WABA GLOBAL FORUM II23rd - 27th September, 2002.

Arusha, Tanzania

Topic: PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV

By Dr. Augustine Massawe

Department of Paediatrics

Muhimbili University College of Health Sciences,

Dar es Salaam, Tanzania

BACKGROUND

MTCT of HIV is the major cause of HIV infection in children. Each year approximately 700,000 children are infected.

Without intervention, up to 40% of children born to HIV infected women will be infected. Infection can take place:

in uteroduring labour and delivery

postpartum through breast milk

Risk factors include:Mode of delivery

Prolonged rupture of membranes for more than 4 hours

Some factors may be associated:-Episiotomy

-Intrapartum haemorrhage

-twin delivery,1st twin higher risk

-Invasive foetal monitoring

RELEVANT STATISTICS IN AFRICAGlobally 1.3 million children under 15 years

of age live with HIV/AIDS

Nearly 4 million children under 15 years old have died of disease since the epidemic began

Majority of these children were born to mothers infected with HIV acquiring the

virus the duringpregnancy delivery breastfeeding

Relevant statistics#2SSA has 70% of the worlds HIV infected children,

80% of the deaths and 90% of AIDS orphans10% of children under 15 in some African are now

orphansMore than 13 million children worldwide are single

or double orphans of these 90% live in SSAComparing the under five mortality rate and IMR in

Sub Sahara Africa to industrializedUnder five mortality rate in SSA is 173 while IMR is 107 Under five mortality industrialized countries was 37(1960) now is 6 (1999) with IMR of 6 in 1999

Estimated impact of AIDS on under-5 child mortality rates – Selected African countries, 2010

Source: US Bureau of the Census

250

200

150

100

50

0

per 1000 live births with AIDS

98036-E-25 – 1 December 1999

Botswana Kenya Malawi Tanzania Zambia Zimbabwe

without AIDS

HIV/AIDS EFFECT ON CHILD SURVIVE IN TANZANIA

HIV prevalence antenatal women 12% MTCT Transmission rate 40% 72,000 babies every year added = 200 babies a day 25,200 through breastfeeding Underfive mortality from 137 (1996) to 150 per 1000 live

births (1999) (TRCHS) Infant mortality 88 per 1000 live births 1996 to 99 per

1000 live births in 1999 Neonatal mortality increased from 28 per 1000 live births

1996 to 44 per 1000 live births 1999 20% paediatric admissions HIV+ve (2000)

MODE OF HIV INFECTION IN TANZANIA

Heterosexual 82% Mother to child transmission 6%– 0 - 4 yrs 78.3%– 5 - 9 yrs 17.5%–10 - 14 yrs 4.2%

Blood transfusion 1%

Timing of Transmission

Intrauterine: one third(1/3)

Intrapartum (during labour and delivery)(two thirds2/3)

Post-natal through breastfeeding(14%)

Factors associated with increased risk of MTCT in HIV

Strong evidence Intermediateevidence

Limitedevidence

Maternalfactors

High viral load Immune deficiency Viral characteristics Advanced disease HIV infection acquired

during pregnancy orbreastfeeding period

Chorioamnionitis Anaemia Vitamin A

deficiency Sexually

transmittedinfections

Smoking

Frequentunprotectedsexualintercourse

Multiple sexualpartners

Drug useinvolvinginjection

Obstetricfactors

Vaginal delivery(compared to electivecaesarean section)

Invasiveprocedures

Episiotomy

HIV & Infant Feeding

Background:

HIV in breastmilk- 1985

Transmission 14% - 20%

Increased risk of transmission with longer duration of breast feeding

Mixed feeding carries higher risk than EBF

Prevention of Perinatal Transmission:Prevention of Perinatal Transmission:Major issuesMajor issues

• Reduction of postnatal transmission Reduction of postnatal transmission • breast feeding dilemmabreast feeding dilemma•exclusive breastfeedingexclusive breastfeeding•mixed breastfeedingmixed breastfeeding•prolonged breastfeedingprolonged breastfeeding•mastitismastitis•cracked nipplescracked nipples•oral thrush in the babyoral thrush in the baby•right to breastfeedright to breastfeed•stigmastigma•undisclosureundisclosure

• Care of uninfected children born of HIV-infected mothersCare of uninfected children born of HIV-infected mothers• care of orphanscare of orphans

• Prevention of pregnancy among HIV-infected womenPrevention of pregnancy among HIV-infected women• Prevention of HIV infection among womenPrevention of HIV infection among women

PMTCT THROUGH BREASTFEEDING

Breast feeding in Tanzania98% of women initiating breast feeding immediately after delivery

60% within one hour,

88% within 24 hours 95% continue to breastfeed

38.5% exclusively breastfeed for 4 months!

Medium period for breastfeeding is 22 months in Tanzania

59 hospitals are baby friendly.(128 hospitals trained)

PMTCT THROUGH BREASTFEEDING

Availability of infant formulae in the market Heavy workload for women

Lack of enough supportive policies and regulations

Inappropriate hospital routines or practices.

PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV

Research

Regime Reduction

Petra 61%

Thailand 50%

Nevirapine 47%

Mitra (Petra Arm A) + Infant up to 6 months

HAART therapy from second trimester + ECS less than 2%

HAART therapy - viral load 0- normal vaginal delivery

Study Drug

!4-2

8w

ks

28

-36

wk

s

>3

6w

ks

Lab

our

Del

iver

y

1 w

k P

P

1-6

wk P

P

Eff

icac

y

Pra

ctic

alit

y

ACTG 076 ZDV I ++++ +

HarvardThai

ZDV +++ ++

HarvardThai

ZDV I +++ +++

HarvardThai

ZDV I +++ +++

HarvardThai

ZDV I +++ ++

DITRAME ZDV M ++ ++

CDC ZDV ++ +++

PETRA A ZDV3TC

M+I ++ +++

PETRA B ZDV3TC

M+! ++ +++

HIVNET/SAINT

NVP I ++ ++++

Wk=weeks; M=mother + = least effective/practicalI=Infant, PP = Postpartum ++++ = Most effective/practical

CONCLUSION

AZT+3TC started at the onset of labour and for one week postpartum to the mother and the child significantly reduced MTCT of HIV by 37%, in a breastfeeding population.

