xvii international aids conference mexico city, 3-8 … · lessons learned from rwanda nyankesha...
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SCALING-UP NATIONAL PMTCT PROGRAM
Phasing more efficacious ARV regimen for PMTCT in resource
limited setting
Lessons Learned from RWANDA
NYANKESHA Elévanie, RN, BSc, MPH
Head of VCT/PMTCT Department
XVII INTERNATIONAL AIDS CONFERENCE
MEXICO CITY, 3-8 August 2008
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Outlines
• Background
• National HIV/AIDS response
• PMTCT program milestones
• PMTCT program strategies
• Key results
• Lessons learned
• Challenges
• Way forward
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Background - Rwanda
East African country of 26,338 km2
Population: 9,100,000 inhabitants.
Rural population: 83 % (DHS III, 2005)
Administrative framework
– 4 provinces and Kigali Council
– 30 districts
– 415 sectors/cells/villages.
Economy
– 52% live under the poverty line.
Access to clean water
– Urban area : 61% (DHS, 2005)
– Rural area : 29% (DHS, 2005)
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Maternal and Child Health Indicators,
Rwanda, (DHS 2005)Fertility rate
– 6.1 children per woman
ANC visit (2 or 3 in pregnancy)
– 68% (95% with > 1 visit)
Age at first ANC visit
– 50% at 6.4 months
– 9% after 8 months
Delivery in a health facility
– 56% (Urban) vs. 25% (Rural)
Immunization coverage in children
– 97% for BCG and DPT1
– 86% for measles
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HIV prevalence by Age and Sex
Rwanda, (DHS, 2005)
• HIV prevalence increaseswith age– Highest in women in age
group 35-39 (6.9 %)
– Highest HIV prevalence inage group 40-44 (7.1 %)
• HIV prevalence sex ratio(F/M):
– 3.6/2.3
• HIV prevalence in pregnantwomen:
– 4.8%
• HIV-exposed infants annually
– 17,000 (TRAC 2005)
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National HIV/AIDS Response
• 1987-2000:
– National AIDS Control Program (NACP).
• 1999:
– First PMTCT site opened.
• 2001:
– National AIDS Control Commission (NACC)
– Treatment and Research on AIDS Centre (TRAC)
– National Strategic Plan against HIV/AIDS (2001 -2005).
• 2005:
– National Strategic Plan against HIV/AIDS (2005-2009).
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PMTCT Program milestones, Rwanda
(1999-2008)
3. Initial expansion of
the Sd-NVP regimen to
decentralized level
1. PMTCT pilot
project (Kichukiro)
2. TRAC defines
National goals for PMTCT
5. - National expansion of
PMTCT services;
- Introduction of early infant
diagnostic (DBS-PCR)
1999 - 2000 2001 2002-2005 2005 2006 - 2008
4. - Introduction of More Efficacious
ARV regimens for PMTCT;
- ART Scaling-up
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Package of services for Mother-infant pair in
the PMTCT program, Rwanda
HIV+ pregnant women
• Routine opt-out counseling and HIV
testing (Promotion of partner testing)
• Laboratory investigation: FBC, CD4 count
(when available), routine pregnancy check-up
• Routine pregnancy medications: Malaria
prevention (IPT + Bednets), anemia
prevention (Iron/Folic acid), etc..
• ARV prophylaxis
l HAART for women eligible
l Biprophylaxis (AZT+SdNVP; Tail
AZT/3TC)
l Sd-NVP ; Tail AZT/3TC (discordant
couple, labor room CT)
• Safe practices delivery
• Infant feeding counseling and support
• Family planning services
• Psychosocial and adherence support
HIV-exposed infants
• Post-exposure prophylaxis– Sd-NVP + AZT (4 weeks)
• Drug package (CTx prophylaxis)– CTx starts at 6 weeks
• Clinical monitoring– Growth monitoring
– Symptoms of early HIV infection
• Early Infant diagnostic (DBS-PCR)– DNA-PCR
• PCR1: at 6 weeks
• PCR2: 6 weeks after end of BF
• Serology• 9 months (1rst)
• 18 months (2nd)
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Clinical and biological criteria for HAART initiation
in HIV+ pregnant women in Rwanda
WHO clinical
stages
CD4 testing not
available
CD4 testing available
1 Do not treat Treatif CD4 cell count
< 350 cells/mm32 Do not treat
3 Do not TreatTreat
if CD4 cell count
< 350 cells/mm3
4 TreatTreat
irrespective of CD4 cell
count
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ARV prophylaxis guidelines for the PMTCT
program in Rwanda (Since Sept 2005)
Clinical scenario Regimen for Mother Regimen for Infant
Pregnant women with
indications for ART
(CD4 count<350 cells/ul)
AP[1]: AZT+3TC+NVP
IP[2]: AZT+3TC+NVP
PP[3]: AZT+3TC+NVP
Sd-NVP
+
AZT x 4 weeks
Pregnant women (28wks-
34wks) who are not yet eligible
for ART (CD4 count>350
cells/ul)
AP: AZT starting at 28 weeks or as
soon as feasible thereafter
IP: Sd-NVP
PP: AZT/3TC x 7 days
Sd-NVP
+
AZT x 4 weeks
Pregnant women tested HIV+
after 34 weeks (late arrival)
AP[1]: AZT+3TC+NVP
IP[2]: AZT+3TC+NVP
(Interrupt HAART after delivery if
not eligible for life)
PP[3]: AZT/3TC x 7 days
Sd-NVP
+
AZT x 4 weeks
HIV women seen in labor who
have not received ARV
prophylaxis/Women in
discordant couple
IP: Sd-NVP
PP: AZT/3TC x 7 daysSd-NVP
+
AZT x 4 weeks
1- AP: Ante-Partum; 2- IP: Intra-Partum; 3- PP: Post-Partum
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Implementation procedures
1. 3 types of sites :
– ART and PMTCT sites : start directly and women follow up
is done by Care & treatment personnel.
