Integration of Reproductive Health into VCT Centers: A Strategic Intervention for HIV Prevention A Multicultural Caribbean United Against HIV/AIDS Dominican Republic 5 – 7 March 2004 Marie Marcelle Deschamps, MD

Background Haiti is the most affected country by HIV after those in Sub-Saharan Africa. Heterosexual contact is the major mode of transmission with a male to female ratio of 1:1. It is estimated that there are up to 235,000 adults between the ages of and as many as 11,800 children are living with HIV/AIDS. Approximately 3% of the women visiting prenatal clinics are HIV (+) and as much as 6% are HIV (+) in the northern region of the country.

Background ( continue ) Maternal mortality rate: 457/100,000 Infant mortality rate: 74/1,000 20% infant mortality caused by AIDS Majority (80%) of women deliver outside a health care setting HIV vertical transmission rate estimate at 30% in Haiti

GHESKIO Centers have developed a comprehensive model of integrated care for VCT and services (HIV/STI/TB/RH). Before 1996 Counseling unit HIV unit STD unit TB unit Pediatric unit Laboratory Data Management After 1996 IEC FP methods Prenatal care/Rapid testing Womens clinic (HIV+ mother/rape victims)

Integration of Reproductive Health at GHESKIO Centers Characteristics New individuals20,000/year Female65% Age (Average)30 years No Income70% HIV (+)20% RPR (+)8% Low contraceptive prevalence rate at enrolment 4%

Objectives: 1. To integrate RH services and family planning methods (FP) into the existing health facilities (STI/HIV/TB clinic). 2. To reinforce knowledge and encourage behavior change among HIV/STI infected individuals and those at risk. 3. To provide adequate VCT services to individuals of reproductive age, using rapid testing for pregnant women. 4. To offer care and anti-retroviral therapy to HIV/STI infected pregnant women.

Strategy Information/Education/Communication (IEC) and Counseling Waiting room using educational and audio visual materials Information sessions and discussions with social workers on HIV/AIDS/TB/STI/FP adressed to all patients Group counseling targeting HIV(+) individuals Focus group targeting HIV(+) pregnant women Face to face counseling with HIV (+) and partners Focus group targeting HIV(+) mother/parents

Strategy (continued) Family Planning Program addressing HIV infected individuals and partners – Information on vertical transmission – Information on FP methods – Condom distribution – Availability of FP methods

HIV status of family planning users at GHESKIO

FP Methods Available at GHESKIO Condom Depo-provera Eugynon Lo-femenal Noristerat Ovrette Vaginal Tab

Results FP Methods Available at GHESKIO Most commonly used methods Condom:70% Depo Provera (injection) :23% Other: 7% Dual protection is recommended to all HIV infected individuals or HIV (-) individuals at risk or discordant couples

Contraceptive prevalence January 1996 – December 2003 Number of users

New individuals of childbearing age (15 – 50 years old) referred to GHESKIO for VCT

Results Population referred for HIV testing March 1999 – December 2003 Population tested for HIV: (70%) Female / Male HIV(+) women identified6458 (18%) RPR(+) women identified2658 (8%) Pregnant women HIV(+) identified460 FP among women after delivery270/430 (64%)

New pregnant women tested at GHESKIO for HIV

Characteristics of Pregnant Women Referred for VCT CharacteristicsHIV(+) pregnant women N= 314 HIV(-) pregnant women N=1475 Age (yrs) Range27 (15 – 49)25 ( ) Weight (Kg) Range53 (36 – 85) 55 (27 – 87) Gravida (0 - 8) (0 – 8) Parity (0 - 8) (0 – 8) Income, annual < 1,000US 80%79% Education < 7 th. grade 77%78% RPR positivity 15%7%p<0.05 Hemoglobin gm/dl ( ) (5-14) Lymphocytes count/ml (1.104 – 8,736) ( ) Number who adopted a FP after MTCT 195/314 (62%)_____

