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Training Programme for Staff Nurses / ANMs on Whole Blood Finger Prick Rapid HIV Test for Screening Pregnant Women OBJECTIVES: 1.Train the ANMs & Staff.

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Presentation on theme: "Training Programme for Staff Nurses / ANMs on Whole Blood Finger Prick Rapid HIV Test for Screening Pregnant Women OBJECTIVES: 1.Train the ANMs & Staff."— Presentation transcript:

1 Training Programme for Staff Nurses / ANMs on Whole Blood Finger Prick Rapid HIV Test for Screening Pregnant Women OBJECTIVES: 1.Train the ANMs & Staff Nurses on National AIDS Control Programme 2.Universal Screening of Pregnant Women including testing of un-booked cases reporting directly to Labour room. 3.Referral of suspected positive cases detected by whole blood test to the nearest ICTC for enrollment under PPTCT programme and further confirmatory tests. 4.Ensuring Institutional delivery of positive pregnant women and ARV Prophylaxis to both mother and baby - presently followed and new WHO Guidelines 5. Infant feeding advise 6.Ensuring registration of HIV positive mothers at any of the ART centre of Delhi 7.Enrollment of HIV exposed baby for Early Infant Diagnosis Programme 8.Initiation of Anti Retroviral Treatment in HIV infected babies

2 Basics of HIV/AIDS



5 Natural History of HIV Infection Initial Infection (lasting 4–8 weeks), Acute HIV Syndrome (lasting 1 week–3 months), HIV-Specific Immune Response (1–2 weeks), Clinical Latency (10 years, median), AIDS-Defining Illnesses (2 years on average),and Death

6 W.P. Natural History of HIV-1 Infection Prior to treatment 4-8 wks Up to 12 years 2-3 years Initial Infection Seroconversion AsymptomaticSymptomatic AIDS Death 1000 500 0 CD4+ Cells/  L ARS


8 The Changing Natural History Of HIV/AIDS In The 'HAART' Era Dramatic reductions in the incidence of 1. HIV Related Deaths 2. Opportunistic Infections 2. HIV-related Malignancies 3. Kaposi's Sarcoma 4. Deaths in advanced AIDS cases

9 WHO Clinical Staging HIV Infection Who Clinical Stage I Asymptomatic, Persistent Generalized lymphadenopathy WHO CLINICAL STAGE II Moderate unexplained weight loss (< 10% of body weight). Recurrent bacterial upper respiratory tract infections (current event plus one or more in last six-month period). Herpes zoster Angular cheilitis, Recurrent oral ulcerations (two or more episodes in last six mths) Skin Lesions- Papular pruritic eruption, Seborrhoeic dermatitis, Fungal nail infections. WHO CLINICAL STAGE III Unexplained severe weight loss (> than 10% of body wt) Unexplained chronic diarrhoea for longer than one month. Unexplained persistent fever > one month Oral candidiasis, Oral hairy leukoplakia. Pulmonary tuberculosis (current). Severe bacterial infection for example, pneumonia, meningitis, empyema, pyomyositis, bone or joint infection, bacteraemia or severe pelvic infl ammatory disease. WHO CLINICAL STAGE IV HIV wasting syndrome i Pneumocystis carinii pneumonia Recurrent bacterial pneumonia. Extra Pulmonary tuberculosis Kaposi’s sarcoma. Cytomegalovirus disease (other than liver, spleen or lymph node) Central nervous system toxoplasmosis. HIV encephalopathy.

10 Epidemiology of HIV/AIDS

11 Global Scenario: Estimates PLHAs-33.4 Million (2008), 33.3 Million (2009)- 2/3 rd Cases in Sub-Saharan Africa, 1/10 th in SEA New Infections -2.7 Million (2008), 2.6 Million (2009) Deaths -2.0 Million (2008), 1.8 Million (2009) Infections /day- 7400 (2008) Spread of Epidemic :- - High risk groups to General population From the Urban to Rural areas From High to Low Prevalence Areas Increasing Feminization (48%) Increased Sexual route spread in IDU High vulnerability of youth (15-24 Yrs)-40%

