AIHA

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AIHAs Pilot Project in Odessa A Comprehensive
MTCT Prevention and Intervention ProgramZoya
Shabarovazoya_at_dds.nlJames SmithAmerican
International Health Alliancejim_at_aiha.com
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Educational Objectives

• Understand the main components of comprehensive
  mother-to-child HIV transmission prevention
  (pMTCT) program
• Learn about the implementation of effective
  comprehensive pMTCT program in the health care
  setting with limited resources in the region with
  concentrated stage of HIV/AIDS epidemic (Ukraine)
• Understand how to apply hospital twinning and
  medical volunteer methodology to pMTCT project
• Learn about a pilot project that can be used as a
  teaching laboratory to implement systemic change

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Strategic Framework to Prevent HIV in Infants and
Young Children

• All women ? prevent HIV infection (level 1)
• HIV women ? prevent unintended pregnancy (level
  2)
• HIV women ? prevent MTCT (level 3)
• HIV women, their infant and family ? provide
  care and support (level 4)
• Source Prevention of HIV in infants and young
  children. Review of evidence and
• WHOs activities. WHO/HIV/2002/08

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Odessa Strategic Framework to Prevent HIV in
Infants and Young Children

• pMTCT
• First Plus prevention of HIV among women of
  reproductive age
• pMTCT Prevention of mother-to-child transmission
  of HIV
• End Plus Follow up care and support for
  families

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Timing and Risk of Transmission

• Tr. Rate
• During pregnancy 5-10
• During labor and delivery 10-20
• During breastfeeding 5-20
• Overall without breastfeeding 15-30
• Overall with breastfeeding till 6 months
  25-35
• Overall with breastfeeding till 18 to 24 months
  30-45
• Source de Cock, JAMA (2000)

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Main Components of pMTCT (Level 3)

• Prenatal voluntary counseling and testing (VCT)
• Prophylactic antiretroviral (ARV) regimens
• Safer delivery practices
• Infant feeding counseling and support

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Prenatal Voluntary Counseling and Testing

• VCT the entry point for HIV prevention and care
• HIV testing must be done with informed consent of
  the woman, using reliable laboratory tests and
  ensuring confidentiality (basic requirements)
• Availability of efficient referral system to
  other services (Family planning, STI treatment,
  MCH, MTCT, etc.)
• Choice of most appropriate and feasible model of
  VCT (individual, group)

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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 WWCs and PHCs including OOH
• PATH VCT training, June 2002, Odessa
• Inter-Donor
• MSF Provide Nevirapine, infant formula,
  C-section delivery kits for OOH and develop
  laboratory capacity
• UNICEF Developed training materials on pMTCT in
  collaboration with OSMU and OOH

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Prophylactic Antiretroviral Regimen

• Ante- and intra-partum regimen reduce viral load
  in mothers blood and genital fluids during
  pregnancy, labor and delivery
• Post-partum regimen act as post-exposure
  prophylaxis (viral particles eventually
  transmitted during birth are eliminated)
• Main regimens (see handout Use of antiretroviral
  regimens for MTCT prevention)

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Safer Delivery Practices

• Planned, hemostatic C-section
• Avoidance of unnecessary invasive procedures
  (episiotomy, rupture of membranes, forceps,
  etc.) reduce infant contact with mothers
  infected blood and genital fluids.
• Birth canal cleansing with chlorhexidine

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Infant Feeding the Ukrainian Context

• Avoidance of breastfeeding eliminates HIV
  transmission through breast milk, but carries
  other risks (infections other than HIV,
  malnutrition)
• Counseling information about the risks and
  benefits of various infant feeding options,
  guidance in selecting the most suitable option
  for their situation.

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pMTCT Follow-up Care of Women and Infants

• Comprehensive care for women
• Primary and HIV specialty care
• OB/GYN and family planning services
• Mental health and substance abuse treatment as
  needed
• Coordination of care for entire family
• Support services
• Follow-up for Infants
• HIV diagnostic testing to determine HIV status
• Referral to an HIV specialist
• PCP prophylaxis initiated at 6 weeks of age
• Long term follow-up of HIV-exposed infants
• Support services for entire family

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Ukraine HIV Profile

• Ukraine epicenter of the HIV/AIDS epidemic in
  Eastern Europe and Central Asia. In Eastern
  Europe and Eurasia HIV is growing faster than
  anywhere else in the world (UNAIDS, 2002)
• Concentrated stage of HIV/AIDS epidemic (USAID,
  UNAIDS, WHO classification, 2000) HIV
  prevalence rate adults -1 (2001) male STI
  patients 13.3 (1996) IDUs 8.6 (1998),
  pregnant women 0.22 (2001)
• Report on the Global HIV/AIDS Epidemic, July
  2002, UNAIDS
• Ukrainian AIDS Prevention Center

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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

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AIHA MTCT Pilot Project Goals

• Reduce the incidence of HIV in women of
  reproductive age (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)
• Prevent occupational exposure to HIV among
  healthcare workers
• Create a model that is adaptable to other cities
  and a teaching laboratory to facilitate
  dissemination and replication (scaling up)

