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Roll out of More Efficacious PMTCT Regimens: Lesotho's National Approach

Roll out of More Efficacious PMTCT Regimens: Lesotho's National Approach






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    Roll out of More Efficacious PMTCT Regimens: Lesotho's National Approach Roll out of More Efficacious PMTCT Regimens: Lesotho's National Approach Presentation Transcript

    • Roll Out of More Efficacious PMTCT RegimensLesotho’s National Approach
      MpolaiM. Moteetee B.Sc,MB.ChB, MPH
      Director-General of Health Services
      Ministry of Health and Social Welfare
      Kingdom of Lesotho
    • Kingdom of Lesotho
    • Kingdom of Lesotho
    • Health Care Pyramid
    • Demographic Information
      Maternal Mortality Ratio: 762/100,000 LB (2004:LDHS, higher 2009 DHS)
      Infant Mortality Rate: 91/1000LB (2009:LDHS)
      Child Mortality Rate: 28/1000LB (2009 LDHS)
      Under Five Mortality Rate: 117/1000LB (2009 LDHS)
    • Impact of HIV in Lesotho 2008
      HIV Prevalence Rate: 23.6%
      270,000 adults & children
      living with HIV in 2009
      Population: 1,880,661
      (Census 2006)
      Children (<18): 800,000
      Orphans: 110,000
      Estimated 21,000 new
      infections & 11,000 deaths
      in 2009
      >57% eligible patients
      (CD4 <350) on ART in 2009
    • Population Impact continued
      Life expectancy at birth: Men - 39 years
      And Women – 44 years
      Little population growth in 10 yrs (0.08% 2006 census)
      Most affected are young adults of child bearing age
      Women affected more than men
    • Government Response
      2003 – Launch of PMTCT initiatives
      2004 – Care and treatment for adults
      Government procurement of antiretrovirals for every citizen
      2005-7 - Know Your Status campaign for 12yrs and above
      2008- Free health center services
      Mitigation efforts for OVCs: school fees and welfare; cash grant 2009
    • PMTCT Services
      Lesotho’s adult HIV prevalence is 23.6 %, one of the highest in the world. The prevalence among pregnant women attending ANC is 27% (MOHSW 2010)
      The rate of ANC care by a health professional is high (91.8%), but only 58.7% of deliveries take place in health facilities (LDHS 2009)
      It is estimated that there are 50,000 annual births in the country, out of which approximately 12,855 infants are born to HIV infected women each year. In the absence of any intervention to prevent vertical transmission of HIV, this would result in approximately 5,142 new paediatric HIV infections per year. (PMTCT Guidelines)
      A national PMTCT scale-up plan was developed in 2007, with the goal of reaching 100% facility coverage by 2011
    • PMTCT Services cont’d
      PMTCT coverage increased gradually from:
      • 16.5% - 31% in 2006
      • 31% - 56% in 2008
      • 56% - 71% to date
    • Health Facilities and PMTCT
    • PMTCT Services, continued
      PMTCT services were made possible through expanded training & decentralization of PMTCT interventions to the H/Cs
      PMTCT services are largely provided by nurses, who have been trained in Integrated Management of Adult and Adolescent Illnesses (IMAI) and are able to assess pregnant mothers and initiate prophylaxis regimens based on HIV tests
    • PMTCT Services, continued
      71% of facilities were providing PMTCT by the end of 2009
      PMTCT uptake for women is at 90% (AJR 2009) at clinics and 34% for infants, but under-reporting is suspected
      The USAID-funded CTA project began in 2005 and went through March 2010. EGPAF supported PMTCT and care and treatment services in 6 of the 10 districts.
    • PMTCT Services, continued
      • Lesotho’s initial PMTCT guidelines (developed in 2004) recommended the use of single-dose NVP given to HIV-positive mothers and infants
      • The revised PMTCT guidelines in 2007 introduced WHO-recommended regimen of:
      • AZT 300mg 12 hourly for mothers from 28 weeks
      • AZT 600 mg and 3TC 300mg and NVP 200mg during labour
      • AZT 300mg and 3TC 150mg 12 hourly for one week post-partum
    • PMTCT Services, continued
      PMTCT Prophylaxis for the Baby
      • Plus single-dose NVP of 2mg/kg to infants
      • AZT 4mg/kg for one week after birth (or 4 weeks if the mother received less than 4 weeks of AZT prior to delivery)
    • The Mother/Baby Package
      Introduced in 2007
      Service to the remote and not easily accessible as well as to the 30% (48%) of the women that deliver at home
      Contents of the Mother Baby Package (MBP) are:
      - AZT from 28 weeks in 1st pill bag
      - AZT/3TC/NVP in labour 2nd pill bag
      - AZT/3TC for 1 week post-partum 3rd pill bag
    • Mother/Baby Package, continued
      Pack for the baby is:
      A capped syringe of 6mg (0.6ml) of NVP for the baby
      AZT syrup 12 mg BID for seven days
      Instructions are given to the mother on when and how to take them in case she delivers at home, but ideally all mothers are encouraged to deliver at the health facilities
