Welcome to the HIVfiles.

PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV

(PMTCT)

The growing complexity of managing children with established HIV infection is well-suited to a virtual exchange of information. Clinical trials data for children continue to lag behind adults and are often limited in scope. Many clinicians make treatment choices based upon preliminary data from adult trials. Others choose to offer patients regimens that have never been studied. The majority of children in care at centers throughout the United States have had many years of drug therapy and often require untested treatment regimens. Little, if any data, may be available to support these treatment decisions. This website provides clinicians the opportunity to ask others to share their management experience and their advice, transforming one’s individual experience into a more generalized collective experience.

Treatment issues for HIV-infected pregnant women are similarly complex and clinicians caring for these women are also offered the opportunity to exchange information. Treatment decisions during pregnancy have broad long-term implications for both the mother and the child. The opportunity to exchange information with other clinicians can supplement valuable knowledge gained from published guidelines and clinical trials data. The website invites providers who care for large numbers of HIV-infected women to share their experiences. For those with limited patient numbers, it offers a place to ask questions and learn from the work of others.

The website offers a forum for HIV providers in countries with limited access to diagnostics and therapeutic interventions to exchange ideas and to interact with colleagues who have had the opportunity and luxury to use a wide variety of treatments. For those who are beginning to experience increased access to treatments, there is much to be gained from both the errors and triumphs of the past decade of therapy. HIVfiles.org also affords users the opportunity to begin a dialogue with colleagues throughout the world about a wide variety of issues affecting care of HIV-infected children and their families.More useful info at fractology.org

In addition to case discussions, the site will provide a forum for discussion of “hot topics” and emerging issues. Each month an invited guest will host a discussion on a topic of interest. Website participants are invited to take the debates which generally occur in the hallways outside meeting rooms into the message board and express on-line opinions. In the coming months, we anticipate hosting discussions on a number of topics including:
aging of perinatally HIV-infected children
role of genotype and phenotype testing in the care of children and pregnant women
diagnosis and management of metabolic disorders
complexities of adherence to antiretroviral regimens
emerging mental health issues
pharmacokinetic interactions of HIV therapies
Participants are invited to suggest topics of interest for this section of the website.
We welcome your comments and feedback about the website. We intend to develop the site to meet the needs of the participants. Ideas for new areas of discussion are welcomed, as are suggestions on improving the present structure. We invite you to enjoy this opportunity to become a vital part of the virtual community of HIV providers sharing their questions and answers on this website.

In support of the goals of the Government of Tanzania and the USG to prevent and treat HIV, the Elizabeth Glaser Pediatric AIDS Foundation is supporting a sizable effort to establish and strengthen PMTCT services in Tanzania. The program is funded and directed through a bilateral project of USAID/Tanzania.

The Foundation has always integrated PMTCT into existing MCH programs through antenatal care, labor and delivery and postnatal services for mother and infant. In 2005, the Foundation will conduct a targeted evaluation to compare maternal-child health services in rural Tanzania prior to and after the introduction of a PMTCT program. The planning and study design was developed in 2004 and is funded with Core USAID funds earmarked for Health, Infectious Disease and Nutrition (HIDN) activities. The evaluation and related data collection and analysis activities planned for 2005 are described here.

2005 Program Goals and Objectives

The purpose of the study is to determine whether introducing PMTCT enhances existing prenatal, labor and delivery, postnatal and under-five child services in rural clinics in Tanzania.

The primary objectives are to:
• Compare MCH services prior to and following introduction of the PMTCT program at selected sites in Arumeru and Monduli Districts, particularly with regard to MOH guidelines for care; and
• Compare MCH services between the Arumeru sites at which PMTCT services have been introduced and the Monduli sites prior to the introduction of PMTCT.

Secondary objectives will focus on 1) comparing health provider knowledge and satisfaction levels prior to and after introduction of the PMTC program; and 2) assessing the rates of HIV infection among infants identified as HIV-exposed through the PMTCT program.
Implementation Plan

This is a population-based study for which aggregate data will be collected about the services provided at designated antenatal care clinics, labor and delivery wards, and under-five child clinics and about the populations who are cared for at these sites. Individuals will not be enrolled. The study will include six sites: one district hospital and two health centers from both the Arumeru and Monduli Districts.