Antenatal Clinic at GHESKIO Enroll HIV (+) pregnant women in the MTCT prevention program after post-test counseling Use standardized protocol with a specific team approach (psycholoigist, physician, social worker, nurse) Provide routine check-ups for prenatal care every month including immunization, iron and vitamins Prevent and treat specific HIV-related infections Provide routine laboratory testing AZT or Nevirapine for women with CD4 cell count >200 HAART to women with CD4 cell count <200

Psychosocial care objective Same day pre and post test counseling Offer emotional support to the HIV (+) women Maintain adherence to AZT/ARV Offer the choice for infant feeding (breast vs artificial milk) Encourage special precautions regarding preparation of milk Propose Family Planning methods to the mothers Face to face counseling and support group meeting Consent form

Protocol Mother Prenatal follow-up AZT: 300 mg bid at 8 th month (36 th week) AZT: 300 mg every 3 hrs during labor Infant AZT: 2 mg/kg q 6 hrs during 1 week Mixed diet not advisable* PCIME** during the 24 months of follow-up *The mother may breastfeed or give artificial milk, a mixed diet is not advised. Early warning (at least 6 months after birth) is recommended ** Prise en charge intégrée des maladies de lenfant

Regimen Protocol Prevention of HIV Transmission from Mother to Infant with Nevirapine Monotherapy MotherInfant PeriodDosage (Pill) p.osDosage (Syrup) p. os During work Ouganda200 mg stat2 mg/kg in the hours of life South Africa200 mg stat and 200 mg in the 48 hours after birth 6 mg in the 48 hours of life N.B: The mother may choose between breastfeeding or artificial milk, a mixed diet is not advised

Women with 2 nd Episode of Pregnancy N= 23 Number (%) 4 (17) : New partner 10 (43): Not on Family Planning 2 (9) : Was using Family Planning irregularly 7 (30): Child died

Rate of Mother to Child Transmission March 1999 – December 2002 There were 190 children born in the program Confirmed rate by NASBA 10/132 children with results: 7.5% Assumed rate and clinical signs 28/190 (14.7%) Estimated range of vertical transmission 7.5% %

Summary Increase in the contraceptive prevalence rate at GHESKIO from 4% to 21% Increase number of pregnant women using VCT services, from 51 (1999) to 1,800 (2003) Reduction of the (MTCT) rate from 30% to 10% Majority (64%) of HIV(+) mothers from MTCT program adopted a FP method to prevent subsequent unwanted pregnancies This model of integration (VCT/MTCT) is being replicated nationwide involving public and private sectors

Conclusion Reproductive health service is critical entry point for HIV prevention and diagnosis and treatment of HIV-infected individuals Family planning methods are essential components of services at VCT as individuals who receive information, counseling and treatment are more likely to avoid unwanted pregnancies, and HIV transmission. Dual FP method is strongly recommended as it can reduce heterosexual transmission and MTCT. VCT/MTCT integration has resulted in a dramatic increase in the number of self-referred pregnant women coming for services.

Integrating Womens Health with Scale- up of AIDS Prevention and Care: Five Lessons from Rural Haiti Dr. Maxi Raymonville Director, Proje Sante Fanm, Zanmi Lasante, Cange, Haiti A Multicultural Caribbean United Against HIV/AIDS Dominican Republic March 5-7, 2004

HIV/AIDS in Haiti ,000 living with HIV/AIDS, end of 2002 Highest prevalence in the Western Hemisphere 30,000 new cases annually Accounts for 50 % of hospital bed occupancies Leading cause of death:30,000 HIV/AIDS deaths in ,000 AIDS orphans by end of 2001 Source: UNAIDS 2002

Prevalence of HIV Infection Among Pregnant Women in Haiti Haitis HIV epidemic is now generalized: Sex ratio is 1:1, male to female In 2000 over 11,000 pregnant women were HIV positive. –5% among asymptomatic women attending rural antenatal clinics >10% in asymptomatic women attending antenatal clinics in urban slums

Introduction of HIV Prevention and Care, Central Haiti 1986: First case of HIV in Central Plateau 1988: Free serologic testing to diagnose HIV 1990: Intensified prevention efforts –hampered by political violence and resulting migration –hampered by gender inequality and deep poverty 1995: AZT to pregnant women in order to block mother-to-child transmission –Transmission reduced from 30% to 8% with AZT and breast milk substitution

