody wants to read. ~ Mark Twain ~

  3. The problem of HIV and MTCT • The problem of resources. • The treatment of HIV • The role of pharmacists • Role of partnerships

  4. The problem of HIV and MTCT • The problem of resources. • The treatment of HIV • The role of pharmacists • Role of partnerships

  5. “Dr. Robert Gallo of the National Cancer Institute had isolated the virus which caused AIDS, It was named HTLV-III, There would soon be a commercially available test for the virus”. Margaret Heckler Human Services Secretary 23rd April 1984 Margaret Heckler Dr. Robert Gallo

  6. A global view of HIV infection 33 million people [30–36 million] living with HIV, 2007

  7. In India… • The first AIDS case in India was detected in 1986; since then HIV infection has been reported in all states and union territories. • The highest HIV prevalence rates are found in Maharashtra, Andhra Pradesh and Karnataka in the south; and Manipur, Mizoram and Nagaland in the north-east.1 • Four southern states (Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka) account for around 63% of all people living with HIV in India. • HIV Sentinel Surveillance and HIV Estimation, 2006", NACO, 2007 • It is now thought that around 2.5 million people in India are living with HIV. • UNAIDS/NACO/WHO, 6 July 2007

  8. Children and HIV/AIDS • Everyday about 1200 children under 15 years of age become infected with the virus • The majority acquire the virus before birth, during pregnancy, delivery or when breastfed. • Over 90% of new infections in infants occur through MTCT. • HIV/AIDS is particularly aggressive in children: • ±50% of those infected and without treatment, die before their second birthday.

  9. Prophylaxis – current status • Only 9% of HIV+ pregnant women in low/ middle income countries received ARV prophylaxis in 2005. • Only 7 countries provided ARV prophylaxis to more than 40% of pregnant women in 2005 (Brazil, Argentina, Jamaica)

  10. PMTCT – Possibilities • High income countries have reduced infection rates at birth to less than 2%. • Cost for pediatric ARVs has been reduced to less than US$0.16 or US$ 60.00 per year. • Annual mortality rates due to AIDS among children began to fall since 2003 due to scale up treatment and PMTCT.

  11. PMTCT and MDG’s PMTCT directly affects the achievement of three MDGs (to be met by 2015): • 4th MDG: Reduce by two thirds the mortality rate among children under five • 5th MDG: Reduce by three quarters the maternal mortality ratio • 6th MDG: Halt and begin to reverse the spread of HIV/AIDS

  12. Policy – ahead of its time • United Nations Comprehensive Approach - 2003 • Universal Access of Prevention, Treatment and Care – G 8 at Gleneagles July 2005 • Abuja Call to Action 2005 • The Declaration of Commitment - UNGASS June 2001-

  13. The problem of HIV and MTCT • The problem of resources. • The treatment of HIV • The role of pharmacists • Role of partnerships

  14. Overall Strategic Approach • Decentralized approaches: • Sub national teams are responsible for the planning, implementation and monitoring of PMTCT services, including the training of service providers • Continuous political commitment • Incorporating whole family care with models such as MTCT Plus – a package of HIV prevention, care, support and treatment for mothers, children and their families.

  15. The total population calculated for 1 March 2001 was 1,027,015,247, making the 2001 census the first to count more than a billion Indians. http://www.censusindia.net/results/resultsmain.html • The population had risen by 21.34% compared to the 1991 total. http://www.censusindia.net/results/

  16. Although India occupies only 2.4% of the world's land area, it supports over 17.5% of the world's population 1.13 billion people. • 31.8% of Indians are younger than 15 years of age. • As per the 2001 census, 72.22% of the people live in more than 550,000 villages, and the remainder in more than 2000 towns and cities.

  17. Till September 2004, around 633,108 doctors were registered with different State Medical Councils of India. • This implies 1 doctor for 1622 persons (or 61 doctors per 100,000 populations) as against 1 doctor per 182 persons and 401 persons in the United States and Australia respectively.

