1. Successful Scaling Up of Prevention of Parent-to-Child Transmission of HIV Program in India

2. Successful Scaling Up Approaches to PMTCT : India Country Experience
Dr. Bir Singh, MD
Professor of Community Medicine
All India Institute of Medical Sciences (AIIMS)
New Delhi , India
Formerly: Project Officer, PPTCT
UNICEF India

3. Greetings from
AIIMS, New Delhi
INDIA

6. Prevention of Parent- to- Child Transmission (“PPTCT”)
( generally known as “ PMTCT”)

10. 26 January, 1950 : Became a Republic
15 August, 1947 : Re-gained Independence
26 January, 1950 : Became a Republic

11. 28 States 7 UTs A & N Islands ( India) Lakshadweep Islands ( India)
Pondicherry

12. Multi- Cultural ,
Multi-linguistic Democracy with wide
Socio-economic differences
Population below poverty line: 25%
Rural : Urban :: 70 :30

13. India : An MCH Profile… Total Population 1027 m
Crude Birth Rate /1000
Sex Ratio (F:M) /1000
Annual Pregnancies 27 m
ANC Coverage %
Institutional Deliveries : %
Deliveries attended by skilled birth attendants: %
India : An MCH Profile…

14. Health Care Delivery in India… Rural Areas: 3 Tier System
Health Facility Inter-linkages Coverage
240 Medical Colleges M
602 District Hospitals 1.6 M
3,000 Community Health Centers M
25,000 Primary Health Centers 30,000
137,000 Sub-Centre 5,000
600,000 Village Level 1,000

15. HIV/AIDS: The Problem…..
It has become the most serious public health problem faced by the country since independence.
Women and girls constitute approx. 39% of total PLWHAs in the country .

17. Expanding Disease Burden
1986 to 2005

18. Epidemic shifting towards YOUNG People.
India’s Epidemic is following “ Type 4” Pattern
Has reached General Population
Rising HIV Prevalence in Pregnant Women
and Children
Epidemic shifting towards YOUNG People.

19. National AIDS Control Organization ( NACO)
Under
Ministry of Health and Family Welfare
Govt. of India
National AIDS Control Organization ( NACO)
National AIDS Control Programme Phase - I ( )
National AIDS Control Programme Phase - II ( )
National AIDS Control Programme Phase – III ( )
State AIDS Control Societies ( SACS) : 38

20. Rationale for PPTCT in India
27 million pregnancies per year
1,89,000 infected pregnancies per year
Cohort of 56,700-60,000 infected newborns per year
0.7% prevalence
30% transmission

21. UNGASS Goals :
Reduce proportion of infected babies
- by 20 % by 2005
- by 50% by 2010.

22. MTCT was hardly recognized as a problem till 1998
Gradually, the realization dawned about MTCT
UNICEF India and other partners
collaborated with NACO on PMTCT……..

23. PMTCT Feasibility Study I AZT March 2000 - August 2001
in 11 Centers of Excellence in HP States

24. CDC Thai Regimen
AZT was orally administered after 36 weeks of gestation to the woman in the dose of 300 mg twice a day and 300 mg every three hours during delivery.

25. PMTCT Feasibility Study AZT: March 2000 - August 2001
Total new ANC attendance : 192,474
No. of pregnant mothers counseled : 171,471 (89.1%)
No. of pregnant mothers accepted HIV tests : 103,681 (60.5%)
No. of pregnant mothers detected HIV positive : 1, (1.7%)
No. delivered with AZT : (42.1%)
No. of PCR samples at 48 hrs. tested : 427
No. of samples tested (+) positive : 34/ (8.0%)
No. of additional tested (+) at 2 months : 9
(adding a 2% transmission rate)
No. of women who opted for breastfeeding : 22%

26. NVP 200 mg single dose to mother during first stage of labour
PMTCT Feasibility Study II NVP: October June 2002
Modified HIVNET 012
NVP 200 mg single dose to mother during first stage of labour
NVP 2 mg/kg single dose to newborn within 72 hours
During the 2 phases: “informed choice on infant
feeding”

27. Some Lessons Learnt: Reduced transmission of HIV from mother to infant33 8 10 20 30 40 %
No ARV
With ARV
who acquired HIV
Proportion of infants of HIV (+) mothers
Mumbai PPTCT Meet 2005

28. Some Lessons Learnt: Increased knowledge about how to prevent HIV/AIDS
50.3
35.7
85.1
87.8 50
100
Before counselling
After counselling
Proportion of women who know how to avoid:
acquiring HIV/AIDS
transmitting HIV/AIDS to baby
Mumbai PPTCT Meet 2005