12 HIV Epidemic in India Country Profile: Low HIV prevalence (0.31%) Nearly 2.4 million people infected by HIV (7.2% of Global burden )- India carries the largest burden of HIV behind South Africa and Nigeria. HIV Transmission predominantly through heterosexual route (87%) Heterogeneous epidemic A wide variation in HIV prevalence between states, districts and intra districts even within the states Concentrated Epidemic focused in HRGs (FSWs, MSMs, IDUs) : High Risk Groups (2008 HSS)  Female Sex Workers (4.77%)  Men who have sex with men (6.9%)  Injecting Drug users (9.86%) Bridge Populations (2008 HSS) ▪ Migrants (2.3%) ▪ Truckers (1.48%)

13 Pondichery Gujarat Karnataka Goa Lakshwadeep Dadra Nagar Haveli Maharashtra Madhya Pradesh Kerala Tamil Nadu Andhra Pradesh Punjab Rajasthan Daman & Diu J & K Haryana Uttar Pradesh Himachal Pradesh Delhi Chandigarh Bihar West Bengal Orissa Andaman & Nicobar Mizoram Meghalaya Assam Sikkim Manipur Tripura Arunachal Pradesh Nagaland HIV/AIDS Epidemic in India-2008 >1%in Antenatal mothers >5% in High Risk Groups <5% in High risk groups Total:2.4 million

14 Distribution of PLHAs by States (2007)

15 Categorization of Districts Category of Districts (609 districts) A More than 1% ANC/PPTCT prevalence in district in any time in any of the sites in the last 3 years B Less than 1% ANC/PPTCT prevalence in all the sites during last 3 years Associated with More than 5% prevalence in any HRG group (STD/CSW/MSM/IDU) C Less than 1% in ANC prevalence and Less than 5% in all STD clinic attendees or any HRG WITH KNOWN HOT SPOTS (Migrants, Truckers, Large aggregation of, Factory workers, Tourist etc) D Less than 1% in ANC prevalence in all sites during last 3 years with Less than 5% in all STD clinic attendees or any HRG OR No or Poor HIV Data With No Known Hot Spots/Unknown Districts by category: A – 156 B – 39 C – 296 D – 118 A+B= 195 (32%) districts


17 Trend Analysis of HIV prevalence HSS 2003-2008, India IDU MSM FSW STD ANC Preliminary Results of the 2008-09 HSS

18 Declining Trends of HIV Epidemic in India (2004 – 2009) Female: 38.7% of PLHA; Children: 4.4% of PLHA Source: HIV Estimations, 2008-09

19 Total population - 18 million, First case- 1988 Estimated PLHAs (2011)- 36,000 Low prevalence state (Prevalence in Gen. population- 0.2%) Highly vulnerable state- (Migrant labour- 0.88 million, Truckers stationed/day-35000) Total high risk population ->1.00 Lakh (FSW-61261, MSM- 28999, IDU- 17173) H IV +VE Regd. In HIV Care At ART Centers : 35036 Eligible patients actually started on ART- 16914 No. Currently Alive & on ART- 10126 LFU (7%), DIED (8%) OR TRANSERRED OUT TO ART CENTRES (21%) OF OTHER STATES. DELHI SCENARIO (DEC 2011)

20 HIV Trend Among Ante Natal Cases, Delhi


22 Declining HIV Positivity rate in ICTC of Delhi 2007-2011

23 Goal: To halt and reverse the epidemic in India over the next five years Objectives: – Prevent new infections by saturating coverage of HRG through TI and scaled up interventions in the general population. – Provide greater care, support and treatment to larger numbers of PLHIV – Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment programme at district, state and national levels – Strengthen the nationwide SIMS NACP-III (2007-12) : Goal & Objectives

24 Preventive Strategies 1.Prevention in High Risk Groups & Bridge Population- Targeted Intervention- Condom Promotion, BCC, STI management, ICTC referrals 2.Prevention in General Population-IEC, Blood Safety, STI prevention & treatment, PPTCT, ICTC, PEP