  18. Serving the reproductive needs of Half a Billion Women

  19. The Possible solutions • Strengthen capacity • Increase the number of providers

  20. Capacity

  21. The Place of Private Health Care • India spends less than 1 percent of its GDP on health. • Only Pakistan spends less among its South Asian neighbors. • Sri Lanka and Bhutan which are poorer than India spend 6 percent and 10 percent respectively of their GDP on health.

  22. Gross underutilization of ‘free’ care • In general, in India people depend more on the private sector for health care than they do on the public sector. • The private health sector in India is one of the largest in the world: 80 percent of all qualified doctors, 75 percent of dispensaries and 60 percent of hospitals in India belong to the private sector • Narayan et al, 2003. • According to the NFHS II, only 23.5 percent of urban residents and 30.6 percent of rural residents choose to visit a government health facility as their main source of health care services.

  23. Increase the number of providers

  24. What has changed? • Technology • Demography • Development of cadres of non physician providers • Physician perception

  25. Who will be the “increased” providers… “The terms “non-physician” and “mid-level providers” refer to a broad range of non-physician health workers, including midwives, nurses, clinical officers, physician assistants and paramedics, among others, whose training and responsibilities differ from one country to another, but who are involved in the provision of reproductive health care or primary health care services” • WHO 2003.

  26. FOGSI’s position on the inclusion of MLP’s • Acknowledging the problem • The gap between the number of providers needed and the providers available • Defining the MLP’s • Setting standards for training • Taking cognizance of the legal scenario

  27. FOGSI is committed to… • To introduce or change policies to facilitate MLPs to provide care after receiving adequate training • To capacity build the MLPs for ensuring continued and sustainable services towards maintaining the quality of care and services. • To provide MLPs with sufficient educational materials. • To ensure availability of up to date operational guidelines for the MLPs to act as a quick reference. • To ensure that the MLPs also promote and recognise the reproductive and sexual rights of women.

  28. The way forward…. • Safe and Effective Technology is available. • The problem is reaching it to those who need it the most • Inadequate and Inequitable access • Increase access by increasing the number of service providers and build good quality capacity • Partnerships with the government, NGO’s and other stakeholders.

  29. The problem of HIV and MTCT • The problem of resources. • Management • The role of pharmacists • Role of partnerships

  30. Issues for us… • Universal Precautions • MTCT • Contraception and HIV • PEP • Abortion and HIV • Infertility and HIV

  31. The UN PMTCT response • Primary prevention interventions within services related to reproductive health • Appropriate counseling and support to women living with HIV to enable them make an informed decision about their future reproductive life, with special attention to preventing unintended pregnancies. • HIV testing be integrated in maternal child health units where ARVs are provided to prevent infection being passed on to their babies and also the woman’ s own health; and adequate counseling is provided on the best feeding option for the baby. • Better integration of HIV care, treatment and support for women found to be positive and their families. • 2003

  32. HIV Infection in pregnancy • Informed universal screening • interventions can reduce maternal-to-child transmission from 25-30% to less than 2% • Confidentiality and disclosure • Antenatal monitoring and advise • Screening for fetal abnormalities • Look for complications of therapy.

  33. HIV Infection in PregnancyGeneral Principles of ARV Therapy Nucleoside/nucleotide reverse transcriptase inhibitors • reduce the growth of HIV • Inhibit prolongation of DNA chain insert false nucleotide • Zidovudine, lamivudine Non nucleoside reverse transcriptase inhibitors • keep HIV from making copies of itself • Bind directly to reverse transcriptase preventing activity • Nevirapine, efavirenz Protease inhibitors • prevent HIV from being formed • Inhibit cleavage of viral packaging prior to viral release • Indinavir, saquinavir mesylate, nelfinar mesylate • Livingstone, Curr Wom Health Rep, 2:245, 2002

