III. Strengthening PMTCT Programs: Prevention First


�One of our best opportunities for progress against AIDS lies in preventing mothers from passing on the HIV virus to their children. Worldwide, close to 2,000 babies are infected with HIV every day, during pregnancy, birth or through breast feeding. Most of those infected will die before their fifth birthday. The ones who are not infected will grow up as orphans when their parents die of AIDS. New advances in medical treatment give us the ability to save many of these young lives. And we must, and we will.�

President George W. Bush
June 19, 2002

Mother-to-child transmission is the leading cause of HIV infection in children. It remains a major public health problem worldwide, with the greatest burden in resource-poor settings. Infants and children with HIV are more likely to become ill and die shortly after birth. PMTCT programs provide a package of services that ideally include: counseling and testing for pregnant women; short-course preventive ARV regimens to prevent mother-to-child transmission; counseling and support for safe infant feeding practices; family planning counseling or referral; and referral for long-term ART for the child. In addition, where possible, these programs serve as an entry point for full ART services for the entire family, thus protecting the family unit and preventing the tragedy of a generation of orphans.

For children who are uninfected, prevention of sexual transmission of HIV as they approach reproductive age is key. The Emergency Plan supports programs for children up to age 15 that focus on abstinence and faithfulness, and has issued policy guidance on the application of prevention strategies in youth programs.

KEY FOCUS COUNTRY PREVENTION RESULTS (as of March 2005):

PMTCT sites supported: 2,200
PMTCT workers trained or retrained: 37,900
Women receiving PMTCT services: 2,000,000
Pregnant women supported with antiretroviral prophylaxis: 198,400
Estimated infant infections averted: 37,600

Emergency Plan PMTCT strategies

Recognizing the importance of PMTCT, in 2002 President Bush announced the U.S. International Mother and Child HIV Prevention Initiative. The Emergency Plan has incorporated this initiative and builds on lessons learned from it. Key Emergency Plan strategies include:

  • Scaling up PMTCT programs by rapidly mobilizing resources
  • Providing technical assistance and expanded training for health care providers on: appropriate antenatal care; safe labor and delivery practices; breast-feeding; malaria prevention and treatment
  • Strengthening the referral links among health care facilities and providers
  • Ensuring effective supply chain management of the range of PMTCT-related products and equipment
  • Expanding access to short-course preventive ARVs
  • Expanding PMTCT programs to include ART for eligible HIV-infected mothers and other members of the child�s immediate family, reflecting a family-focused approach

Significant progress has been made in each of these areas and, as a result, PMTCT programs serve as a key point of entry for women and children for HIV/AIDS education and services.

While progress has been made in increasing access to PMTCT services under the Emergency Plan, it remains challenging to reach the large number of women who need these services. Emergency Plan programs are working on innovative ways to improve uptake of PMTCT services by addressing each of the points along the chain of pregnancy services where women can drop out of the care system.

Examples of these efforts include:

  • Reaching women with antenatal care (ANC) services through community outreach in resource-poor settings
  • Providing comprehensive information, rapid HIV testing and ARVs at the first ANC visit, while encouraging return for subsequent visits
  • Assuring that all women who visit clinics receive the option of an HIV test through pre-test counselling
  • Increasing the proportion of women who are counseled who agree to be tested for HIV through �opt-out� or other approaches
  • Increasing the number of women who receive immediate results through use of rapid HIV tests
  • Ensuring that HIV-positive mothers receive short-course preventive ARVs whether they deliver in a health facility or not
  • Providing PMTCT services in home-based programs

Ensuring that women and children who receive care through PMTCT programs are linked to ongoing care and treatment services is a hallmark of the Emergency Plan approach to service delivery. Children are linked to well-baby follow-up care through these services. Considerable progress has also been made in the area of breast-feeding and the associated risk of transmission from mothers who have the virus. In keeping with World Health Organization (WHO) guidelines, the Emergency Plan supports replacement feeding using a breast-milk substitute where conditions permit this, such as Botswana and parts of South Africa.

With the array of strategies described, the Emergency Plan is striving to reach pregnant women living with HIV/AIDS and their children with PMTCT programs, reducing the number of children who will face HIV infection and the threat of early death.

Results achieved through PMTCT efforts

As of March 31, 2005, the Emergency Plan had provided support for counseling and testing of over 2 million pregnant women. As of the same date, Emergency Plan PMTCT efforts had provided support for short-course preventive ARVs for 198,400 HIV-positive pregnant women in the focus countries. The timely use of such ARVs decreases the likelihood of mother-to-child transmission. While it is not possible to measure directly the number of pediatric infections averted with Emergency Plan support, it is possible to make estimates based on the number of women who have received a preventive ARV intervention.