29. PPTCT included in National AIDS Control Program - Phase II
Project >>>> Service Component in 2002

30. WHO/UNFPA/UNICEF/UNAIDS

31. Scaling Up Strategy: PPTCT
11 Centers of Excellence
Phase
74 Medical Colleges
High Prevalence States
Phase
Phase
159 District Hospitals/
Maternity Hospitals
High Prevalence States
79 Medical Colleges
Low Prevalence States
Phase
450+ District Hospitals/
Maternity Hospitals
Low Prevalence States
Staff CHC/PHC/SC/ICDS Centers/NGOs/CBOs

32. CE TRAINING PROCESS Teams SACS /NACO UNICEF SACS Request for Training
Funds CE
TRAINING
PROCESS
M &E QA
Teams from
Medical
Colleges
Trained
PPTCT
Centre
at DH & MH
established
Teams from District
& Maternity Hospitals
Trained
Sensitization
PPTCT Center
at M C Established 32

33. Training in PPTCT Medical Colleges “Cascade Effect”
Centres of Excellence ( CEs)
Medical Colleges
District Hospitals & Maternity Homes

34. PPTCT Team Trained for 5 Days Consists of : Obs-Gynaecologist -1
: Pediatrician
: Microbiologist
: Counselor
: Senior Staff Nurse -1
Trained for 5 Days

35. PPTCT Intervention Package
1. Ante-Natal Care
2.Group Education / Pre-Test Counselling
3. HIV Testing : after Informed Consent
4. Post-Test Counselling
5. Institutional Delivery : Safe Birthing Practices
6. Administration of Nevirapine to the woman during labour .

36. PPTCT Intervention Package…
7.Administration to the BABY
of SINGLE DOSE of Suspension
Nevirapine ( 2 mg./ Kg.) within first 72 hours
8. Counselling of mother for Infant Feeding Options
9. Care & Support
10. Follow -up
PPTCT Plus

37. Nevirapine Administration
Mother:
Screened for contraindications
Single Dose Tablet of 200 mg.
during First stage of Labour
Baby:
Single Dose of suspension within first 72 hours
Nevirapine Courtesy : Donation from CIPLA

38. Infant Feeding and HIV: Current recommendations…
Informed Choice
through COUNSELLING

40. Enrollment Procedure Group Education Offered HIV test ANC Post-Test
One-To-One
Post-Test
Counseling
HIV Test
Pre-Test
Counseling
One-To-One
HIV +
HIV -
Primary Prevention
Enrollment:
NVP

44. Status of PPTCT Centres ( As of December 2004)
Trained :
Providing Services :
Total States Covered :

45. UNICEF’s Role in PPTCT in India
Monitoring and Evaluation
Quality assurance of services
Research
Infant
Feeding
Study
design
Counseling
PPTCT
“Plus”
Data
Training
District
Models
Dissemination
of results
Drugs

46. Year 2003
Independent Evaluation of PPTCT Training of PPTCT Teams and the Counselors’ training undertaken with support from UNICEF
Found to be unsatisfactory on most counts

47. PPTCT Training Module Revised
Year 2004
PPTCT Training Module Revised
Revision of Counselors Training Module also
undertaken

48. NACO – UNICEF PPTCT Training Module

49. WHO-CDC Generic PMTCT Training Module
4 Parts:
Trainers’ Manual
Participants’ Manual
Wall Charts
Clinical Pocket Guide

50. Global PPTCT Evaluation Tools Adapted
Year 2005
Global PPTCT Evaluation Tools Adapted
Evaluation of PPTCT Services and Program undertaken in all 06 HP States by NACO and SACS in collaboration with UNICEF, WHO & Other Partners such as IAP, FOGSI, PPNs, NGOs, Civil Society
……Critical Evaluation of Data
……Quality of Services

51. : Pool of HIV infected pregnant women:
Conclusions from India Data
Every year in India:
: Total number of pregnant women : 270,00,000 ( 27m)
: Pool of HIV infected pregnant women:
1,89,000 ( 0.7 % prevalence, NACO-2004)
: Pool of HIV infected babies : 56,700 30% transmission)
Percent of pregnant women availing PPTCT
services ( Counseling onwards…) in all PPTCT centres
in India : 10,66,365 / 270,00,000 = 3.94%
No. of M-B pairs received NVP = 4,451
Percent of HIV infected pregnant women being covered
with NVP : 4,451/ 1,89,000 ( all-India) :2.35 %

52. Reduction in proportion of infected babies on
In this pool of 4,451 HIV infected pregnant women ,
number of infected babies expected to have been covered with NVP
= 1,336
Number of Infected babies being protected : 1,336/2= 668
Reduction in proportion of infected babies on
All-India basis : 668 / 56,700 = 1.17 %

