1. THE 6 TH NATIONAL SCIENTIFIC CONFERENCE ON HIV/AIDS Interventions to prevent mother to child HIV transmission in HIV exposed infants who receiving PCR test at 29 provinces, 2010- 2013 Cao Thi Thanh Thuy, MD, PhD Clinton Health Access Initiative, Vietnam

2. The 6 th National Scientific Conference on HIV/AIDS Outline 1.Background 2.Objectives 3.Methods 4.Results & Discussions 5.Conclusions 6.Recommendations

3. The 6 th National Scientific Conference on HIV/AIDS Background PMTCT and HIV infection in children in the world and Vietnam Around 90% of HIV infected children are from mother to child transmission. As of March 2015 1 : –73% (68- 79%) of pregnant women living with HIV had access to antiretroviral medicines to prevent transmission of HIV to their babies in 2014 –Worldwide, new HIV infections among children have declined by 58% in 2014 (220 000 cases) since 2000 (520 000 cases) As of July 2014: in Vietnam, 5.779 children living with HIV 2 1.UNAIDS.2014 Global statistics. 2015. 2. MOH. VAAC report. 2014

4. The 6 th National Scientific Conference on HIV/AIDS Background HIV testing among pregnant women and ARV access for PMTCT among pregnant women living with HIV: Low increasing Estimated rate of HIV transmission from mother to child is 12.5% in 2014 VAAC report. 2015 % of HIV-positive pregnant women who receive ARV for PMTCT % of pregnant women who receive HIV test and know their result

5. The 6 th National Scientific Conference on HIV/AIDS Continue ART during labor and ARV prophylaxis for baby after delivery Background PMTCT interventions create high difference on HIV situation in children ART during breastfeeding and ART is continued for life HIV testing for pregnant women and ART during pregnancy HIV testing for pregnant women and ART during pregnancy Limited national assessment on PMTCT in Vietnam

6. The 6 th National Scientific Conference on HIV/AIDS Objectives Evaluate the situation and result of prevention of HIV transmission from mother with HIV infection to their children (PMTCT) and some barriers related to PMTCT interventions in 29 provinces, 2010- 2012

7. The 6 th National Scientific Conference on HIV/AIDS Methods The study was conducted from January 2010 to December 2012. Study subjects: Quantitative component : Medical records, PMTCT cards and logbooks of HIV exposed- infants (HEIs) that were provided with PCR tests from 1/ 2010 – 12/ 2012 at HIV C&T sites in Vietnam Qualitative component Participants were: Provincial HIV/AIDS Centre (PAC) leaders, healthcare workers (HCWs) from Outpatient Clinics (OPCs) and obstetric facilities, caregivers, 28 in-depth interviews and 06 focus group discussions at 13 provinces.

8. The 6 th National Scientific Conference on HIV/AIDS Methods ( cont. ) Study design: The study used mixed methods. Both quantitative data and qualitative data were collected. The sample size was calculated: Estimated number of HEIs needed for recruitment : 3602. A total of 3,665 medical records of HEIs were enrolled in this study. 29 provinces in total selected in this study, including 25 randomly selected provinces from 50 provinces where implemented EID and 4 purposive selected provinces/cities.

9. The 6 th National Scientific Conference on HIV/AIDS Methods ( cont. ) −Data collection was collected by using a designed forms. −Data were analyzed with SPSS 16.0 −Qualitative data was analyzed by topics by NVIVO 8.0. We will analyze answers of important questions regarding HIV status, PMTCT implementation − This research received approval from the IRB Committee in the Hanoi Public Health School.

10. The 6 th National Scientific Conference on HIV/AIDS Result and discussion

11. The 6 th National Scientific Conference on HIV/AIDS Information related ANC care and nutrition for newborn (n=3665) CharacteristicsFrequencyPercentage (%) Gender Male188451.4 Female178148.6 Place of birth General Hospital67918.5 Provincial/City Hospital216959.2 District Hospital49914.6 Commune Health Center681.9 Place transfer in Obstetric/PMTCT site 342683.9 Self referral 316.2 Other department 2236.1 No information 1393.8 Methods of delivery Vaginal Delivery167545.7 C-section98826.9 No information100227.4 Nutrition until PCR testing Replacement Formula297181.1 Breastfeeding330.9 Mixed 481.3 No information 38219.6

12. The 6 th National Scientific Conference on HIV/AIDS Detection of mothers’ HIV status (n= 3665)

13. The 6 th National Scientific Conference on HIV/AIDS ARV access for PMTCT among pregnant women living with HIV and their babies 15.2 % of mother did not receice any ARV medication 9.5% infants did not receive ARV prophylaxis ARV prophylaxis No ARV prophylaxis No information

14. The 6 th National Scientific Conference on HIV/AIDS Result of prevention of HIV transmission from mother with HIV infection to their children (n=3665) PMTCT interventionsPCR + n (%) PCR (-) n (%) Tổng ART for mother + ARV prophylaxis for infants + Replacement Formula 5 (0.7)681 (99.3)686 ARV prophylaxis for mother during pregnancy+ ARV prophylaxis for infants+ replacement formula 25 (2.4)1003 (97.6)1028 ARV prophylaxis for mother during labor+ ARV prophylaxis for infants+ replacement formula 30 (5.5)520 (94.5)550 No information of ARV for mother and nutrition + ARV prophylaxis for infants 56 (6.5)808 (93,5)864 ARV prophylaxis for mother + No ARV prophylaxis for infants 4 (6.6)57 (93.4)61 No ARV for PMTCT (mother and their babies)120 (45.1)146 (54.9)266 No information on ARV using72 (34.3)138 (65.7)210 PMTCT assessment in Malawi 2013: PCR rate in HEIs was 4.1%, in group that mothers and their babies received ARV prophylaxis was 10.3%, in other group that mothers received ART was 1.4%. 90% mother with HIV infection were breastfeeding mothers. Kim M. H.et al. PLoS One, 2013 PMTCT assessment in Malawi 2013: PCR rate in HEIs was 4.1%, in group that mothers and their babies received ARV prophylaxis was 10.3%, in other group that mothers received ART was 1.4%. 90% mother with HIV infection were breastfeeding mothers. Kim M. H.et al. PLoS One, 2013