    • Challenges Based on Evidence, 2009
      Rotation of nurses from the health facilities affects the provision of PMTCT services
      Concentration only on HIV + mothers and those HIV negative not attended to
      Though mothers given PMTCT MBP, its difficult to monitor whether the mother has taken drugs or not
      There sometimes are drugs stock outs experienced at H/Cs; some of the mothers are not given MBP
      Wastage of AZT syrup as a baby has to be given 240 ml in seven days and the remaining syrup is discarded
      Some mothers get confused learning of their HIV status for the 1st time & being given instructions on how to take the drugs.
      Will the mothers remember the instructions especially if they deliver at home
    • Partners for PMTCT Interventions
      WHO PIH
      PEPFAR Clinton Foundation
      CIDA MSF
      UNITAID Baylor
    • Results of MBP
      By September 2008, all 138 health facilities providing PMTCT used the MBP
      UNICEF assisted in the assessment of the Lesotho minimum package in 2009 and the findings informed the development of UNICEF/SD MBP and the decision for Lesotho as one of the pilot sites for the MBP
    • Findings of the Mother Baby Pack Assessment,2009
      Strong Partnerships:Health partners have formed a solid relationship with the MOHSW to implement the key elements of the PMTCT program in the country
      Coverage of PMTCT:There was general confidence that targets set by the MOHSW, to reach PMTCT coverage of 80% by end of 2010 and 100% by end of 2011, was achievable
      Integrated Programs: PMTCT is well integrated with other MCH services. There is a degree of continuity of services and support during ANC and after through education and enrolment into support groups for HIV-positive women
      Satisfied Users: Over 80% of women indicated general satisfaction with the packaging and physical appearance of the MBP
      Quick Preparation Time: Facility supervisors estimated that staff spend a relatively short time preparing the MBP (46%). Nearly 70% of service providers said they spend less than 10 minutes putting together one package. 83% of supervisors indicated that they pack it when it is prescribed rather than in advance
      Storage Location: The most frequently cited places for storing the MBP by women were handbags and cupboards in the kitchen or bedroom
      Use of Medications: The actual use of the MBP during delivery outside the health facility environment is not yet know and calls for further investigation
    • Recommendations
      Improve systems to deal prevent and to deal with stock outs of medications.
      Community awareness campaigns need to encourage women to deliver in facilities and to address stigma and discrimination.
      Need more male support groups so that men can talk about issues relating to HIV.
      PMTCT training among service providers was indicated to be high, though there is about 20% of service providers who may require in-service or refresher training.
      Clear written instructions are required for the use of the MBP.
      Need to train community support structures so as to be able to help in providing services when users cannot access the facilities. This is especially with regards to home deliveries and adhering to proper use of the Minimum Package.
      Patients recommend that the MBP should have a strong “container” for medications which would withstand wear and tear.
      Syrups should be packed in smaller bottles for AZT for infants and it should be packed in containers suitable for the period prescribed.
    • Way Forward
      The MOHSW has again reviewed the PMTCT guidelines and has incorporated the WHO recommended regimen of starting PMTCT prophylaxis at 14 weeks for mothers & at birth until the babies stop breastfeeding
      Sensitization and empowerment campaigns will be continued to encouraging women (husbands and mothers-in-law) to deliver at health facilities
    • Way Forward, Continued
      The MOHSW has to again orientate the health professionals on the new WHO Recommendations on PMTCT regimen
      The MOHSW will disseminate the latest revised PMTCT guidelines
    • Conclusion
      The strong political will, and Government support, for HIV and AIDS including PMTCT facilitates innovations and fast roll out of interventions.
      Lesotho will reach 100% PMTCT coverage with the support from the partners.
      The Ministry will continue to develop strategies for ensuring that mothers deliver in the health facilities and delivering HIV negative babies.
      The MOHSW (and GOL) appreciates and is immensely grateful for the support by its partners.
      We look forward to even closer and improved efforts towards attaining the goal of 100% PMTCT
      We acknowledge and register the support by EGPAF (positive experience) and are looking forward to the national coverage (from 6 to 10 districts) for not only PMTCT but to the broad HIV and AIDS control