– New PMTCT sites : Start the PMTCT activities with the
new regimen
– Old PMTCT sites without ART:
• Training of providers by a team from the district hospital
• After this training: samples are transferred for CD4 count and FBC
before starting the treatment.
• A Doctor from a District hospital has to go to the PMTCT sites
every 15 days to give an ART to women in need.
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2. To put in place a TOT agenda
3. To put in place an training agenda for Health Care
providers.
4. To put in place a Doctors team to assist HC to
initiate ART for HIV+ pregnant women and their
follow up.
5. To develop M&E tools for the new ART regimen.
Implementation procedures (cont’d)
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Trend in health facilities with PMTCT services, National
PMTCT program, Rwanda
(1999- May 2008)
Geographic Coverage: 71% (May 2008)
1 2 1133
53
120
209234
281
308
0
50
100
150
200
250
300
350
1999 2000 2001 2002 2003 2004 2005 2006 2007 M a y -
0 8Years
Nu
mb
er o
f s
ite
s
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Uptake of HIV counseling and testing in ANC among
women, National PMTCT program, Rwanda
(2003 – May 2008)
84%80%
90%95% 95% 97%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2003 2004 2005 2006 2007 May-08Period
%
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CD4 Testing among HIV+ Pregnant Women in 18 health
facilities in Rwanda, Jan - Sept 2007cumulative 613 HIV+ women) (as an example)
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Trend in ARV prophylaxis among HIV+ mothers,
National PMTCT program, Rwanda
(2007)
0
10
20
30
40
50
60
Q 1 Q 2 Q 3 Q 4Pe r i o d
%
NVP seule AZT/NVP Trithérapie
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Health facility deliveries among HIV+ women vs. all
women, National PMTCT program, Rwanda
(2005 – May 2008)
47%
60%
68%
59%
48%
61%
87%
77%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2005 2006 2007 May-08Period
%
% health facility delivey among all women
% health facility delivery among HIV+ women
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Coverage of ARV prophylaxis among HIV-exposed
Infants, National PMTCT program,
Rwanda (2005- May 2008)
58%
83% 85% 87%
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
2005 2006 2007 May-08Period
#
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
%
Expected children for ARV prophylaxis
Children received ARV prophylaxis
%
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Infant feeding practice at birth among HIV+
mothers, National PMTCT program, Rwanda,
(2005 – May 2008)
85%82%
86% 88%
15%18%
14% 12%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2005 2006 2007 May-08Period
%
% Exclusive Breast feeding % Exclusive Artificial Feeding
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Lessons learned• Coordination
– Leadership of MOH (TRAC Plus)
– An active technical working group
• Shifting to more efficacious ARV regimens requires
– High political leadership
– Decentralization of CD4 count system to district level
– Reorganisation of services
– Development of job aids and revision of monitoring tools
• Exposed infant follow-up need to be instituted and integrated
within MCH to improve
– CTX prophylaxis coverage
– Early infant diagnostic
– Infant feeding counselling and support
• Community-based Health Insurance schemes
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Challenges
• Scaling up the more efficacious regimen will requires
more decentralized capacities for laboratory (CD4
count, biochemistry, etc..),
– Insufficient number of laboratories performing CD4 count
compared to the number PMTCT sites.
– Means of transport
– Samples for CD4 count don’t reach the laboratory the same
day they are taken.
– Delay of the results
=> DELAY IN TREATMENT FOR PREGNANT WOMEN
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• Scaling up early infant diagnostic will require more
DNA-PCR laboratory capacities at the national
level.
• Post-natal HIV transmission during breastfeeding
remains a constraint to a successful PMTCT.
• ART prescription by Doctors only:
– Lack of Doctors in the country
=> DELAY IN TREATMENT FOR PREGNANT WOMEN
• Treatment (ART) follow up in eligible women after
delivery.
Challenges (cont’d)
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Way Forward
• Integrating the monitoring of the more efficacious regimen within
the National electronic HIS (TRACnet).
• Strengthening the capacity of laboratory for CD4 testing at
decentralized level
• Clinical mentoring to support scaling up of more efficacious
regimens
• Scaling up early infant diagnosis (EID)
• Mothers2mothers approach to strengthen psychosocial support
and adherence to programs
• Weaning food initiative:
– Fortified porridge (6 months to 18 months for all HIV exposed
infants)
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