PMTCT, and National's - Health Systems Trust

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Impressive infant follow up rates have been achieved in the Western Cape (73%) and KwaZulu- Natal (78%) possibly due to the extensive coverage of these provinces with PMTCT services enabling easier follow up of infants at the clinic level. A further factor enabling improved follow up of infants in the above provinces is the expansion plan which focused on geographical areas and referral systems rather than sites and facilities. This facilitates improved tracking of mothers and infants between delivery centres and feeder clinics. The Western Cape tests infants at 9 months despite the national PMTCT protocol for the pilot sites calling for 12 month testing. The province is concerned that delaying testing until 12 months will result in higher loss to follow up. As a result of this policy, approximately 40% of infants are testing false positive at 9 months and have to have a repeat test at 15 months. The province is planning to change to early PCR testing of infants to improve both follow up and clinical management. In the other seven provinces the follow up rates are low. This may be due to the fact that in many of these provinces, particularly in Gauteng and Mpumalanga, PMTCT services have not been extended to many feeder clinics as expansion has been focused primarily on hospitals. Mothers therefore have to return to the primary PMTCT site, usually a hospital, in order for their infants to be tested for HIV. The low rate of follow up occurs for a variety of reasons that include: • Inadequacies in the routine monitoring system • Poor referral networks between hospitals and clinics • Limited numbers of clinics offering the PMTCT programme • Tracking/coding systems using patient-held records not implemented or ineffective • Mothers reluctance to disclose their HIV status to health workers The high loss to follow up rate means that those infants born to HIV positive women involved in the PMTCT programme, the majority will have their HIV infection status determined for the first time when they present with HIV disease and are not receiving routine medical care recommended for HIV infected children (viz, prophylactic co-trimoxazole under 12 months. They also do not access other medical interventions that might benefit their health such as nutrition support and multivitamins in the case of growth faltering. Out of the 949 infants in the pilot sites (excluding the De Aar site) that were tested for HIV, 170 tested HIV positive (18%). It is important to note that over half of the infants tested were from the Western Cape and KwaZulu-Natal, the number of infants tested in the other 7 provinces is extremely small. Given the small number of infants tested and the testing method used, (antibody test between 9 and 12 months) this figure can not be considered an accurate reflection of the vertical transmission rate amongst this group of infants. In order to determine transmission rates in infants receiving care through the PMTCT programme and to facilitate improved clinical management of infants born to HIV positive women, either the follow up of infants to 12 months needs to be drastically improved, or an alternative method of determining infant HIV status needs to be adopted. Such an alternative testing recommendation is discussed in this chapter. Counselling for the infant HIV test Pre and post test counselling is also required when testing infants for HIV. This evaluation found that health workers were generally unsure as to how to counsel mothers for their infant’s HIV test. There was also lack of clarity regarding who could be given the infant HIV test result; the mother, father or a caregiver. The current PMTCT protocol provides no guidelines in this regard. There are many issues that should be discussed at the time of the infant’s HIV test including the implications of the test result, requirements for further follow up care of the infant including prevention of opportunistic infections in the case of a positive diagnosis and care and support of the mother. This component of the programme should receive as much time and attention as the counselling associated with maternal testing. Ongoing training of clinic nurses may be necessary to familiarise them with the follow up needs of mothers and infants. 27
DISCUSSION HIV Diagnosis in Infants The purpose of testing perinatally exposed infants is three fold: firstly, on an individual level to determine an infant’s true HIV infection status in order to make clinical management decisions; secondly, to determine the relative efficacy of various interventions to reduce vertical transmission; and finally, at a population level, to evaluate the effectiveness of the PMTCT programme. The diagnosis of HIV infection in infants requires careful timing of the initial HIV antibody based (ELISA) diagnostic test (including the Abbott Determine HIV-1/2 and other rapid tests which are currently used at PMTCT sites). This is due to the presence and persistence of maternal HIV-specific antibodies in all perinatally exposed infants for many months after birth. Sero-reversion may occur as early as 9 months (40-60%) but maternal HIV antibodies have been shown to persist for up to 18 months 2 . To accurately assess the effectiveness of the PMTCT programme, accurate, affordable and timeous infant HIV diagnostic protocols are required. General Principles of HIV Testing in Infants 1. Diagnosis needs to be made in the clinical context of the case, with knowledge of the various test options and their interpretation depending on the age of the child. 2. Different protocols may be needed for different areas depending on accessibility to laboratory tests. However, data presented here proposes that where testing can be centralized to a reference laboratory, an HIV DNA PCR test is recommended. 3. Infant feeding must be taken into consideration. In the case of a woman who has chosen to breastfeed, early HIV testing (using an HIV DNA PCR) to determine status may serve as (a) an incentive to stop breastfeeding if child is negative or (b) encouragement to continue breastfeeding if the child is already positive, or (c) a guide to considering relactation if the woman has not been breastfeeding and the child is already positive. CURRENTLY AVAILABLE INFANT HIV TESTS Antibody Tests A. Serum HIV ELISA Tests These tests include onsite rapid tests and laboratory based analyzer assays. The later in life they are performed in infants the more accurate the results, but this means longer periods of follow up of large numbers of HIV exposed children, most of whom will be negative. To date this has resulted in enormous loss to follow up. The Abbott Diagnostics Determine HIV-1/2 Rapid Test can be purchased at US$0.85/test or provided free of charge through the company’s PMTCT support programme. Confirmatory Rapid tests like Unigold which confirm initial rapid positive results cost about R25.00. Less than1% of these rapid tests are discordant. Laboratory based HIV-1/2 ELISA tests requested from the NHLS cost the state R33.50/test. The advantage of rapid tests is that they can be performed on site rapidly by both lay counsellors (the screening test) and nurses, and do not require specimen transport to a laboratory except in the case of ELISA confirmation. B. Oral fluid Based HIV ELISA Tests Oral fluid contains lower concentrations of antibodies, including anti-HIV antibodies, than serum. Waning maternal anti-HIV antibodies at 12 months of age in HIV uninfected children are therefore less likely to give false positive HIV ELISA tests results when measured in oral fluid as compared to serum. Oral fluid tests are currently not recommended for diagnostic purposes and have not been evaluated in children under 13 years of age. Both sensitivity and specificity on 204 patients using OraSure is 94%. 28
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 and 30: Figure 6.2.1: Nevirapine dispensing
Page 31: 6.3 Infant Testing and Outcomes BAC
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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