Overview of Elimination of MTCT of HIV programme in Sri Lanka
Trend of Annual Reported HIV cases Males
Females
Total 186196
200
Source: SIMU/NSACP
2013
2011
2009
2007
68
2003
42
54 47 50
2001
1997
1995
1993
27 37 23 22 30 32
1991
0
13 2 3 11 7 1989
50
55
1999
100
146 137 129 119 121 102 91 95
2005
150
1987
N. of HIV cases reported
250
Estimated number of HIV + pregnant women and who are in need of ART for PMTCT, 2007-2015 90 80
74 69
70
64 57
60 Number
77
35
50
50
43
40
36
54
31 30
42
59
63
49
36 20
26
31
10 0 2007
2008
2009
2010
2011
2012
2013
2014
2015
Pregnant women in need of ART for PMTCT Source: National STD/AIDS Control Programme_Report on HIV Estimates and Projections 2009
3
Estimated number of children (0-14 years) living with HIV, 2007-2015 90 80 70
Number
60 50 40
Female Male
30 20 10 0
Source: National STD/AIDS Control Programme_Report on HIV Estimates and Projections 2009
4
Reported cases of Paediatric HIV due to MTCT Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total
2013 – 11 cases
Male 1 0 2 4 3 1 6 2 3 2 4 1 3 4 36
Female 0 1 1 0 1 4 1 1 6 2 2 2 21
Total 1 1 3 4 3 2 10 2 4 3 10 3 5 6 57
Paediatric HIV cases in 2013 File number
Clinic
Age at the time of diagnosis
COF 832/13
Colombo
5y + 6 months
Mother HIV + Father -
3y+ 6 months
Mother HIV + Died Father Not known
GP F 001/13 GPF 054/13 Gampaha
Family details
GP F 67/13
Gampaha
4y+ 6 months
Mother HIV + -Died Father +
IDF 48
IDH
4 years
Mother HIV + Father -
COF 863/13
Colombo
5y + 4 months
Mother HIV + -Died
COM 865/13
Colombo
5y + 6months
Mother + Father +
GPF 138/13
Gampaha
4y+ 6 months
Mother + Father + brother +(GPF 139))
4y+ 6 months
Mother + Father + brother +( GPF 138)
GPF 139/13
Gampaha
COM 875/13
Colombo
5y + 4 months
Mother + Father + brother +(COM 905)
COM 891/13
Colombo
1y + 6 months
Mother + Father +
2y + 6 months
Mother + Father + Sister + (COM 875)
COM 905/13
Colombo
ART services for PMTCT initiated in 2002 Services were for identified pregnant females with HIV
PMTCT data 2008
2009
2010
tested
positive
tested
positive
tested
positive
Gampaha
2290
1
2259
0
1655
0
Kalutara
988
1
741
0
567
0
DMH
8961
1
10180
2
10373
3
CSHW
-
-
-
-
884
0
Total registered antenatal population per year – 350,000 – 400,000
ART services for PMTCT introduced in 2002 Constraints Pilot project/ sentinel sites limited Accessibility for •information and •counselling and testing facilities
Number of antenatal samples screened for VDRL and HIV in government centres in 2012 Type of testing
Total number Number of deliveries screened
Coverage
Number positive
VDRL
320,518
194,153
60.6%
45
HIV
320,518
17,822
5.6%
3
Assess the situation • Antenatal HIV screening coverage 5.6% • VDRL testing coverage close to 98% (60% through STD clinics) • Need to increase HIV testing coverage
Assess the situation • High cost for testing • debate on cost effectiveness of universal screening in a low prevalence setting • Lack of interest of others
Consultative Meeting held on 21.05.2013 • All venereologists agreed on universal testing and elimination of MTCT – May 2013 • Decisions taken to call the programme as “Elimination of Mother to child transmission of HIV and congenital syphilis programme” • To scale up testing sevices for HIV to provide universal screening for all pregnant mothers in few years.
