AIHA’s Pilot Project in Odessa:

A Comprehensive MTCT Prevention and Intervention Program

Zoya Shabarova

American International Health Alliance

zoya@shabarova.nl

AIHA Strategic Framework to Prevent Mother-to-Child-Transmission of HIV in

Odessa

“Plus-pMTCT-Plus”

First “Plus”: prevention of HIV among women of reproductive age and family planning for women with HIV

pMTCT: Prevention of mother-to-child transmission of HIV

End “Plus”: Follow up care and support for families

Ukrainian Context for MTCT Strategy

Prenatal HIV screening is widely available Prenatal, perinatal and postnatal coverage is almost

universal High percentage of HIV+ women are IDUs; high

percentage of infants are born addicted to drugs Replacement feeding can be carried out by HIV infected

mothers without major risks and obstacles Because numbers of identified HIV infected women is

still limited, it is still affordable to provide pMTCT interventions

The current, relatively low number of MTCT cases provides a window of opportunity to prepare the health care system to cope with the emerging problem

AIHA MTCT Pilot Project Goals

Reduce the incidence of HIV in women of reproductive age, increase the early identification of HIV+ pregnant women (Plus-pMTCT)

Prevention of MTCT during pregnancy, delivery and postpartum (pMTCT)

Provide follow up care and support to infants, mothers and families to ensure that children born to HIV+ mothers grow up in a sustainable, nurturing environment (pMTCT-Plus)

Prevent occupational exposure to HIV among healthcare workers

Create a model that is adaptable to other sites and a teaching laboratory to facilitate dissemination and replication (scaling up)

MTCT Project Strategic Partners in Odessa

Odessa Oblast Clinical Hospital

Odessa State Medical University

Odessa Oblast AIDS Center

Odessa Oblast and Odessa City Health Administrations

Boulder Community Hospital

University of Colorado’s Health Sciences Center

Children’s Hospital of Denver

International Donors Organizations and NGOs (MSF, UNICEF, PATH, Odessa PLWA NGOs)

Coordination of USAID Donor and Inter-Donor Efforts in Odessa

USAID Donors JHPIEGO Family Planning Trainings including counseling

component 1997-8, Odessa Oblast Hospital AIHA Consultation Training and Pre- and Post- HIV Testing

Counseling workshop, May 2002, Kiev. Attended by all AIHA Women Wellness Centers (WWC) and PHCs including OOH

PATH VCT training, 2002-2003, OdessaInter-Donor MSF: Provide Nevirapine, infant formula, C-section delivery kits for

OOH and develop laboratory capacity; cooperation on Satellite Clinic development at OOH

UNICEF: Developed training materials on pMTCT in collaboration with OSMU and OOH

Main Components of AIHA’s Odessa Pilot Project

Develop a comprehensive strategy and establish widespread community support for key components.

Creation of a “center of excellence” at a designated healthcare facility (OOH).

Restructuring of health care delivery system: effective communication and referral system between health institutions, effective allocation of limited resources.

Development and implementation of relevant, evidence-based practical guides, informational brochures, and patient charts among others.

Training of healthcare professionals. Assure high quality of care at designated health care facility (OOH). Provision (including substantial donations) of essential medical

equipment and supplies. Coordination of activities with other donor organizations (MSF,

UNICEF, PATH) and Odessa PLWA NGOs.

Project Milestones (1) A catalogue of reference documents was developed (practical guides for healthcare

workers, patient’s charts, and patient education materials).

A clinical training program was initiated in Denver in April 2002.

MTCT supplies and equipment were delivered to the Odessa Oblast Hospital.

A case management Monitoring and Evaluation PMTCT database was developed (in MS Access), data entry is in progress; preliminary results are available.

A MTCT training course curriculum for Odessa HCWs was developed.

Odessa Oblast Health Administration issued an order requesting HCWs from all women's consultations to participate in the MTCT training course (May 2002).

Odessa Oblast Health Administration issued an order in May 2002 that all HIV-positive pregnant be referred for prenatal care and for delivery to OOH.

Project Milestones (2) Five abstracts based on project results were published in the XIV International AIDS

Conference abstract book, six articles were published in the special volume containing the extended versions of the abstracts and five posters were presented.

MOH decided to use Odessa PMTCT M&E database as the basis for the development of national MTCT M&E database.

UNICEF asked AIHA to demonstrate the PMTCT M&E database during the UNICEF sponsored PMTCT Study Tour for CARK policy makers.

Satellite Clinic was opened for HIV+ people at the OOH in June 2003 (in collaboration with MSF).

The Odessa PMTCT Training center was opened in June 2003. In September , based on WHO/GTZ mission assessment visit, Odessa PMTCT Training center was chosen by as the element of WHO Knowledge Hub, focused on PMTCT.

Two abstract were published in Abstract book of 2nd IAS conference on HIV pathogenesis and treatment and two posters were presented at the conference in Paris.