25 Targeted interventions STI care Condom promotion Enabling environment Blood safety Integrated Counselling and testing including PPTCT STI Care IEC and social mobilisation Mainstreaming ART HIV-TB Co- ordination Treatment of Opportunistic Infections Community Care Centres Post-Exposure Prophylaxis HIV Sentinel Surveillance Behavioural Surveillance Monitoring and evaluation Operational research DAPCU Technical Resource Groups Enhanced HR at NACO, SACS and districts Enhanced training activities Prevention High risk populations Low risk populations Care & support Monitoring and Evaluation Institutional Strengthening Care, Support & Treatment Strategic Information Management Capacity Building

26 ICTC Programme

27 What is an ICTC ? Integrated Counseling & Testing Centre (ICTC) is a place where a person is counseled and tested for HIV on his own free will or as advised by a medical provider

28 Functions of an ICTC Early detection of HIV Provision of basic information on modes of transmission and prevention of HIV/AIDS so as to promote behavioral change and reduce vulnerability (both for HIV positive and negative) Link people with other HIV prevention, care and treatment services

29 Who needs to be counseled and tested in an ICTC ? It is not the mandate of ICTC to test everybody in the general population. – For e.g. Spouse of HIV-ve pregnant women are not to be tested without any valid indication Populations who are more vulnerable to HIV or practice high risk behavior are the target for counseling & testing at ICTCs. All clients with risky behaviour (FSWs, MSMs, IDUs, Bridge population), TB patients, patients with STIs,

30 Informed consent for HIV testing Pre-test counselling should include: —engagement and assessment —risk reduction and planning assistance —review and signing the consent form Post-test counselling should include: —presentation and encouragement —priorities and follow-up

31 What is confidentiality? Confidentiality arises when: There is a confidential relationship, the nature of which may be dependent on factors of trust, knowledge and skill Information which otherwise would not be divulged is exchanged For example, doctor–patient and counsellor– client relationship

32 Exceptions to confidentiality In the best interest of the patient (disclosure to medical team if necessary for the treatment of the patient) To protect another person (partner notification) Necessary in public interest

33 Confidentiality (contd) Mr X vs hospital Z (1998) 8SCC296 Supreme Court of India ruled that: Disclosure permissible to wife/prospective wife— her fundamental right to a healthy life outweighs the fundamental right of the PLHA to confidentiality.

34 ICTC/PPTCTC Linkages ANC ART ICTC/ PPTCTC Blood bank Access to condom Access to legal services Psychosocial support CCC Peer support Group (DIC) STI Services- RCH TB-RNTCP


36 Aids to Communication in ICTC The IEC material which must be available in an ICTC are: TV and DVD player in a lockable stand for provision of information on HIV/AIDS to clients. Posters and Information Materials on the walls. Communication aids like flip charts. Condom demonstration models. Leaflets/pamphlets as take home material for clients.

37 HIV testing in an ICTC HIV Testing in an ICTC will be done only using rapid HIV diagnostic kits. The Laboratory Technician will ensure that results are delivered to the client the same day. All those who are detected HIV +ve are referred to the ART Centre All infants born to HIV +ve mothers will be tested for HIV using DNA PCR at minimum 6 weeks as per National guidelines.

38 Testing algorithm

39 Quality Assurance – Testing Internal – Lab Quality assessed through supervision – Standard Operating Procedures – Internal Control (+ve and –ve tested at regular intervals as per guidelines External – EQAS- Quarterly samples sent to 118 SRLs across the country – Every 6 months SRLs send coded samples to the ICTCs

40 PPTCT & EID Programme

41 Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT)

42 Prevention of Parent to Child transmission (PPTCT) Programme – Mobilize pregnant women for PPTCT services and linkage of HIV +ve pregnant women for pre-ART registeration/ CD4 count test – Line listing of HIV +ve of pregnant mothers – Ensure institutional delivery and antiretroviral (ARV) prophylaxis – Nevirapine prophylaxis ( T. Nevirapine 200mg single dose for mother and for baby 2 mg/kg body wt.) – Follow up the mother–baby pair till 18 months. – Ensure that the HIV-positive mother and the baby are linked with the nearest ART centre. – Identify a family member whom the HIV-positive woman can confide in and who will be a source of support and strength for her.