53. INTERPRETATIONS OF 2004 DATA
PPTCT: REALITY CHECK
STATE: ANDHRA PRADESH
DATA
INTERPRETATIONS OF DATA
POPULATION:
82m
Crude Birth Rate
20.6
1. # of pregnant women expected
18,572,00
ANC Sero-prevalence Rate
1.58%
2. # of HIV infected pregnant women expected
29,344
Mother-baby pairs recd. NVP
1936
3. # of HIV infected babies expected
8,803
Institutional Delivery
66%
4. % of all pregnant women accessing PPTCT services
2,01, = 11%
: Public Sector
28%
5. # of HIV infected babies - being covered
being protected
968
: Pvt. Sector
38%
6. Proportion of infected babies reduced
11%
Deliveries at Home
34%
7. Shortfall in UNGASS goal for 2005 9%
TARGET FOR 2005:Target additional MB pairs
Will protect
1600
800 babies
HOW ?

54. STATE: Andhra Pradesh Place Pregnant women being covered %
Infected pregnant women actually being covered out of expected number in this pool
Medical Colleges & District Hospitals
2,01,719
11%
(3187) (60.8%) (100%)
6.6% (11%) of the total pool
Place
Likely No. of pregnant women %
Likely No. of HIV infected pregnant women
Likely No. of HIV infected babies
Other public sector facilities
3,18,297
17%
5030
1,508
Private sector
7,05,736
38%
11,151
3,345
Home
6,31,448
34%
9,977
2,994
Sub Total
16,55,481
89.0%
26,158
7,847
TOTAL
18,572,00
100%
29,344
8,803

55. Table 4: Road map for scaling up services in HP States
For reaching these additional 19,77,217 pregnant women, we need to scale up services as given :
Table 4: Road map for scaling up services in HP States 1 2
Total of col.1+2 will fetch 3 4
Total of col. 3+4 will fetch
STATES
Sub-district health facilities (catering to number of pregnant women/ deliveries)
Pvt. Sector
(catering to number of pregnant women/ deliveries)
50% of column 1
50% of column 2 AP
3,03,411
6,85,520
9,88,931
1,51,706
3,42,760
4,94,466
Maharashtra
2,84,611
5,73,318
8,57,929
1,42,306
2,86,659
4,28,965
Mumbai
75,173
1,48,500
2,23,673
37,587
74,250
1,11,837
Karnataka
2,31,401
5,14,008
7,45,409
1,15,700
2,57,004
3,72,705
T N
4,57,745
5,55,554
10,13,299
2,28,873
2,77,777
5,06,650
Manipur
4,000
10,000
14,000
2,000
5,000
7,000
Nagaland
7,500
9,000
16,500
3,750
4,500
8,250
TOTAL
13,63,481
24,95,900
38,59,381
6,81,922
12,47,769
19,29,691

56. Road Map for Scaling Up of the Program
with assurance of quality prepared for all
High Prevalence States for increasing coverage.
District level Plans developed.
Scaling up plans for other States drawn

57. Year
International PPTCT Mission to India : January 2006
IAP Consultation on Pediatric HIV/AIDS held to frame
guidelines for Pediatric AIDS Management
To address the issue of NVP resistance, National
Technical Committee at NACO recommended
Change of NVP based regimen to multi-drug regimen
during pregnancy and post natal period
Operational Feasibility study being implemented in
a few districts in High Prevalence states with the new
regimen

58. PPTCT Centers (as of July 2006)
Exclusive PPTCT Centres: 506
Integrated VCCT – PPTCT Centres: 1300
Services have been established at CHC level in High Prevalence States

59. PPTCT: India Challenges,Issues,Concerns
Low Coverages
How to maintain QA while going to scale? (Training, Counseling).
Strategies for low prevalence (V / HV) states ?
PPTCT only for institutional deliveries?
(Out -reach, District Model)
Implementation of Prong 1 and 4 of the ‘PPTCT Strategy’ with Primary Prevention and continuum of care: Care and Support

60. Challenges,Issues,Concerns ...
Infant Feeding dilemma
Integration into the National Reproductive & Child Health program.
Involving Private Sectors / Practitioners
Stigma, Discrimination, Attitude of health care providers, Communication Strategy, Male Involvement
Alternative Regimens for ARV
Poor FOLLOW UP ( PPTCT Plus) , Testing of babies ?
Capacity of Pediatricians to manage children with HIV/AIDS

61. Willingness, openness to change Will on part of the Government
Conclusions…..
Evidence based, strategic programming
Willingness, openness to change
Will on part of the Government
Critical support from partners and stakeholders

62. International AIDS Society NACO, Govt. of India UNICEF AIIMS
Acknowledgements
International AIDS Society
NACO, Govt. of India
UNICEF
AIIMS

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