HAART and The Pregnant woman - ICAP

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HAART and The Pregnant woman - ICAP

HAART and The Pregnant Woman

Providing HAART

within the MCH setting

Experience from ICAP-Lesotho

ICAP Collaborative PMTCT and Pediatric HIV

Strategic Planning Workshop

April 13-17, 2008, Breakwater Lodge, Cape Town

R. Ntumy


Background

Lesotho PMTCT and ART Program

• 2003: PMTCT program launched in 8 pilot hospitals

• 2005: National ART program launched

• 2006: Nationwide PMTCT rollout to all district hospitals

• Before ICAP presence PMTCT program components:

– Voluntary counseling and testing (consent form, opt-in)

– No CD4 count during pregnancy

– SD-NVP to the mother and baby

– Poor infant follow up, no PCR testing

ICAP- Supported Sites

• 2006: 5 sites (3 hospitals, 2 filter clinics)

• 2007: 9 sites (5 hospitals, 2 filter clinics, 2 health centres)

• 2008: 26 sites ( 4 hospitals, 2 filter clinics 20 health centres

• ART in MCH: 4 hospitals


Rationale for bringing ART to MCH

• Long waiting time in ART

• No special arrangement for

pregnant women

• No CD4 done or delayed

collection of CD4 results

• Different review dates for ANC

and ART

• High loss to follow-up at ART

clinic by pregnant women

• Stigma

• High HIV sero-prevalence

HIV Prevalence

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

33%

ART Clinic waiting area

HIV Prevalence at ANC

ICAP-supported sites

34% 35%

35%

32%

31%

33% 34% 35%

36% 36%

35%

34%

33% 34% 33%

31%

29%

Oct-06

Nov-…

Dec-…

Jan-07

Feb-…

Mar-…

Apr-07

May…

Jun-07

Jul-07

Aug-…

Sep-…

Oct-07

Nov-…

Dec-…

Jan-08

Feb-…

Mar-…


CD4 Count Tests Results of HIV Positive Pregnant Women

ICAP-Supported sites

Oct 06-Mar 08

CD4 > 350/mm 3 ,

1073

59.8%

CD4 ≤ 350/mm3

721

40,2%


Steps taken in bringing ART to MCH (I)

• Advocacy and sensitization of site leadership to increase

awareness and prioritize the needs of the HIV positive

pregnant woman

• Seek buy-in and commitment from site staff through MDT

meetings

• Training/sensitization of all health care workers in ANC to

provide ART at MCH

• Infrastructure enhancement and renovations

• Creating a consulting room „ART Room” in the MCH

• Patient flow redesign


To:

Adult C&T

Pediatric C&T

Maternity Dept

DBS for

6/52 infants

ART for

Pregnant

Women

To: Adolescent health Waiting areas Waiting areas

Waiting areas

Well Baby Clinic:

Integrated F/U for

HIV exposed infants

(including growth

monitoring and IF

counseling)

Waiting areas

•Adherence

counseling

•CD4 results

•Prescribing

ARV prophylaxis

•Referral for

ART

Family planning

Blood

•CD4, Hb, Syphilis

•baseline for ART

(LFTs, U&E)

MCH staff office

•Records

•Dispensing

ARV prophylaxis

All Pregnant women

•Counseling

•HIV testing

Pregnant women living with HIV

•First ANC Visits

HIV exposed infants and children

Waiting areas •HIV testing

Redesign of patient flow in MCH in QE II Hospital

p

a

l

p

a

t

i

o

n

p

a

l

p

a

t

i

o

n


Steps taken in bringing ART to ANC (II)