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Project History

• Pre-project background Active AIHA partnerships
  in Odessa (IC, WWC, NRP, PHC) developing
  long-term relationship with Odessa Oblast
  Hospital (OOH) and Odessa State Medical
  University (OSMU)
• Fall 2000 Identification of Odessa, Ukraine as
  MTCT project site (hot spot for region) to be a
  replicable model for change in Ukraine
• February 2001 Key Ukrainian participants attend
  8th Conference on Retroviruses and Opportunistic
  Infections in Chicago
• Spring 2001 Collaboration scheme developed with
  Medicins sans Frontieres (MSF)
• Spring 2001 Development of workplan, training
  needs identified (role of AIHA partnership)
• March - August 2001 Cooperation with Cook County
  Hospital, Chicago
• September 2001 present Collaboration with
  Denver Health Medical Center, University of
  Colorado Health Sciences Center, Childrens
  Hospital of Denver, Boulder Community Hospital
  (hospital twinning and medical volunteer)
• August 2001 to present AIHA project team
  collects data, performs monitoring, develops
  materials for dissemination, conducts clinical
  training

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Main Components of AIHAs 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 protocols, 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 NGOs

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Project Milestones

• A catalogue of reference documents was developed
  (practical guides for healthcare workers,
  patients 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 Monitoring and Evaluation database was
  developed, data entry is in progress preliminary
  results are available.
• A MTCT training course curriculum was developed
  and approved by the Odessa Oblast Health
  Administration.
• Odessa Oblast Health Administration issued an
  order requesting HCWs from all women's
  consultations in Odessa to participate in the
  MTCT training course. Developed a patient
  flowchart and redesigned the referral system for
  MTCT.
• Odessa Oblast Health Administration issued an
  order in May 2002 that all HIV-positive pregnant
  women be referred for prenatal care to the Odessa
  WWC and for delivery to OOH
• 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 conference abstracts and
  five posters were presented at the conference.

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FY03 Workplan

• Improve the system of follow up care for women
  with HIV and babies born to HIV infected women in
  cooperation with UNICEF/Kiev and MSF/Kiev
• Enhance the HIV ELIZA testing capabilities at OOH
  lab to provide primary HIV testing for pregnant
  women
• Strengthen the nursing component of healthcare
  delivery to HIV pregnant women, their infants
  and families
• Develop consecutive and interactive pMTCT
  management model of primary prevention, prenatal,
  delivery, postnatal care, infant preventive care
  and monitoring, including follow up care for
  families with HIV
• Improve the health care of HIV infected women who
  are IDUs and their babies
• Initiate cross-border collaboration on pMTCT
  (Constanta, Romania)

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Incidence of Babies Born to HIV Mothers at
Odessa Oblast Hospital
represents first nine months of 2002
represents projection for 2002 (Jan-Dec)
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Preliminary Project Results
HIV status of all babies are verified by HIV PCR
tests/ELISA and WB tests
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MTCT Practical Guides

• Purpose Provide improved practice guidelines for
  OB/GYNS,
• neonatalogists, pediatricians, family physicians,
  nurses, midwives, social
• workers, microbiologists and lab technicians on
  various aspects of treating
• HIV patients.
• Prevention and Treatment of STIs
• Treatment of STIs in HIV Pregnant Women
• Infection Control Practices
• Voluntary Counseling and Testing
• Lab Testing
• Prenatal Care for HIV Women
• Prevention of MTCT During Delivery
• Pediatric Care for Infants Born to HIV Mothers
• Primary Health Care for HIV Patients
• Family Planning
• Infant Feeding

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Other MTCT Products for Dissemination

• 1. Questionnaires
• Purpose 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 Packages
• Purpose Disseminate information among women of
  reproductive age and HIV
• women on HIV prevention, pregnancy and HIV
  testing, HIV, newborn and infant
• care
• 3. Patient Charts
• Purpose Collect and maintain information about
  HIV infected women and
• infants

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Integration of pMTCT into the MCH System
PMTCT interventions
MCH schedule
HIV/STD counseling HIV testing, STI
screening Anemia prevention
Prenatal visit 1
Confirmation of HIV, post-test counseling STI
treatment ARV treatment counseling Infant feeding
counseling
Prenatal visit 2
Initiation of ARV treatment Individual counseling
Prenatal visit 3
Intrapartum ARV component Avoidance of
unnecessary invasive procedures Universal
precautions
Labor/Delivery
ARV treatment for infant (if needed) Support for
infant feeding Family planning counseling Referral
to support groups
Postpartum
Growth and development monitoring Nutritional and
infant feeding counseling Infections
prevention/treatment Possible vaccination
Infant follow up
HIV testing of baby Referral for pediatric care
if baby is HIV
HIV screening schedule
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National and Regional Support for pMTCT Activities

• Ministry of Health Support for project
  activities and possibility of implementing pilot
  project in other sites across the country
• Odessa Oblast Health Administration Support for
  restructuring the referral system, facilitating
  communication between healthcare institutions
  that provide care to HIV patients, healthcare
  worker training and allocation of limited
  resources

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Applying AIHA Partnership Methodology to the
pMTCT Project

• Partnering/Hospital Twinning Long term
  commitment that brings people, institutions and
  communities together to achieve common goals
  through sharing of ideas, labor and even risks.
• Volunteering The project is founded on a
  community-based approach and volunteerism to
  create effective sustainable change in health
  care.
• Project Buy-in Instill a strong sense of
  ownership within the partner communities by
  focusing on appropriate and sustainable solutions
  to healthcare problems.