An international consensus has developed on an algorithm to calculate the number of infections averted. In order to arrive at an estimate, a background transmission rate of 35% for all HIV-positive delivering mothers and a reduced transmission rate of 16% for mothers receiving short-course preventive ARVs were assumed, based on research on mother-to-child transmission in the developing world. The difference, 19%, was then applied to the number of women receiving preventive ARVs in the focus countries, yielding an estimate of 37,600 infections averted with Emergency Plan support.

Actual numbers are likely to vary from this estimate in either direction depending on the regimens used and whether mothers and children are able to take an optimal course of preventive ARVs. Table 5 includes an estimate of the infant infections averted in programs supported by the Emergency Plan.

[Editor's note: The following table also is available as text-only.]

Table 5: Estimated number of infant infections averted in the focus countries, 2003-2005
Timeframe

October 2003 - September 2004

October 2004 - March 2005

October 2003 - March 2005

October 2003 - September 2004

October 2004 - March 2005

October 2003 - March 2005

  Number of pregnant
women who received
short-course preventive ARVs
for PMTCT (a)
Estimated number of infant infections (b)
 

FY04 Total Results

FY05 Mid-year Results

Emergency Plan Total Results: cumulative total of FY04 and FY05 mid-year results

FY04 Total Results

FY05 Mid-year Results

Emergency Plan Total Results: cumulative total of FY04 and FY05 mid-year results

Botswana

2,000

2,800

4,800

375

532

907

Cote d'Ivoire

1,900

1,100

3,000

350

209

559

Ethiopia

200

300

500

41

57

98

Guyana

67

45

100

13

9

22

Haiti

500

300

800

93

57

150

Kenya

16,600

8,900

25,500

3,149

1,691

4,840

Mozambique

2,300

2,200

4,500

442

418

860

Namibia

1,300

800

2,100

243

152

395

Nigeria

600

1,200

1,800

103

228

331

Rwanda

2,800

2,600

5,400

533

494

1,027

South Africa

76,000

37,900

113,900

14,392

7,201

21,593

Tanzania

1,800

2,900

4,700

339

551

890

Uganda

6,600

3,500

10,100

1,254

665

1,919

Vietnam

0

200

200

3

38

41

Zambia

12,800

8,200

21,000

2,436

1,558

3,994

All Countries

125,500

72,900

198,400

23,766

13,860

37,626

NOTES: Numbers may be adjusted as attribution criteria and reporting systems are refined.
(a) All numbers above 100 are rounded to the nearest 100. The total number of pregnant women who received short course preventive ARVs for PMTCT includes women reached through upstream, system-strengthening support as well as those receiving downstream, site-specific support. See text box on �How the U.S. provides support.�
(b) The number of infant infections averted was calculated by multiplying the total number of pregnant women who received short-course preventive ARVs (upstream and downstream) by the efficacy rate of this intervention, currently estimated to be 19%. Estimates for infant infections averted are not rounded, in order to ensure consistency with estimates previously published in Engendering Bold Leadership: The President's Emergency Plan for AIDS Relief, First Annual Report to Congress, March 2005.

Expanding PMTCT capacity

Developing capacity to address HIV in children is an essential component of PMTCT programs. Strengthening health care systems,including improving monitoring of PMTCT programs, is key. As of March 31, 2005, the Emergency Plan supported training for approximately 37,900 health care workers in PMTCT services, and provided support for approximately 2,200 PMTCT service sites. Table 6 provides information on capacity-building efforts to date.

One example of an activity in this area is the development of a model system for monthly PMTCT indicator reporting.  U.S. Government technical assistance has assisted the Ministries of Health in Botswana, Nigeria, and Tanzania with the implementation of this system, which is focused on improving services to mothers and children.

Improving the use of rapid HIV tests so that women are able to get their results immediately and do not need to make additional trips to the health center is another high priority to improve the quality of care. The U.S. Government and WHO have developed �Guidelines for Assuring Accuracy and Reliability of HIV Rapid Testing: Applying a Quality Systems Approach,� which has special implementation guidance for PMTCT program managers and sites.

The Emergency Plan has been instrumental in supporting host government efforts to incorporate an �opt-out� model of provider-initiated HIV-testing, in which patients are tested for HIV as part of routine health care unless they ask not to be. In Namibia in 2004, Katutura Hospital, the nation�s largest, began to implement the opt-out HIV testing approach in its antenatal clinic as part of its PMTCT program.  The new strategy has resulted in a considerable increase in women being tested.  In 2002-2003, before the policy was implemented, only 8.5% of women using the antenatal clinic services were tested for HIV. With the new policy in 2004, 90% of the women accessing these services were tested.  Additionally, the new policy is now included in the national PMTCT guidelines. As new PMTCT sites come on line, nurses implement the new policy, helping to prevent thousands of HIV infections in children.