ELIMINATION OF MTCT OF SYPHILIS AND HIV PROGRAMME
Elimination of MTCT of STI • Mile stones – Prevention of MTCT of syphilis – 1952 – Prevention of MTCT of HIV - 2002 – Elimination of congenital syphilis – 2009 – Elimination of MTCT of HIV – 2013
Objectives of EMTCT of HIV programme by 2017 • >95% of ANC attendees received Provider Initiated Testing and counseling services for HIV • 100% of identified HIV-positive pregnant women received antiretroviral medicines to reduce the risk of mother-to-child transmission • 100% of infants born to identified HIV-infected mothers received ARV drugs 4 strategies were identified.
Strategy 1 - Ensuring advocacy for a successful EMTCT programme
• Advocacy to give high priority to programme and allocate resources • Strengthen linkage between MCH and STI services • Demonstrate the cost benefit of interventions • Establish a national level steering committee
Advocacy • Concept paper submitted to MOH • Meeting with Directors of major maternity units in the country DMH, CSHW • Meeting with Director, FHB • Meeting on EMTCT at Kathmandu, Nepal organized by UNICEF for MCH services and STI services – September 2013 –helped to improve links between MCH services and STI services • Advocacy meeting - country programme to introduce EMTCT services – sensitization (UNICEF) at Hotel Taj Samudra – with participation of all provincial MCH staff and STD staff • sensitization of stakeholders including private sector
WHO Recommendation for low prevalence settings Consolidated guideline 2013 – August
PROVIDER INITIATED TESTING FOR ALL PREGNANT WOMEN IF NOT DONE IN PREGNANCY AT CHILD BIRTH DURING POST PARTUM PERIOD
• NAC meeting – October 2013 – Highlevel meeting chaired by the secretary, ministry of Health • Approved the programme. • Steering committee formed. • Target given to cover 50% of pregnant women by end 2014.
National level steering committee, appointed by the Secretary • Ministry of Health –, DGHS, DDG PHS 1, DDG PHS 2, DDG LS • NSACP Director, PMTCT coordinator, Microbiologist • FHB Director, PMTCT coordinator • Director MSD, Director private medical institutions • Representatives from College of Obstetricans and paediatricians • Funding agencies – UNICEF, WHO, WB
Linkages between MCH services and Provincial STI services FHB MO MCH
Policy, guidelines, TOT programmes Provincial Administration
NSACP
VENE/ MO STD
RE Coordination, adminis trative, logistic support Medical Officer of Health (Primary health care Unit)
Training Testing services PMTCT services Obstetrician
District STD Clinic
Linkages between MCH services and Provincial STI services FHB MO MCH
NSACP
Provincial Administration
VENE/ MO STD
RE
Medical Officer of Health (Primary health care Unit)
•Improve awareness •Promote PICT •Infant feeding
District STD Clinic
Obstetric management Obstetrician
•Testing facilities •ART for mother •ART for baby •Care and support services for mother and baby
How to inform relevant authorities regarding decisions taken? Ministry of health issued Circular
• All pregnant women are to be screened before 12 weeks of gestation for Syphilis and HIV. • Antenatal clinic services have to arrange collection of 5cc of blood and transport to the STD clinic. • STD clinics have to carry out Syphilis and HIV screening tests. • The reactive VDRL reports and HIV positive reports need to be informed to the MO, MOH or VOG. • The screening test positive pregnant women need to be referred to the STD clinic for further management. • All pregnant women with Syphilis or HIV should be provided appropriate services. • Programme need to be reviewed at the district level every six months.
Strategy 2
Increase access to and quality of syphilis and HIV services at maternal and child health services – Expand provider initiated testing and counseling for HIV – Ensure all antenatal mothers are screened – Maintain quality of testing – regular training of primary health care workers – Non stigmatizing referral
Scaling up EMTCT services 2013 Colombo Gampaha Matara Hambantota Galle and Kandy
Source: Strategic Information Management Unit, National STD/AIDS Control Programme, 2010.
27
Scaling up EMTCT services 2014 Nothern province North western province North central province
Source: Strategic Information Management Unit, National STD/AIDS Control Programme, 2010.