43 Rationale For PPTCT Services in India Annual pregnancies-27 million HIV infected pregnancies-43,000 30% Transmission rate * Infected newborns-12,900 * Risk of transmission from HIV infected mother to child can be reduced by administration of life long triple ART/prophylactic Nevirapine tablet to the mother and baby

44 The PPTCT programme Pregnant woman come for ANC registration Pregnant woman coming for ANC are given pre- test counseling Pregnant woman is tested for HIV Pregnant woman undergoes post test counseling HIV positive pregnant woman Pregnant women coming directly for labour are given pre-test counseling Pregnant woman come directly to the Labour Room HIV negative pregnant woman 1.Referred to ART Centre for CD4 count & Pre ART Registration 2.Mother and Baby Given prophylactic Nevirapine 3.Babies born are tested at minimum 6 weeks using DNA PCR as per National Guidelines

45 Current PPTCT regimen in India Consists of a single dose of prophylactic Nevirapine (SD NVP) to the mother and the new born infant. SD NVP is effective, cheap, less toxic and programmatically easy to implement Currently ~ 70% of HIV +ve pregnant women and the infants born to them get prophylactic SD NVP at ICTC centres.

46 Infant Feeding Counseling for HIV+ve pregnant women The HIV +ve pregnant women will be given the option of replacement feeding or exclusive breast feeding for 6 months Guidelines give emphasis on exclusive breast feeding for 6 months through counseling.

47 Detection of HIV positive pregnant women & coverage of Mother-Baby pairs with Nvp Prophylaxis (2007-2011), Delhi

48 Early Infant Diagnosis Launched in Dec 2010 EID Test Lab for DNA-PCR testing-1 (NCDC, New Delhi) EID sample collection sites- 19 ICTCs Whole Blood Collection for DNA-PCR sites (ART centers)- 7

49 What is a dried blood spot (DBS)? Whole blood dried on filter paper Usually obtained from pricking skin, not from phlebotomy Requires only a small amount of blood Easy to store Easy to transport Overhead 4-1

50 Required supplies for DBS collection Gloves Pen Lab forms DBS card Lancet or glucolet Disinfectant for skin Gauze or cotton wool Overhead 4-3

51 Procedure for heel prick 1.Warm the area 2.Wash hands, put on gloves 3.Position baby with foot down 4.Clean area, dry 30 sec 5.Press lancet into foot, prick skin 6.Wipe away first drop 7.Allow large drop to collect 8.Touch blood drop to card 9.Fill entire circle with drop 10.Fill at least 3 circles 11.Clean foot, no bandage <5kg infants 5-10kg infants Overhead 4-5

52 Valid DBS specimen Overhead 4-34

53 How to package DBS for storage 1.At the end of each day, pack the dry DBS (leave for next day if not dried for 3 hrs). 2.Separate each card from the others. 3.Insert into sealable plastic bag. 4.Add (minimum) 10 desiccant packets. 5.Add 1 humidity card. 6.Press air out of bag. 7.Label bag and seal. 8.Put into refrigerator if not going to the lab that day. Overhead 4-53

54 Insert into sealable plastic bag (no more than 10 samples per bag) Overhead 4-54

55 Add desiccant packets (minimum 10 packets per bag) Minimum 10 packets per bag Overhead 4-55

56 Add humidity card, press air out of bag, and seal bag Overhead 4-56

57 How to store DBS Keep packaged DBS (in sealable plastic bags) refrigerated until transported to reference laboratory. Avoid leaving in vehicle, as sun and heat will deteriorate DBS. Overhead 4-57