  34. How many antiretrovirals?

  35. Single dose nevirapine • The simplest of all PMTCT drug regimens was tested in the HIVNET 012 trial, which took place in Uganda between 1997 and 1999. • This study found that a single dose of nevirapine given to the mother at the onset of labour and to the baby after delivery roughly halved the rate of HIV transmission.6 7 • As it is given only once to the mother and baby, single dose nevirapine is relatively cheap and easy to administer. • Since 2000, many thousands of babies in resource-poor countries have benefited from this simple intervention, which has been the mainstay of many PMTCT programmes. • Connor et al, NEJM 331(18), 3 November 1994 • Guay et al, The Lancet 354(9181), 4 September 1999

  36. When is single dose nevirapine appropriate? • Because of concerns about drug resistance and relatively low effectiveness, there is now general agreement that single dose nevirapine should be used only when no alternative PMTCT drug regimen is available. Whenever possible, women should receive a combination of drugs to prevent HIV resistance problems and to decrease MTCT rates even further. • Nevirapine, however, is still the only single dose drug available to prevent MTCT.

  37. Optimize Labor Care • Late rupture of membranes • Avoid invasive procedures such as fetal electrodes, scalp blood sampling • Avoid traumatic or instrumental delivery • Vaginal lavage with chlorhexidine is not efficacious

  38. Elective LSCS • With effective ART it may have a limited role. • Breast Feeding • If she takes no preventive drugs and breastfeeds then the chance of her baby becoming infected is around 20-45%.

  39. Post Delivery Care • Antibiotics, wound care, analgesics and discharge as per routine • If the mother chooses to breast feed, teach and support her • If the mother opts not to breast feed, suppress lactation

  40. Child’s Serostatus • Child is HIV positive if : • PCR is positive at any time after birth • ELISA test is positive after 18 months age • ELISA positive before 18 months does not mean that baby is infected • Timing of transmission by timing of PCR positivity: • < 48 hours : antenatal • 48 hours to 7 days : intrapartum • > 7 days : postnatal transmission

  41. Contraception • Condoms should be used even if the couple is using other methods • Hormonal methods are suitable for pregnancy prevention • In asymptomatic HIV positive patients, IUCD is not contraindicated, but is best avoided

  42. PEP

  43. What is PEP? • The term “Post-exposure prophylaxis” or PEP refers to the prophylactic use of antiretrovirals to prevent establishment of HIV infection after an occupational exposure to HIV Types of occupational exposures • Percutaneous • Needle stick • Sharps injury • Mucocutaneous • Contact with skin which is abraded, chapped, inflamed or an open wound • Direct contact with concentrated HIV in a laboratory • Isolated skin exposure

  44. Hepatitis B virus 6-30% Hepatitis C virus 1.8% HumanImmunodeficiency Virus 0.3% Risk of Transmission of Different Viruses Following Accidental Needle Injury

  45. What Is The Risk? Occupational Percutaneous 0.3% Mucous membrane 0.09% Sexual transmission 0.018% to 3% Mother to child 25% Infected blood products 95% Antiviral therapy 1998; 3 (Suppl 4): 45-47

  46. Factors Influencing Risk • Depth of injury • Size and type of needle • Device visibly contaminated with blood • Procedure involving a needle placed in artery or vein • Use of zidovudine • Source patient’s viral load

  47. How To Reduce Risk? • Number of procedures • Double gloves • Gowns, facemasks, goggles. Care during procedures where splattering of blood is anticipated • Use of impervious needle-disposal containers • Transport of samples in sealed containers • Universal precautions

  48. Antiseptics effective against HIV • Undiluted Savlon solution • Chlorhexidine • 2% glutaraldehyde • Household bleach • Formalin 4% • Povidone iodine 2% • IPA, ethanol 70% • Dettol solution – no effect

  49. Treatment Of Exposure - Immediate Measures • Use of soap and water to wash any wound or skin • Flush exposed mucous membrane with water • Report to the concerned authority • Counselling • Antiretroviral therapy