Odessa model was the element of the PMTCT review in Ukraine conducted by WHO, UNICEF, Ukrainian MOH and international organizations. Two Odessa experts participated in this review in Kiev and Dnepropetrovsk.

Project Monitoring and Evaluation

Purpose of M&E: to ensure that implementation is progressing as

planned, to examine activities and determine the degree of achievement in meeting set objectives

Two types of results:

1. Replicable management tools (practical guides, information brochures, charts, etc.)

2. Clinical

MTCT Practical GuidesPurpose: Provide improved practice guidelines for OB/GYNS, neonatalogists, pediatricians, family physicians, nurses, midwives, social workers and lab technicians on various aspects of treating HIV+ patients.

Family Planning for Women with HIV Prevention and Treatment of STIs Treatment of STIs in HIV+ Pregnant Women Infection Control Practices Voluntary Counseling and Testing in Prenatal Care Prenatal Care for HIV+ Women Prevention of MTCT During Delivery Infant Feeding for Babies Born to HIV+ Women Pediatric Care for Infants Born to HIV+ Mothers Primary Health Care for HIV+ Patients PMTCT among women who are IDUs

Other MTCT Products for Dissemination

1. QuestionnairesPurpose: Assess knowledge of HIV/AIDS and MTCT of healthcare workers in maternity houses and pediatric settings. Questionnaires have also been developed for parents and guardians of children born to HIV infected mothers and for HIV+ pregnant women.

2. Information PackagesPurpose: Disseminate information among women of reproductive age and HIV+ women on HIV prevention, pregnancy and HIV testing, HIV, newborn and infant Care.

3. Patient ChartsPurpose: Collect and maintain information about HIV infected women and Infants.

Monitoring of Clinical Results

Within “Plus-PMTCT-Plus” approach, PMTCT can be considered as a cascade of program intervention to stop the transmission of HIV from mother to child, integrated into the MCH and PHC schedule (UNAIDS, 1999; UNICEF, UNAIDS, WHO, 2001).

The MCH schedule provides a basis for monitoring and evaluating the PMTCT project clinical results. Cascade of interventions is based on the best available evidence, adapted to regional situation.

Main M&E Indicators• MTCT rate in OOH.• Number of HIV positive women who was registered for prenatal

care before the 2 trimester of pregnancy (delivery at OOH).• Number of HIV positive pregnant women who had PMTCT

counseling at OOH.• Number of cases where the HIV positive status was known before

delivery in OOH.• Number of HIV positive pregnancies appropriately treated for

PMTCT at OOH. • Number of HIV positive deliveries appropriately handled for

PMTCT at OOH. • Number of babies, exposed to HIV, appropriately treated for

PMTCT at OOH.• Number of HIV positive women and their babies who received

family oriented follow up care at OOH Satellite Clinic.• Number of health care professionals, trained for PMTCT, in

Odessa region.

Selected PMTCT Project Preliminary Data

Baseline 1997-99 2001 - 2002

% increase in the number of cases where the HI V+ status was known before delivery

56% 96%

% of HI V+ women who registered for prenatal care before 2nd trimester of pregnancy (delivered at OOH)

40% 60%

% of HI V+ pregnant women and mothers aware of safe lifestyle practices for PMTCT

66% (2001) 86% (2003)

# of information materials on PMTCT developed and disseminated 0 3# of HI V+ pregnant women consulted on PMTCT in OOH (delivered at OOH)

80% 96%

% of HI V + pregnancies appropriately treated for PMTCT (ARV therapy, use of multivitamines, folic acid, STI diagnosis/ treatment, family planning and infant feeding counseling) 2%

94%

% of HI V + deliveries appropriately handled in OOH (ARV therapy, C-section/vaginal delivery, avoidance of invasive procedures, birth canal cleaning) 2%

94%

% of babies appropriately treated for PMTCT 2% 100%New Regulation adopted by OOHA on referral patterns to reffer HI V+ pregnant women from the oblast to OOH for prenatal care/counseling and delivery 0 Yes

# of Practical guides on PMTCT developed 0 10OOHA issued Regulation with recommendation for health care workers to receive training on PMTCT

0 Yes

Training program developed and introduced on the topic of prevention, counseling and treatment for MTCT

0 Yes

# of practitioners appropriately trained in preventive approaches, clinical practice guidelines and laboratory techniques for MTCT, and in occupational health

0 93

I mproved policies related to health professions training on PMTCT

Objectives & selected indicators Odessa, Ukraine

I ncreased capacity to deliver comprehensive preventive and curative services to pregnant women and newborns for PMTCT in OOH

I ncreased awareness of MTCT risk factors among HIV-positive pregnant women and mothers

I mproved early identification of HIV+ pregnant women

Future Directions

• Replication of Odessa PMTCT Model in other regions in Ukraine and the NIS

• Development of comprehensive model of care and treatment to women with HIV and HIV infected children

• Further development of the Odessa PMTCT Training Center as “Teaching Laboratory” on PMTCT for the NIS region