Proje Sante Fanm Free standing womens health clinic Founded in 1998 based on needs recovered by Groupe détude du SIDA dans la Classe Paysanne (GESCAP) research project on HIV vulnerability among women Proje Sante Fanm provides family planning, prenatal care, and treatment for symptomatic STIs 2 OB/GYN specialists, 5 Nurse midwives

Picture of Proje Sante Fanm

HIV Testing and Treatment Algorithms

Interventions to prevent HIV transmission from mother to child A pregnant woman seen at Clinique Bon Sauveur or public health clinics in the central plateau. VCT is offered by midwife nurse –Lab examinations routine for prenatal care –HIV test Pregnant women with HIV positive is referred to the ID clinic

Positive Negative Refer to HIV clinic Confirmatory test: Capillus Positive Negative Discordant results: Western Blot Positive Negative Routine prenatal care, HIV prevention HIV Testing Algorithm: ( Abbott Determine rapid test)

What did MTCT teach us about prevention and care of HIV? Access to medications increases the uptake of VCT: –prior to offering AZT about 40% of women refused HIV testing, once AZT was made available (1995), >90% of women accept testing. Comprehensive approach is required –Because the benefit of AZT lost if infants are breast fed intervention requires access to breast milk substitution –water projects

Global Fund to Fight AIDS, TB and Malaria In 2003, Zanmi Lasante received part of the Haiti grant for the expansion of AIDS prevention and care in the central plateau Expansion based on a comprehensive HIV program integrated into the provision of primary health care in the public sector –4 public health clinics in 2003, 2 additional in 2004 and 3 more clinics by –Program based on the Four pillars. Programs that link prevention, testing and care.

Use of CD4 Monitoring and HAART

Further Reducing MTCT Combination antiretroviral therapy has led to perinatal transmission rates of less than 2% in developed countries ZL has implemented measures to further reduce transmission. –Women in all expansion sites have access to OB/GYN care

Maternal Factors Associated with HIV Transmission Presence of sexually transmitted diseases: addressed in the ZL program Anemia: addressed in the ZL program Increased viral load Low CD4 counts: addressed in the ZL program multiple sexual partners: addressed in the ZL program

HIV positive women are treated based on CD4 and symptoms >350 and asymptomatic <350 or clinical symptoms Mother: AZT/3TC/NVP at 28 weeks until birth. Infant: 1 dose of NVP at birth and AZT/3TC for 1 week. Mother: AZT at 36 wks until labor. During labor administer 300mg po Q 3 hours. Infant: AZT 2mg/kg/day Q 6hrs for1 wk

Picture of FACS machine/Tanya

CD4 >350 Number of women 65/125 CD4 count relying on a FACTS COUNT machine If CD4 >350 protocol regimen by the MOH, AZT monotherapy at the 36 th week of pregnancy: 300mg (BID/day) until delivery During delivery 300mg every 3 hours Infant:2mg/kg every 6 hours during 7 days Breast milk substitution Nevirapine is given when the pregnant woman is new to the clinic

CD4 count <350 Number of women 23/125 CD4<350: three-drug regimens are applied: AZT, 3TC, NVP Treatment will continue post partum If pregnant woman with symptoms treatment will be provided for infection opportunistic Three-drug regimens are more effective than both AZT and NVP monotherapy in preventing mother-to child transmission and in improving maternal survival

Four Pillars of HIV Prevention and Care Access to Voluntary Counseling Screening and treatment for TB Screening and treatment for all STIs Prenatal care and womens health

Detection and Treatment of TB Voluntary Counseling and Testing Maternal Child Health & MTCT Detection and Treatment of STI HIV prevention, case detection, care, ARV treatment Public Health Clinic Implementing an HIV Program in the Public Sector

Expansion sites

MTCT in the Expansion Project 6,306 pregnant women tested for HIV from December 02 to December % acceptance of VCT 125 pregnant women newly diagnosed as HIV positive (2% sero-prevalence) –transmission rate cannot be determined until 18 months from start of program –70% of HIV positive pregnant women on ARV: HAART 23, AZT 44

Expansion Sites and Integration of Traditional Birth Attendants 160 pregnant women referred by TBAs 303 TBAs trained in MOH corriculum Monitoring number of pregnant women referred by TBAs as the TBA training is still in process in some sites Pregnant women were referred to the public health clinics in the expansion sites or Clinique Bon Sauveur where PMTCT services are integrated with prenatal care.