60 Summary of State PPTCT-EID Program-Dec 10-March11 No of ANC +ve Pre ART registra tion CD4 test Y/N CD4 > 350 CD4< 350 If < 350 ART Started or not Institutiona l del/ANC +ve –MTP- due EDD) MB pair MTPANC Client from other states 364 (0.22%) 302 (83%) 281 (93%) >155 (55%) < 124 (44%) 2 – report awaited 101 (81.5%) 238/305 (78.03%) 217 (91%) 13 (3.6%) 39 (10.7%) EDD yet pending ANC HIV+ LFUs Mother Counsel ed for Exclusiv e Breast Feeding 6 weeks CPT 6 Week DBS Result of DBS PCR whole Blood at ART Centre Result of Whole Blood 46 (12.6%) 60 (16.5%) 152 (63.9%) 87 (36.5%) 60 (25.2%) 19 (31.7%)12 (63.2%) 5 +VE, 7–VE Dr.A.K.Gupta,New Delhi

61 EID Data Dec 2010-Dec 11 1.DBS DNA PCR testing No. of tests done – 189 No. reported upon- 149 No. found positive- 50 No. found negative- 99 No. of reports awaited-40 2. Whole Blood DNA PCR testing No. of tests done- 50 No. found positive-20 No. of reports awaited – 6 3. No of HIV infected infants started on ART- 10

62 Option AOption B Mother If CD4 >350 AntepartumAZT(from14weeks) sdNVP+AZT/3TCatdelivery AZT/3TCfor7dayspostpartum If CD4 ≤350:LifelongART Mother If CD4 >350 HAARTfrom14weeksofpregnancy until1weekafterbreastfeedinghas stopped If CD4 ≤350:LifelongART Infant Ifbreastfeeding:dailyNVPfrombirthuntil onewkafterbreastfeedinghasstopped Ifnot breastfeeding or mother on ART: NVPfor6wks Infant NVPfor6weeks(regardlessof whethermotherisbreastfeeding) New WHO PPTCT Guidelines (To be adopted) India will adopt option B in 2012 for virtual; elimination of Pediatric HIV ARV supplies have been received NACO will arrange for trainings soon

63 ART Regimens for HIV Positive Pregnant Women 1 st Line2 nd Line PreferredAZT+3TC+NVP(orEFV)TDF+3TC+LPV/r AlternativeTDF+3TC+NVP(orEFV)AZT+3TC+LPV/r If anemic (Hb<7.5g/L), replace the AZT-containing regimen with TDF If 1st trimester, do not use EFV-containing regimen: Use NVP PMTCT Regimens for pregnant women eligible for ART Baby receives daily NVP for 6 weeks after birth (breastfeeding or replacement feeding)

64 Infant Age NVP Daily Dose (10mg/ml formulation) Birth to 6 weeks Birth weight 2.0 to 2.5 kg 1ml once daily Birth weight>2.5 kg 1.5ml once daily Dosing schedule for infant NVP prophylaxis in Revised WHO PPTCT Guidelines

65 HIV TB Cross Referrals

66 Anti Retroviral Treatment

67 Goals of ART 1.Clinical goal To prolong life & improve quality of life 2.Virological goal Greatest possible reduction in viral load for as long as possible to halt disease progression and to prevent or delay resistance 3.Immunological goal Immune reconstitution - CD4 within normal range

68 Eradication of HIV? Not yet… And …. …in spite of plasma RNA below detection, there is evidence of genetic evolution in reservoirs.

69 WHEN TO START? - Initiation of ART in Adults and Adolescents National Guideline Revised National Guideline (April 2009) WHO Clinical Staging CD4 (cells/ I and IITreat if CD4 Count < 350 III Treat irrespective of CD4 Count IV

70 National ART regimen First-line ART: First-line ART is the initial regimen prescribed for an ART naïve patient when the patient fulfils national clinical and laboratory criteria to start ART. (Current NACO treatment guidelines for first-line ART recommends two classes of drugs for initial treatment ie 2 NRTI + 1 NNRTI.) Zidovudine / Lamivudine / Nevirapine Or Stavudine / Lamivudine / Nevirapine ( Efavirenz in place of Nevarapine if coinfected with TB or side effects with NVP, Tenofovir for special situations only)

71 Initiating ART: Patient Education It is not curative, but prolongs life Treatment is lifelong, expensive High level of adherence is critical (>95%) Short and long term adverse events Drug interactions Safer sex still essential Do not share drugs with friends, family members Start ART when patient is ready

72 Cumulative Outcome of PLHAs on ART, India



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