II. PROGRESS TOWARDS TARGET INDICATORS FOR PMTCT PROGRAM

During the last quarter 34 new sites started PMTCT services with support of the Foundation, making a total of 100 sites providing a package of PMTCT services which includes but is not limited to pre- and post-test counseling for HIV to all pregnant clients, rapid HIV testing, provision of Nevirapine for all HIV infected mothers and their exposed infants, modified safe obstetric practices, counseling on exclusive breast feeding, nutritional feeding for the mother and family planning. Of those 100 sites, 33 are run by Faith Based Organizations (FBOs). For all sites supported by the Elizabeth Glaser Pediatric AIDS Foundation see attachment I.

The PMTCT services are fully integrated in the MCH and labor and delivery services and are supporting an essential package of prenatal care, which includes at a minimum the following components: 1) focused visits, 2) birth preparedness, 3) disease detection, including Hb, syphilis and other testing, 4) prevention and treatment of diseases, including intermittent presumptive treatment of malaria with SP, and 5) counseling on nutrition, including providing supplementation of micronutrients.

Supplies of Nevirapine, Capillus and Determine

In January the programs were ready to start but unfortunately the Nevirapine and Determine through the donation program was not yet cleared through customs. Fortunately, Axios/Tanzania shared commodities for the start up the services, and after a few weeks the commodities were returned. Stocks of Determine and Nevirapine are sufficient to last at least 6 more months. The supplies were distributed by EMS during a meeting in Arusha.

The memorandum of understanding with MSD was finalized and signed. Capillus was bought from MSD and the sites were able to pick up the test kits at the zonal stores. Unfortunately this did not go very smoothly, and a lot of follow up was necessary. None of the sites were without test kits or NVP.

Compliance training for EGPAF personnel and sub grantees

In February 2005, the Technical Director, the PMTCT Program Officer and the Compliance Assistant and 1-2 representatives from each sub grantee attended a USAID Rules and Regulation workshop in Arusha presented by the Association of Private Volunteer Organization Financial Managers (APVOFM). For each sub grant, the program manager and financial manager/accountant was invited. The training was useful and gave a better understanding of compliance issues, especially for sub grantees new to USG funding.

Dispensing of NVP to mothers and infants

The dispensing of NVP to HIV infected mothers and their infants is still a challenge. At this moment all sites provide, according to the national PMTCT guidelines, NVP at 28 weeks of pregnancy or later at the ANC clinic. Mothers are instructed to swallow the tablet by the onset of labor. This is to accommodate women who, for different reasons do not deliver at the facility. NVP is also provided at the labor ward. However, we still do not reach all the mothers, because some do not return after 28 weeks and do not deliver in a health facility and we do not know how many of the mothers who received NVP during ANC actually swallow the tablet at home.

For infants there is still no proper dispensing mechanism at this moment. The NVP donation was packaged together with special syringes in which NVP can be dispensed to take home and administer in the event of a home birth. However, this is not according to the national PMTCT guidelines and therefore will need further discussion with the PMTCT Secretariat. According to the manufacturer, NVP is stable for 2 months in a normal syringe and 6 months in a special syringe.

Follow up of mothers and infants
The follow up of mothers and infants after delivery remains to be a big challenge. Although we believe that most women and infants do have regular contact with a health institution (high vaccination rates), we are not able to longitudinally follow up the mother-infants pairs because they are not recognizable in the system. They might go for vaccinations to a different clinic which is closer and since the infant card does not carry information from the mother, the child is not recognized as being exposed to HIV. Mothers hardly attend the clinic for themselves after delivery; post natal care attendance is low in Tanzania. The Foundation will begin an operations research project next quarter, whereby information will be transferred from the mother to the infant to determine if this will improve infant follow up, as well as improve post natal care to increase attendance and follow-up of the mother.

We also discussed whether new PMTCT sites can start recording HIV infected mothers once they are diagnosed and develop a mechanism for follow up of them and their infants. Depending on the site this could be through TBAs, Community Health Workers, Home Based Care workers or facility based staff.