28
Countrywide services in 2016
Scaling up plan • Year 2013 – cover Colombo, Gampaha, Galle, Matara, Hambanto ta and Kandy districts (to start with HIV testing to be done in all samples sent to government STD clinics/ centres for VDRL testing)
• Year 2014 – scale up to Nothern, North Central, North Western provinces • By year 2016 – to consider possibility to cover all the districts
Laboratory - Increase HIV testing services • Procure test kits
– WHO - US$10,000 – test kits – WB – US $ 200,000 – test kits
• Training of MLT when necessary • Quality of testing Lack of human resources Increased work load Overtime approval Protocol for testing Logistics
• ELISA machines – UNICEF NSACP, Matara, Badulla, Negombo • Vacutainer tubes • Protective gear kits –for the team involved in delivery • carrier boxes – to transport samples to be distributed among MOH offices
Training • Training programmes for health care workers – MCH staff • Colombo district • Kandy district • Southern province • Gampaha district Only few get opportunity to participate Need to do more training of HCW at district or MOH level Use of local resource
Consultative workshops - 3 Institutional staff • DMH, CSHW,CMC • Kalubowila, Homagama, Awissawella hospital staff • STD clinic staff of SP, Kandy, WP • • • •
2014 Kalutara MCH staff NSACP staff NP, NWP, NCP staff
UNICEF funds to improve facilities Item
Unit
Numbers
computers
EMTCT unit, Reference laboratory Galle, Gampaha, Kalutara, Kandy, Vavuniya, Jaffna,
8
multi media projectors -
EMTCT unit, Matara
2
Fax machines
EMTCT unit Reference laboratory
2
IEC Material • Posters – To make public aware of MTCT of HIV • Leaflets – To introduce testing services package in ANC services, Hb, UFR, GTT, Blood gp and Rh, VDRL, HIV • Laboratory form – improved to send ANC samples to STD laboratory (currently being printed.)
CD – • Health talk for ANC mothers • Community awareness programmes for women and girls • Advocacy programmes for community leaders • Management of pregnant women with HIV • EMTCT scale up plan
Strategies 3: Elimination of HIV transmission from women living with HIV to their children by promotion and integration/linkage of EMTCT with related services – Ensure that all positive mothers and partners are treated at the STD clinic. – All babies be managed appropriately with the support of the venereologist/ MOIC of the STD clinic and paediatrician.
Guidelines • MCH - guideline on antenatal care services for MCH staff • Preconception services guidelines • standard of care of management of pregnant women with syphilis or HIV •
• NSACP - PMTCT guideline including paediatric care 2012 • ART guideline including paediatric care - 2014 • ECS strategy - 2009 • EMTCT of syphilis and HIV strategy – 2014 (to be printed)
Prevention of mother to child transmission of HIV Provider initiated Counselling and testing (PICT)
ART at 14 weeks /if diagnosed later, as soon as possible
Obstetric management according to guidelines LSCS/ vaginal
Infant feeding (AFASS feeding)
ART for baby for 6/52
PMTCT Programme in Sri Lanka • • • • • • • •
Guidelines are developed. ART for all eligible. ART for PMTCT from 28 weeks. Obstetric management with LSCS at 38-39 weeks ART for baby Infant feeding protocols are in place. Free provision of formula feeding by an NGO FP services for women with HIV
Rapid advice WHO - 2009 ART - B + option Three drugs AZT+3TC+LPV/Rt TDF+FTC+LPV/Rt To continue ART after delivery for lifetime
Strategy 4: Strengthen surveillance, monitoring and evaluation systems – Improve collection of data – Regular review of the programme
