PMTCT, and National's - Health Systems Trust

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NEVIRAPINE ADMINISTRATION TO INFANTS Figure 6.2.2: Nevirapine dispensing rate to newborns in the 18 pilot sites, 2002 100 % 80 60 40 20 0 NW LP FS GP MP WC EC NC KZN Average Nevirapine administration to newborns is a more accurate reflection of antiretroviral coverage as it is usually dispensed in one facility and sometimes one ward. However, it is important to note that this indicator represents treatment coverage only in infants of women who have been identified as being HIV positive therefore missed opportunities are not included. This rate will also be inaccurate when two doses of nevirapine are administered to babies born to mothers that are untreated or inadequately treated or when mothers delivering at home bring their babies to the labour ward or postpartum ward for treatment. In these situations proportions in excess of 100% may be found. The national PMTCT protocol for the pilot sites stipulates that all infants born to HIV-infected women should receive a single dose of nevirapine suspension between 24 and 72 hours after delivery. Figure 6.2.2 shows that an average of 99% of infants born to HIV positive women in the pilot sites received nevirapine. This rate is extremely high across all provinces although this only reflects coverage of infants born to HIV positive women who were identified as being HIV positive during labour. Given the low rate of nevirapine dispensing to mothers, it is likely that a significant number of HIV positive women do not identify themselves as being HIV positive in labour. RECOMMENDATIONS 1. There needs to be a distinction made between pharmacy stock control of nevirapine and monitoring to determine nevirapine coverage. In order to improve the accuracy of this indicator, nevirapine dispensing should be recorded in one place, preferably the labour ward. Nevirapine dispensing in the antenatal setting can be controlled by the pharmacy. 2. Greater efforts should be made to identify HIV positive women in the labour ward setting to prevent missed opportunities for nevirapine coverage of mothers and infants. Staff should not rely on tracking numbers on patient cards or folders to identify HIV positive status; this should be done by asking women in privacy. 3. The change in the clinical protocol for nevirapine dosage should be communicated to all facilities to ensure that repeat doses are not given. REFERENCES 1. WHO/UNICEF/UNAIDS. Local monitoring and evaluation of the integrated prevention of mother to child HIV transmission in low-income countries. Geneva: WHO, 2001. 2. Chopra M. Personal communication, July 2003. 3. Wilfert C. Prevention of mother to child transmission of HIV: reflections on implementation of PMTCT in the developing world. Acta Paediatrica 2002; 91:863-865. 4. Moodley D, Moodley J, Coovadia H, Gray G et al. A multicenter randomised controlled trial of nevirapine versus a combination of zidovudine and lamivudine to reduce intrapartum and early postpartum mother to child transmission of human immunodeficiency virus type 1. Journal of Infectious Diseases 2003; 187: 725-35. 25
6.3 Infant Testing and Outcomes BACKGROUND One of the anticipated aims of the national PMTCT pilot programme was to assess the effectiveness of this programme in reducing mother-to-child transmission of HIV. A great deal of public anticipation of the “results” from these pilot sites has therefore been generated. It is important, however, to clarify that the design of the pilot sites allowed for an evaluation of the operational issues associated with providing PMTCT care but was not appropriate for determining transmission rates. A prospective cohort study has been commissioned by the National Department of Health in order to measure vertical transmission rates. However, important lessons can be learnt from this evaluation relating to operational issues associated with the testing of infants. The primary objective of the PMTCT programme is to reduce the transmission of HIV from a mother to her infant. The national PMTCT protocol for the pilot sites stipulates that all children should be tested for HIV 12 months after delivery. If the infant tests positive at 12 months they should be retested at 15 months to ensure that the 12-month test was not a false-positive test due to residual maternal antibodies in the infant. For mothers