1. PMTCT - The Platform for integrating HIV/AIDS Services in the MCH Clinic. Bola Oyeledun, MD, MPH Track 1.0 Partners Meeting Washington DC. August 2008

2. Limitations of current PMTCT approach Limited efficacy of single drug regimen for PMTCT – Imperative to move beyond concept of sd-NVP for PMTCT Does not address health needs of the woman Based on “single-visit” model… inconsistent with chronic disease Need to move rapidly to MTCT-Plus Model

3. Linkage of MCH & ART Programs Ineffective High loss to follow-up when women are referred Long waiting time in ART clinics – Pregnant women not prioritized – Missed opportunity to provide effective pMTCT Missed opportunity to address health need of HIV+ woman within her medical home (MCH)

4. Follow-up of HIV-Exposed Infants Ineffective Women who missed pMTCT during pregnancy are likely to visit clinics with their infants HIV exposed infants NOT routinely followed HIV-exposed infants lost to follow-up are generally receiving immunizations and routine care in MCH clinics

5. Opportunities in Maternal and Child Health (MCH) Platform Maternal Child Health (MCH) Programs are: Part of the health system attending to the needs of women and young children (comprehensive, integrated and continuous care approach) PMTCT traditionally provided within ANC/MCH Post-partum women and their infants are usually seen in these programs (well baby, immunization clinics etc). HIV resources can enhance MCH services Integration of MTCT-Plus Components in MCH Programs

6. MCH Spectrum Identification of HIV status: testing & counseling across all MCH services Assessing maternal health status and ART eligibility within MCH services  Clinical staging & evaluation  CD4+ cell count Providing multi-drug ART regimens within MCH  Short course (AZT+ sd-NVP)  HAART for women with advanced disease Providing effective follow-up of HIV-exposed infants  Cotrimoxazole  Growth monitoring  Monitoring for evidence of HIV disease  Early infant diagnosis of HIV Enhanced postnatal follow-up of mother and infant  Ongoing Infant feeding counseling and support  Universal access to family planning services  Evaluation of maternal health status during period of lactation Promoting community based capacity to support identification and follow-up of mothers and infants at risk for disease progression

7. ANC Labor & Delivery Vaccination or Well- baby Clinics Post- Partum Follow-up of Women HIV testing of women CD4 test and clinical staging of women & treatment for women with advanced HIV More efficacious regimens for PMTCT Engaging and testing of partners Complete package of interventions HIV testing of women Engaging women with HIV in HIV care services Engaging partners HIV testing of women and linkage to HIV care services Follow-up of exposed infants  Cotrimoxazole  Growth monitoring & monitoring for evidence of HIV disease  Early diagnosis of HIV, linkage to Peds services and early initiation of ART HIV testing of women with unknown status Follow-up of women with HIV: counseling on infant feeding CD4 test and clinical staging of women ART for women with advanced HIV Complete package of interventions Engaging & testing (partners, other children)

8. NIGERIA: PMTCT UPTAKE AT ICAP SUPPORTED SITES Pre-intervention: February 06 – March 07 Post -intervention: April 07- March 08

9. RWANDA: Shift from sd-NVP to multidrug ARV regimens among HIV+ pregnant women in ANC, July 06 –Dec 07 # sites n1=5n2=5 n3=14n4=18n5=18 Total ARV regimens T1=71 T2=136T3=144T4=200T5=163T6=139 n6=19

10. Summary-1 Approaches may differ based on setting and sero- prevalence but MCH platform can be effectively used to enhance PMTCT efforts ART pre-screening services at MCH are a key component in getting pregnant women to initiate HAART early MCH referral to ART clinic achievable with excellent results when ART clinic available on-site

11. Summary-2 In countries where ANC attendance and health facility delivery rates are low, HIV testing and counseling in EPI clinics can identify HIV+ women and facilitate enrollment of mother-infant pairs in care and treatment HIV exposed infants can receive appropriate interventions through focus on integrating their care into MCH platform MCH Platform can catalyze a transformation of services for pregnant women and their children

12. THANK YOU THANK YOU!