Indicators • % pregnant women attending ANC in selected districts offered testing services for HIV • % pregnant women attending ANC identified as having HIV infection • % identified HIV infected pregnant women receiving PMTCT services according to national guidelines
Districts
ANC VDRL coverage 2013
Pregnant mothers registered
1917 12121
36.73 61.93 81.4
19572 1672719943
10577
10983
26779 +8816 (CMC)14559
Puttalam Gampaha
Mannar Matale Matara NuwaraEliya Polonnaruwa Ratnapura Trincomalee Vauniya Kilinichchi Muuaitivu
Syphilis Coverage(%)
5219
Ampara Anuradhapura Badulla Monaragala Batticalloa Colombo
Hambanthota Jaffna kalutara Kalmunai Kandy Kegalle Kurunagala Galle
Number tested for syphilis
16336 312892983
16789 +
6033 (NIHS)
383,383
12976 10435 9399 28187 15419 30652 188633539 2118 10245 15483 14629 8639 20161 9228 35064981 2216 2107
2286 1829 829 15941 104 13719 8229 5864 934 4250 13653 7191 22197 6038 1941 5676 9918 10099 7514 14971 4644
217870
16.65 43.23 97.58 53.71 63.42 56.20 4.2 45.22 48.44 46.64 72.42 50.77 91.64 55.40 64.06 69.03 86.98 74.26 50.33 63.6 56.8282892
ANC HIV tests 2013 Districts Ampara Anuradhapura Badulla Monaragala Batticalloa Colombo Puttalam Gampaha
Hambanthota Jaffna kalutara Kalmunai Kandy Kegalle Kurunagala Galle Mannar Matale Matara NuwaraEliya Polonnaruwa Ratnapura Trincomalee Vauniya Kilinichchi Muuaitivu
Number tested for HIV
Number positive
0
0
0
0
772
0
0
0
0
0
20050
2
2
0
1263
0
240
0
0
0
2347
2
0
0
0
0
673
0
HIV coverage(%)
4.62
56.3
7.73
8.27
2.95
0
0
1911
0
6.78
793
0
5.14
465
0
25.91
4422
0
0
0
0
0
0
1016
0
0
0
0
0
39
0
0.19
57
0
0.62
55
0
0.7
34105
4
6.56
8.895803935
ANC HIV tests 2014 Q1, Q2 District Ampara Anuradhapura Badulla Batticalloa Colombo Puttalam Gampaha
Hambanthota Jaffna Kalutara Kalmunai Kandy Kegalle Kurunegala Galle Mannar Matale Matara Monaragala NuwaraEliya Polonnaruwa Ratnapura Trincomalee Vauniya
No.tested 0 0 126 0 8628 5 2062 1 1515 2933 994 2358 0 758 1 6754 752 0 1252 3009 0 0 3591 0 0 0 25 11 4 34779
No.positive
No.tested 0 0 0 0 8402 60 3275 0 2044 4327 1683 2237 0 773 0 7176 2004 0 1257 2621 0 0 2856 335 0 0 17 8 6 39081
No.positive
2 2
Targets by 2017 â&#x20AC;˘ Reduce mother to child transmission of HIV to <0.5 cases/1000 live births â&#x20AC;˘ Reduce the incidence of congenital syphilis to <0.5 cases/1000 live births
Year
Outcome of PMTCT services Positive pregnant women
Known
Newly identified
outcome
Mode of delivery
Abortion -2 Negative babies - 4
LSCS - 4
2011
6
2012
5
3
2
Negative babies - 5
LSCS – 4 NVD - 1
2013
6
0
6
Negative babies - 6
LSCS
2014
8
4
4
Abortion – 1 LSCS – 4 5 delivered NVD - 1 2 to deliver
Total
25
12
13
16 negative babies No positive babies
Challenges Lack of human resources – MLT Lack of facilities to transport samples Delay in testing Lack of storage facilities at STD clinics- refrigerators Problems in labeling tubes – mix up Uniformity in data collection Local training of HCW – within the district ?Stigma ?maintenance of confidentiality PLHIV – reluctance to use FP services, need bigger families • Management of paediatric HIV cases
• • • • • • • • •
Proposed • Training on EMTCT PLHIV 1 day programmes • Consultative workshops - 3 NP, NWP, NCP • Printing of strategy • Regular training of MCH staff by the local resource • Introduce training of EMTCT into pre-service training - public health staff - NIHS, PHM training, Doctors - undergraduate, postgraduate • Regular reviews - National level, Provincial level • Involvement of private sector • Involvement of professional colleges – obstetricians, paediatricians
Thank You
Thank You To all Who contributed to the success of the EMTCT programme