The Emergency Plan has provided considerable support, in partnership with WHO, to the development of training curricula and guidelines for health workers in PMTCT. Training is needed by health care providers, health managers who ensure that essential systems (such as systems related to drug supply) are in place, and the community outreach workers who combat stigma and refer women and children to services.

Abstinence and fidelity education for youth

As children who were not infected at birth or in early childhood approach their reproductive years, they begin to face the risk of sexual transmission of HIV. The Emergency Plan supports programs for children up to age 15 that focus on abstinence and faithfulness � the �A� and �B� elements of the successful ABC strategies originally developed in Uganda. The Emergency Plan has issued policy guidance on the ABC prevention strategies that specifically addresses their application in youth programs.

For 10-to-14-year-olds, the guidance explains that the Emergency Plan funds age-appropriate and culturally appropriate �AB� programs. These programs are to include promotion of: (1) children�s dignity and self-worth; (2) the importance of abstinence in reducing the transmission of HIV; (3) the importance of delaying sexual debut until marriage; and (4) the development of skills for practicing abstinence. Along with PMTCT programs for newborns and infants, these programs for older children are part of a comprehensive strategy to protect children from HIV infection.

[Editor's note: The following table also is available as text-only.]

TABLE 6: PMTCT capacity-building in the focus countries, 2002-2005
Timeframe

October 2002 - March 2004

October 2003 - September 2004

October 2004 - March 2005

October 2002 - March 2004

October 2003 - September 2004

October 2004 - March 2005

October 2003 - March 2005

  Number of USG-supported service outlets providing the minimum package of PMTCT services Number of workers trained or retrained in PMTCT services (b)
 

2003 (a)

2004

2005 Mid-year Results

2003 (a)

2004

2005 Mid-year Results

Emergency Plan Total Results: cumulative total of 2004 and 2005 mid-year results

Country

 

 

 

 

 

 

 

Botswana

382

12

15

600

100

45

145

Cote d'Ivoire

10

26

34

400

900

0

900

Ethiopia

27

22

54

700

1,300

3,700

5,000

Guyana

24

24

36

100

200

77

277

Haiti

33

21

71

100

1,000

1,000

2,000

Kenya

163

500

754

1,900

3,500

1,500

5,000

Mozambique

5

21

43

300

500

300

800

Namibia

11

21

30

700

1,600

300

1,900

Nigeria

32

17

22

2,000

700

78

778

Rwanda

23

86

109

500

500

800

1,300

South Africa (c)

18

1,100

294

5,100

8,800

3,400

12,200

Tanzania

28

100

145

400

1,400

600

2,000

Uganda

71

100

177

1,100

2,800

1,000

3,800

Vietnam

(d)

9

9

(d)

200

0

200

Zambia

84

95

228

800

1,100

500

1,600

All Countries

911

2,200

2,021

14,700

24,600

13,300

37,900

NOTES: Numbers may be adjusted as attribution criteria and reporting systems are refined. All numbers above 100 are rounded to the nearest 100. Reporting in 2003 was for an 18-month period, from October 2002 through March 2004 as the U.S. International Mother and Child HIV Prevention Initiative was integrated into the Emergency Plan. Reporting in FY04 was from October 2003 through September 2004. As such, there is some overlap in reporting during the months between October 2003 and March 2004. USG-supported service outlets or programs are those that receive at least some funding or support from the U.S. Government. Country service outlets or programs may be supported by funds from varied sources. Since U.S. Government clients cannot be distinguished from other clients in a U.S Government-funded service or program, all clients are counted toward Emergency Plan goals. In multi-service or program institutions, only clients for the service or program component that is funded by the U.S. Government are counted.
(a) 2003 data is from The President's Emergency Plan for AIDS Relief, Annual Report on Prevention of Mother-to-Child Transmission of HIV Infection, June 2004.
(b) Data on the number of health workers trained in PMTCT services reflect only results achieved through downstream, site-specific support.
(c) In FY2004, a USG advisor was placed within a team in the South African Government to support specific PMTCT sites as they scaled up. Since then, the PMTCT program has matured and the role of the advisor now focuses on providing upstream support to the national program (e.g. developing a PMTCT policy, guidelines and general support.) As a result, many sites that received downstream USG support in FY2004 no longer receive such support and fewer sites are reported in FY2005. These sites continue to provide PMTCT services, but without USG downstream support.
(d) Vietnam was not included in the U.S. International Mother and Child HIV Prevention Initiative.

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