PMTCT, and National's - Health Systems Trust

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• Reduction in Mother/Family anxiety Early infant diagnosis relieves the majority of HIV positive mothers of the emotional burden of having infected their children (since between 70-94% of babies will be born negative). The emotional and human value of this is beyond measure. • Informed formula feeding choice Early knowledge of the HIV status of an infant may enable mothers to make a more informed decision regarding feeding choices. Mothers who have been breastfeeding may want to change to formula milk if they know that their infants are negative or women opting for formula may want to consider relactation in the event that the infant is HIV positive. This would still need to occur within the context of adequate infant feeding counselling and an assessment of the individual home circumstances. • Reduction in cost of and use of co-trimoxazole All infants born to HIV positive mothers are given co-trimoxazole from age 6 weeks until 12 months. Since the large majority of these infants do not require this, some saving and a reduction in side effects experienced from the drug can be achieved. • Earlier entry into infant hiv management protocols Holistic medical management of an HIV infected child requires that the child’s HIV infection status be established as early as possible. Prevention of opportunistic infections, treatment of intercurrent infections and emotional support for the child and family, derived from counselling and peer groups, improve the child’s quality of life even in the absence of antiretroviral therapy. Diagnostic algorithm for the use of nucleic acid testing in the public sector Guidelines for infant HIV diagnosis, both internationally 6 and in the local private sector 7 , recommend 2 PCR tests before 12 months of age (the 2 nd PCR is done primarily to confirm the first PCR result). International experience is that the sensitivity of the DNA PCR at 6 weeks of age in a non breastfeeding population approaches 98% 3 . Local experience in the Coronation PMTCT infant diagnostic study suggests that a single DNA PCR at 6 weeks, together with a clinical assessment, yields accurate results 4 . Assuming that the large numbers of HIV affected children in SA make 2 HIV PCR tests per child unaffordable, an alternative diagnostic protocol that offers a vast improvement on the current situation is required. Taking all this into consideration, the following recommendation for infant HIV diagnosis is made, irrespective of infant feeding status. It is based on the assumptions: • That visits to the clinics for HIV diagnosis should be timed with routine clinic/immunization visits, making it cost effective and practical for both the state and families. • That HIV results can be given before starting the co-trimoxazole prophylaxis to eliminate unnecessary long term prophylaxis of HIV negative babies. • That a concise diagnostic algorithm that is merely an add on to current paediatric management guidelines (IMCI) can be effectively communicated to all primary care personnel enhancing its application and effectiveness (HIV diagnosis should be one component of overall child health care). • That this algorithm would enhance follow-up, care of HIV negative and HIV infected infants and allows for measurement of the effectiveness of the PMTCT programme. • That primary health care nurses understand the limitations of a single PCR test at 6 weeks of age (due to possible sample mix ups and post natal transmission of HIV), and that they are able to perform basic clinical assessments that would alert them to the need for further age-appropriate HIV testing. 31
Proposed Infant HIV Test Timelines 6 weeks 1 st well baby clinic visit Clinical assessment HIV DNA PCR test 10 or 14 weeks Timing of 2 nd and 3 rd immunization visit Clinical assessment HIV DNA PCR result • PCR positive – child is HIV infected – refer for HIV specific care, reinforce infant feeding choices + start co-trimoxazole • PCR negative – mother counseled that child is HIV uninfected at present and educated on feeding practices Note: test not infallible as breastfeeding and other exposure would mean possible window period infection status {+ specimen mix up possible but limited (12 months age AND • >3 months after breastfeeding has ceased Positive Children If no ART and no HIV stigmata • Confirm HIV status by rapid HIV test at 18 months Note: this test would pick up any children misdiagnosed as positive probably by specimen mix up at 6 weeks. Note: It is envisaged that this diagnostic protocol would enable the majority of children (>97%) to be correctly diagnosed at 6 weeks of age. By reducing the number of children requiring follow up for HIV by approximately 90% at 10-14 weeks of age, scarce health care resources can be focused on HIV infected children. Child health care workers would need to maintain a high index of suspicion in HIV exposed children who present with clinical stigmata of HIV later on in life in order to diagnose post natal transmission of the virus and to refer these children for appropriate medical management. Practical Issues Surrounding Implementation of NAT Testing for PMTCT follow-up • The DOH and NHLS need to work more closely to leverage their significant, but currently inefficiently employed, resources to make this diagnostic method deliverable. • Provinces should be able to decide when to implement alternative testing strategies depending on their capabilities. In places where rapid tests are not yet available this should be implemented prior to nucleic acid testing as a basic requirement. • The same problems experienced already with rapid testing such as stocks running out, poor quality control, and inadequate staff training will occur with an alternative form of testing. These logistical and infrastructural issues should therefore be addressed before a new method of testing is made widely available otherwise this could worsen existing services. • Thorough investigation is needed to determine the adequacy of transport systems to facilities to enable this form of testing to be undertaken. • The NHLS laboratory network (>150 nationwide) needs to be exploited and staff trained at all clinics on how to use this system. Currently the NHLS has links to all antenatal clinics and systems in place for transport of specimens to tertiary centers that have NAT capability. The decision to use NAT would require these logistics to be effectively mobilized. Currently NAT capability exists in Cape Town, Durban, Bloemfontein, Johannesburg and Pretoria. Consideration to use dried blood spots vs EDTA collection tubes would need to be investigated. This is a separate discussion that should be held with the relevant team from the NHLS but is definitely achievable. 32
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 and 32: 6.3 Infant Testing and Outcomes BAC
Page 33 and 34: DISCUSSION HIV Diagnosis in Infants
Page 35: Current Status of Infant Testing Cu
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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