• Augment staff with dedicated nurse clinician to run the ART

clinic at MCH

• Use of expert patients to support adherence counseling

• Bring in ART registers to MCH

• Encourage task shifting/sharing within the MCH to support the

provision ART

• Integration of multidisciplinary approach to service delivery to

promote collaborative management of patients

• Provision of special job aids on ART for pregnant women

• Continuous presence of ICAP team at the MCH for supportive

supervision and mentoring

• Instituting “fast tracking” of patients at the ART in MCH


Initiating HIV Infected Pregnant Women on HAART at MCH

1 st visit at ANC

Routine HIV counseling and testing

Immediate CD4 count testing

Counseling on infant feeding and PMTCT

Essential antenatal care

3-day follow up appointment for CD4 count results

2 nd visit at ANC

Conduct immunological and clinical assessment

Initiation of Cotrimoxazole prophylaxis

Baseline laboratory investigation for ART

ART preparatory and adherence counseling

1 week appointment for those eligible for ART

3 rd visit at ANC

2 nd ART preparatory/adherence counseling

Recording in ART file, clinical evaluation, drug education

Initiate ART for eligible pregnant women

2 to 4 weeks appointment

Regular follow up visits at ANC

On-going adherence counseling assessment and support

Counseling and support on ART prophylaxis

Clinical follow up, refilling of Cotrimoxazole and ARVs

Routine ANC and postnatal care

Follow up visits every 4 weeks


Primary Outcomes of bringing ART to MCH

• Time taken to receive CD4 cell count results has

reduced

• Time between HIV diagnosis and initiation of HAART

has reduced

HAART initiation is now at earlier gestational age

• Increase in the number of weeks on ARV treatment

prior to childbirth

• Increase in the proportion of eligible pregnant women

being initiated on HAART


No. of women

90

80

70

60

50

40

30

20

10

0

0

Cum.

before

Jan 06

HIV Positive Pregnant Women Initiated on HAART

QEII Hospital

3

0

Started

HAART At

MCH

1

32

(N=299)

64

29

33

56

81


No. of women

30

25

20

15

10

5

0

1 1 1 1

Cum.

before

Jan 06

HIV Positive Pregnant Women Initiated on HAART

Mohale's Hoek Hospital

(N=85)

2

3

Started

HAART At

MCH

11

16

26

23


No. of women

30

25

20

15

10

5

0

9

Cum.

before

Jan 06

HIV Positive Pregnant Women Initiated on HAART

Mafeteng Hospital

0

6

1

5

(N=94)

Started

HAART At

MCH

3

11

15

28

16


No. of women

16

14

12

10

8

6

4

2

0

3

Cum.

before

Jan 06

HIV Positive Pregnant Women Initiated on HAART

Quthing Hospital

(N=24)

0

4

0 0 0 0

2

Started

HAART At

MCH

1

14


Ongoing challenges

• Increasing number of eligible pregnant women at

ART creating need for additional resources

• Quality of counseling around adherence remains

difficult

• Post-natal re-location of mothers

• Post-natal transfer of patients from MCH to ART

clinic

• Resistance to the idea of ART in MCH by some

senior ministry staff


Lessons Learned

• A dedicated nurse/nurse clinician is crucial to the success of

providing ART in MCH

• Using expert patients to augment staff for adherence

counseling could be helpful

• Ongoing adjustments have improved quality and uptake of

services dramatically

• ART at MCH a key reason for early HAART initiation of

pregnant women

• Providing HAART at MCH appears to be reducing infant

infections as expected ( MTCT 2.5% from sites)

• It is important to change strategies and approaches to

respond to the changing science


Acknowledgements

ICAP Lesotho Team

• Lesotho MOHSW

• Cristiane Costa

• Elaine Abrams


Thank you


Back Up Slides


HIV Prevalence

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Oct-06

Nov-06

HIV Prevalence in New ANC Clients

All ICAP supported sites

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

All sites Sites in Maseru Sites outside Maseru

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Jan-08

Feb-08

Mar-08


DNA PCR results of HIV Exposed infants

Mother received No

PMTCT Intervention

38

21 pos (55%)

Mother received

HAART

81

2 pos

(2.5%)

HEI identified

DNA PCR tested

580

Results Available

449

Mother Received

PMTCT intervention

397

30 pos (7.5%)

Mother received AZT

& SD-NVP

37

1 pos

(2%)

Incomplete results

13

Mother received only SD-NVP

279

27 pos

(9%)

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