15. The 6 th National Scientific Conference on HIV/AIDS PCR test result among HEIs who receiving PCR testing (n=3665) Rate of the PCR positive cases among HEIs who had PCR testing was 8.5%. Estimated rate of HIV transmission from mother to child is 12.5% in 2014 Rate of the PCR positive cases among HEIs who had PCR testing was 8.5%. Estimated rate of HIV transmission from mother to child is 12.5% in 2014 VAAC report. 2015

16. The 6 th National Scientific Conference on HIV/AIDS Some barriers related to PMTCT interventions Mothers have not receive HIV testing and late diagnosis with HIV, Mothers with HIV infection/ babies were not or late to access ARV for PMTCT Mothers have not receive HIV testing and late diagnosis with HIV, Mothers with HIV infection/ babies were not or late to access ARV for PMTCT Children living with HIV 1. B arriers related to mothers ; 2. B arriers related to services, health care workers; 3. Barriers related to social, economic status 1. B arriers related to mothers ; 2. B arriers related to services, health care workers; 3. Barriers related to social, economic status

17. The 6 th National Scientific Conference on HIV/AIDS Some barriers related to PMTCT interventions Barriers related to mother: they did not want to HIV testing or late diagnosis with HIV: Lack of awareness of mothers on importance of PMTCT, self payment,... Pregnant women think that PNMT they have no disease, no risk to get HIV infection so they did not agree to HIV test. All pregnant women receive counseling, but some people refused to HIV test due to self- payment and without cover by health insurance HCW in OBGYN, 45 years oldHCW in OBGYN, 43 years old

18. The 6 th National Scientific Conference on HIV/AIDS Some barriers related to PMTCT interventions (cont.) My baby was 10 months old when I found myself infected with HIV, transmitted from my passed-away husband. Barriers related to PMTCT services: Limited coverage on PMTCT services, available at high prevalence area, project, at high level.. Health insurance has not covered HIV test fee for pregnant women,… Mother of child who was 13 months, In rural and distant areas, pregnant women delivering children at home, health commune stations or even district healthcare centers are not tested for HIV before childbirth. HCWs, PAC, 38 years old HCWs in OPC, 51 years old Mother đii not know HIV status so did not bring children until chidren get sick. This group has a very high rate of HIV infection. Our hospital is implementing counselling and HIV testing for children suspected with HIV infection

19. The 6 th National Scientific Conference on HIV/AIDS Some barriers related to PMTCT interventions (cont.) Barriers related to PMTCT services: –Limited human resource, limited counseling, practice for infected mothers at obstetric care facilities. We could not do anything for pregnant women at labor because there were not enough equipment and It was not easy to confirm HIV status, so ARV prophylaxis did not provide for pregnant women during labor. We only wish that our staff at the obstetric department can have more trainings on HIV knowledge and PMTCT. We need more awareness on this issue to provide better counselling. HCW in OBGYN, 38 years old HCW in OBGYN, 41 years old

20. The 6 th National Scientific Conference on HIV/AIDS Some barriers related to PMTCT interventions (cont.) Stigma and discrimination in family and community are still key barriers to mothers to access PMTCT and HIV status disclose More mothers get HIV infection before get ting married. Mother might be worried about family breakdown after husband knowing the mother and maybe the child have HIV, so women had to go to other provinces where HIV test will not be performed. We provided counseling on ARV during pregnancy but she did not agree because she think that if her husband is tested negative, he will kick us out of house. HCW in PAC 45 years old HCW in OBGYN, 45 years old

21. The 6 th National Scientific Conference on HIV/AIDS Conclusion The rate of pregnant women who were detected HIV infection status during labor and after delivery was high. It were limited to receive ARV for PMTCT The PCR positive rate among HEIs who born to a mother who received ART during pregnancy was very low Lack of awareness among HCWs on PMTCT, unavailability of services, and stigma and discrimination are still the key barriers of mothers accessing PMTCT

22. The 6 th National Scientific Conference on HIV/AIDS Recomendation Provide early HIV test for pregnant women and ART for pregnant women with HIV infection for effective PMTCT program. Implement effectively new guidance related to PMTCT to increasing the accessibility HIV testing and ART for pregnant women and bread feeding mother with HIV infection

23. The 6 th National Scientific Conference on HIV/AIDS Study Team : Do Thi Nhan, Duong Hoai Minh, Nguyen Thi Minh Thu, Le Thi Huong, Pham Van Anh, Bui Duc Duong Supports from patients, care givers, HCWs in OBGYN, C&T sites Provincial HIV/AIDS Centres Vietnam Authority on HIV/AIDS Control Clinton Health Access Initiative, Vietnam Acknowledgment

24. The 6 th National Scientific Conference on HIV/AIDS Thank you for attention! Forward…. Nacer sin VIH-... Cuba received formal validation from PAHO/WHO that it has eliminated mother-to-child transmission of HIV.