Use of Community Health Workers Medications are delivered by accompagnateur (village health worker) or traditional birth attendants Health workers can observe for complications of pregnancy and of treatment Adherence issue will be addressed

Breast milk substitution Our program relies on breast milk substitution as well antiretrovirals Kitchen utensils are offered as well as education about clean water Efforts to improve quality water and water quantity –Zanmi Lasante has engaged a full time sanitary engineer as part of this effort

Conclusions: Integration of Womens Health Services in Public Health Sector Access to obstetrical care Prenatal care including nutrition, vaccinations for tetanus Family planning, condoms Post partum care Ongoing primary and secondary prevention in the context of enhanced HIV care and improve clinical outcomes

January 2004 Contrasida // Consperanza HIV/STI PREVENTION, CARE FOR PREGNANT WOMEN AND CONTRACEPTIVE CARE FOR MIGRANT WOMEN WHO RESIDE ILLEGALLY ON CURAÇAO AND/OR HAVE NO HEALTHCARE INSURANCE Researchers Contrasida/Consperanza Marion Schroen M.Sc.-Midwife Alberto Dambruck MD Lily D. Faas M.Sc. - RN

January 2004 Contrasida // Consperanza Netherlands Antilles Population Netherlands Antilles: 175,653 Population Curaçao: 130,627

January 2004 Contrasida // Consperanza Population Characteristics Curaçao The population on Curaçao is changing in favor of migrants, while there is an out-migration of Antilleans mainly to Holland which intensifies the immigration effect

January 2004 Contrasida // Consperanza Netherlands Antilles & HIV: Facts and figures Ministry of Health: Number of HIV infections registered until year 2002: 1332 Sub- registration suspected: real number of HIV infections possibly around = %

January 2004 Contrasida // Consperanza Project Consperanza: Obstetric care for migrant women Objectives: Ensure Safe Motherhood Prevent MTCT of HIV and STIs Offer male + female condoms and contraceptives Provide information on HIV/STIs Lower STI in pregnant women using the Syndromic Management Model (SMM)

January 2004 Contrasida // Consperanza Consperanza: A project of Fundashon Contrasida Caribbean The aim of Contrasida is: To protect the health of FCSWs To prevent and manage HIV / STIs To prevent unwanted pregnancies and To offer legal assistance in case of abuse

January 2004 Contrasida // Consperanza ContraSida: Regional participation in PSI-A

January 2004 Contrasida // Consperanza Contrasidas project Consperanza: obstetric care for migrant women Consperanza Client group Colombia (31%) Dominican Republic (26%) Haiti (18%) Jamaica (10%) All without healthcare insurance

January 2004 Contrasida // Consperanza SYNDROMIC MANAGEMENT MODEL (SMM) STIs What is SMM? Diagnosis and treatment of selected STIs based on the identification of a syndrome through a clinical flowchart (= algorithm, decision tree) Without the use of sophisticated laboratory tests and/ or facilities Can be practiced either with or without use of speculum

January 2004 Contrasida // Consperanza Nevirapine protocol as part of the Curaçao SMM to prevent MTCT Woman in labor and HIV status (un)known HIV rapid test (Abbott) If positive: 1 tbl. Nevirapine 200 mg during delivery 1 tbl. Post Partum Take blood sample for HIV confirmation test Abstain from breastfeeding (sponsoring artificial milk for 6 months) Newborn within 48 hours Nevirapine syrup 2 mg/kg at the office of the Pediatrician Protocol has been introduced among all midwives and gynecologists on Curaçao

January 2004 Contrasida // Consperanza Problems Often at first the pregnancy is not desired (50%) Abuse Cytotec (15%) STIs. No money for care: pre-natal care laboratory Ultrasound Legal problems First presentation when in labor (5%) 80 deliveries per year HIV

January 2004 Contrasida // Consperanza Consperanza Why we have to pay extra attention to adequate HIV/STI prevention and care directed at pregnant migrant Women?