When started at 36 weeks of pregnancy until delivery and for one week postpartum to the mother and the child MTCT was significantly reduced by 50% in the same population.

When given during intrapartum only, AZT+3TC had no effect on prevention of MTCT of HIV.

No difference between the arms in infant mortality from birth to 6 weeks.

HIV test results of informed husband and partners who agreed to undergo the test following counselling

Event Number percent

Tested 29 60.4

Refused 19 39.6

HIV+ve 20 69

HIV-ve 9 31

Demonstrate a high rate of couple discordance

Infant feeding pattern of children born to HIV infected women in Dar es Salaam following counselling (N=267)

Number %

Breastfeeding 250 93.6

Never breastfed 17 6.4

Recurrence of Pregnancies subsequent to participation in PETRA Study

18/255(7.1%)

Source of the new pregnancy in those who conceived.

Person Number percent Responsible same Husband 9 50%

New Partner 3 16.7% Casual partner 6 33.3%

Total 18 100%

HIV test results of informed husband and partners who agreed to undergo the test following counselling

Event Number percent

Tested 29 60.4

Refused 19 39.6

HIV+ve 20 69

HIV-ve 9 31

Demonstrate a high rate of couple discordance

PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV IN TANZANIA

ELEMENTS OF PILOT PROJECTS

Strengthening ANC

Modification of obstetric practices

VCT and ANC

Short-course AZT

Infant feeding counselling and support

Follow-up

Monitoring and evaluation

CURRENT PMTCT SITES IN TANZANIA MARCH 2002

PMTCT SITES:MOH:1.MVH1.MVH 2.KCMC2.KCMC 3.BUGANDO3.BUGANDO 4.MBEYA4.MBEYA 5.KAGERA5.KAGERA

AXIOS(NOG):1.HAI:1.HAI 2.KILOMBERO2.KILOMBERO

TANSWID/SAREC DSM**

HAVARD:1.DSM(MUCHS)** UNAIDS/WAF UNICEF-TEMEKE*TEMEKE*

PASADA:RCA DSM*

ANGLICAN CHURCH:DODOMA*:DODOMA* TANGA*TANGA* KAGERA*KAGERA*GTZ:MBEYA**

MDM SPAIN: COAST REGIONMDM FRANCE: KAGERA

•

SITUATION ANALYSIS - FINDINGS

- Limited awareness of MTCT- ANC attendance adequate, but full service package not always delivered- Variation in obstetric practices- VCT not widespread- Different HIV tests, costs- Counselling often lacks MTCT- AIDS training lacks MTCT, infant feeding- Importance of support services underestimated.

MAIN OBJECTIVE

To reduce mother-to-child transmission ofHIV-1 among the regular catchment population of the five hospitals by at least 50% when compared to pre-intervention levels.

INTERIM GOALS

- Make available good quality antenatal care, voluntary and confidential counselling services to pregnant women.

- Provide antiretroviral therapy, infant feeding counselling and support to HIV + pregnant women

- Provide follow-up care to HIV + women and their children.

Constraints

Inadequate counselling skills Involvement of male partners Compliance to ARV Limited space for counselling at health facility Insufficient human resources Low motivation of counsellors and other personnel High defaulter rate and lost to follow up Lack of community mobilisation strategy Insufficient data collection and handling Poor monitoring Irregular supply of drugs and consumables.

•

ELEMENTS OF PMTCT

Strengthening ANC

VCT

Modification of obstetric practices

ARV

Infant feeding counselling and support

Follow-up

Monitoring and evaluation.

•

Capacity Development and Support

- Improve the knowledge and skills of the counsellors in all

aspects of the PMTCT

- Infant feeding counselling requires adequate knowledge,

skills and time on part of the counsellors

- In appropriate counselling influence mothers to make

inappropriate choices on infant feeding.

- Formal training on HIV counselling and breastfeeding to

improve the knowledge and skills of the counsellors

Monitoring in PMTCT sites, Tanzania 2000 - 2001

22,409

19,116

3,059

625 356 2690

5,000

10,000

15,000

20,000

25,000

Numbercounselled

Number HIVtested

HIV positive HIV positiveon ARV

Full ARVcompliance

Partial ARVcompliance

Num

ber

•

SCALLING UP OF PMTCT ISSUES

Areas requiring strengthening:

Counselling,

Personnel

Follow-up

Infant feeding,

Care and support for mothers, children and the family -

nutrition care, psychosocial support

Communication strategy for PMTCT - stigma, male

participation, community participation

LESSONS LEARNED

90% of women attend ANC MCH Clinics Voluntary Testing and

Counselling: 90%accept to be tested but 1/3 missed this opportunity

Community involvement

- Local leaders -Religious Leaders -Respected elderly e.g. in laws, grandparents, TBA

What is their contribution e.g paying for test kit

Involvement of Male partner

- support on prevention and care

- Stigma

- nutritional support Care of Mother: during pregnancy,

labour and delivery and postnatal Care of the Child professional counsellors/Lay

Counsellors Others NGOs in HIV programs Family Planning

THANK YOU FOR LISTENING.