continuing to breastfeed after 12 months, an HIV test should be performed at least 3-months after the mother ceases breastfeeding. This section will present key findings from the evaluation that relate to infant testing as well as presenting an alternative testing strategy to improve the follow up component of PMTCT. KEY FINDINGS FROM THE EVALUATION Uptake of Infant HIV Testing This evaluation found fairly low uptake of infant HIV testing at 12 months across most provinces. Table 1 displays the infant testing rates in all 9 provinces. It is difficult to draw conclusions from this data as some provinces test infants at 9 months and others at 12 months. In addition, some provinces changed their testing protocol from 9 months to 12 months during 2002 and the researchers were not always able to determine exactly when this change occurred. Specificity of the rapid HIV ELISA test at 9 months and 12 months is only 59% and 89% respectively 1 . Approximately 40% of truly negative infants would therefore test positive at 9 months, making the data which includes 9 month test results an unreliable indicator of HIV transmission. A large proportion (50%) of the infants born to mothers who received nevirapine, were not followed up and tested. The HIV status of these infants is therefore unknown and could potentially vary substantially from the results of infants that were followed up and tested. It is therefore not possible to draw any conclusions on impact or effectiveness of the programme from this data. Table 6.3.1: Infant testing rates Province Number of live births Number of infants tested for HIV HIV testing rate Number of infants testing HIV positive Eastern Cape 1 Free State 1 Gauteng 2 KwaZulu-Natal 2 Limpopo 1 Mpumalanga 2 North West 1 Northern Cape 1 Data only available for GDH site Western Cape 3 TOTALS 305 (Sept 01 – March 02) 129 (Aug 01 – March 02) 403 (May – Dec 01) 470 (Sept – Dec 01) 45 (Nov 01-March 02) 55 (Sept –Dec 01) 11 (July 01 – March 02) 65 (Aug 01 – March 02) 424 (April 01-March 02) 1907 76 (June – Dec 02) 56 (May-Dec 02) 40 (May – Dec 02) 368 (Sept – Dec 02) 17 (Aug – Dec 02) 12 (Sept –Dec 02) 44 (April –Dec 02) 25 (May-Dec 02) 311 (Jan-Dec 02) 949 25% 43% 10% 78% 38% 22% 39% 38% 73% 50% 4 21 3 38 3 3 8 17 73 170 (18%) Note: 1. Province changed infant testing policy from 9 to 12 months during 2002 2. Province tests infants at 12 months 3. Province tests infants at 9 months 26
Page 3 and 4: An Evaluation of the Prevention of
Page 5 and 6: CONTENTS 1. Executive summary 2. In
Page 7 and 8: Dispensing of Nevirapine Nevirapine
Page 9 and 10: SCALING UP THE PMTCT PROGRAMME Ther
Page 11 and 12: AIM OF THE EVALUATION METHODOLOGY A
Page 13 and 14: OVERVIEW OF THE PMTCT PILOT SITES *
Page 15 and 16: DESCRIPTION OF ROUTINE PMTCT INDICA
Page 17 and 18: Nevirapine (NVP) dispensing rate to
Page 19 and 20: 6.1 Antenatal Counselling and Testi
Page 21 and 22: This rate has increased slightly si
Page 23 and 24: Group education followed by individ
Page 25 and 26: WHO 2 recommends that at least 50%
Page 27 and 28: APPENDIX 6.1: EXAMPLE OF A PEER COU
Page 29: Figure 6.2.1: Nevirapine dispensing
Page 33 and 34: DISCUSSION HIV Diagnosis in Infants
Page 35 and 36: Current Status of Infant Testing Cu
Page 37 and 38: Proposed Infant HIV Test Timelines
Page 39 and 40: 6.4 Maternal and Infant Follow Up I
Page 41 and 42: RECOMMENDATIONS FOR IMPROVING THE P
Page 43 and 44: KEY FINDINGS FROM THE EVALUATION In
Page 45 and 46: There is a need for caution when in
Page 47 and 48: Differences in provincial policies
Page 49 and 50: With only moderate support (one hom
Page 51 and 52: 4. Ensure on-going Support After De
Page 53 and 54: 6.6 Health Care Infrastructure This
Page 55 and 56: Two options exist for the contracti
Page 57 and 58: B. TRAINING OF HEALTH CARE WORKERS
Page 59 and 60: Logistical and administrative suppo
Page 61 and 62: 6.6.2 Management A. NATIONAL MANAGE
Page 63 and 64: C. MANAGEMENT OF CONSUMABLES AND SU
Page 65 and 66: The changes made in data elements a
Page 67 and 68: Data flow The PMTCT pilot programme
Page 69 and 70: Appendix 6.6 MTCT REGISTER (to be k
Page 71 and 72: The key to high coverage of the int
Page 73 and 74: Health Care Infrastructure • Stre
Page 75 and 76: Strategies to integrate PMTCT into
Page 77 and 78: SUMMARY We need a fundamental rethi

PMTCT, and National's - Health Systems Trust

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