January 2004 Contrasida // Consperanza Higher prevalence of HIV among migrant pregnant women : total number of HIV cases for Curaçao in children younger than 1 year is 46 Since 1996 four new cases added However… Consperanza encountered six new cases of HIV among pregnant migrant women in 18 months ( ) In 2002 Consperanza encountered: 3 HIV-positive women, of which 2 left Curacao before delivery In 2003 Consperanza encountered: 3 HIV seropositive pregnant women

January 2004 Contrasida // Consperanza Actions Consperanza Development of treatment protocols Team of well trained volunteers Fully equipped consulting room and delivery room Sufficient # prenatal visits (PAHO) Low cost screening and ultrasound Postnatal care at home Results in ……..

January 2004 Contrasida // Consperanza Results 2003 (1) Reducing STI: SMM Treatment for …. Candidiasis: 27% Bacterial Vaginosis: 7% Cervicitis: 1% Estimated prevalence STI on Curaçao (1998): 8.6 per 1000 inhabitants. Prevalence STI in Consperanza 10 times higher! Stunning observation… Since the introduction of the SMM STIs for pregnant women, new- borns of the Consperanza project have remained free of oral candidiasis (sprew)

January 2004 Contrasida // Consperanza Results 2003 (2) Prevention MTCT of HIV: SMM Three HIV-positive migrant women in 2003 received the Nevirapine protocol Two of which underwent a caesarian

January 2004 Contrasida // Consperanza Results 2003 (3) Prevention MTCT of HIV: SMM Thanks to the Nevirapine® protocol : Three newborns Free of HIV infection Confirmed by PCR (NASBA) testing! Worries of the mothers…….

January 2004 Contrasida // Consperanza Results 2003 (4) Worries HIV-positive mothers: Going home is no option! Will her partner stay with her? All partners were HIV negative

January 2004 Contrasida // Consperanza Results 2003 (5) Worries HIV-positive mothers: Living with HIV-disease without healthcare insurance No further care No laboratorial analysis No access to ARVs because of high costs ($3000 on a monthly basis) Fear of dying and leaving behind her children un provided for

January 2004 Contrasida // Consperanza Results 2003 (6) Care for HIV-positive uninsured mothers The HIV specialists and gynecologists cooperate with Contra sida / Consperanza by monitoring these patients and by preventing opportunistic infections BUT…

January 2004 Contrasida // Consperanza Results 2003 (7) Care for uninsured HIV-positive mothers Since the State has to carry the costs of hospital care, these patients are not wanted and will only be admitted WHEN DEATH IS NEAR

January 2004 Contrasida // Consperanza Consperanza OTHER RESULTS…..

January 2004 Contrasida // Consperanza Reducing serious consequences of Syphilis and Hepatitis B 2 women were treated for Syphilis 1 woman was Hepatitis B positive Consperanza took care of necessary laboratory tests, Immunoglobulin, Vaccines and treatment ($500) Not only reducing healthcare problems but also $10, in hospital costs

January 2004 Contrasida // Consperanza Contraception

January 2004 Contrasida // Consperanza Conclusions Commitment of the government of Curaçao in fighting HIV / STIs among migrant women regardless of their health insurance status is warranted The Curaçao SMM for HIV/ STI control among pregnant migrant women is effective The promotion of contraception as an effective tool to diminish MTCT of HIV deserves more attention

January 2004 Contrasida // Consperanza Thank you for your attention!

Por favor deje su auricular en su silla. Veuillez laisser le casque d'écoute sur votre chaise. Laat uw koptelefoons s.v.p. in uw stoel liggen. Please leave your headphones on your chair. Por favor deje su auricular en su silla. Veuillez laisser le casque d'écoute sur votre chaise. Laat uw koptelefoons s.v.p. in uw stoel liggen. Please leave your headphones on your chair.