1. Programmatic issues around PMTCT - Ruth Nduati Senior Lecturer Department of Pediatrics University of Nairobi

4. Urban antenatal HIV prevalence in sub Sahara Africa

5. Infant mortality rates by maternal HIV status (Coulter 1993, Boerma 1998)

6. Magnitude of MTCT transmission of HIV Transmission rate During pregnancy5-19% During labour and delivery10-20% During breastfeeding5-20% Overall without breastfeeding15-30% Overall with breastfeeding <6mths25-25% Overall with breastfeeding 18- 24mths 30-45%

7. Mortality among HIV-1 seropositive breastfeeding and formula-feeding women (Nduati et al. Lancet 2001)

8. Effect of mother’s death on infant survival “Independent of infection status HIV exposed infants were at an 8 fold increased risk of death following their mother’s death Nduati et al., Lancet 2001;357:1651

9. Efficacy of short course AZT in a breastfeeding population (Leroy AIDS 2002;16:631-641)

10. Cumulative mortality at 24 months BreastfedFormulaHazard ratio (95% CI) Overall24.4%20%1.1 (0.7-1.7) Uninfected8.1%10%1.3 (0.6-8.0) Infected46%40.2%0.9 (0.5-1.8)

11. HIV AND INFANT FEEDING: THE DILEMMA

12. Strategic approaches to prevention of HIV related morbidity and mortality in children Prevention of HIV in young women Prevention of unintended pregnancies in HIV infected individuals Prevention of MTCT transmission of HIV Provision of c are to HIV infected women and their families.

13. Steps in implementing a PMTCT Program level –Advocacy with District Health Management Teams and other important stake holders –Consensus building on the package of services –Development of guidelines –Development of IEC materials –Development of monitoring and evaluation tools

14. The PMTCT package Quality antenatal care Universal HIV counseling and voluntary testing Partner involvement in counseling Provision of anti-retroviral prophylaxis Counseling on replacement feeding and safer breastfeeding practices Safe delivery Post-natal care for the infant

15. Provision of quality antenatal care Health education Screening and treatment of STD’s Screening for anaemia Micronutrient supplementation Malaria chemoprophylaxis Immunization against tetanus Screening for other pregnancy related complications eg. Diabetes or eclampsia Family planning counseling

16. Screening for syphilis with RPR Kakamega N=3754 Busia N=3597 Karatina N = 5316 Homa Bay N=4169 % tested40%46%86%18% % RPR +ve 4.8%3.4%1.6%9% Proportion treated 98%59%82%

17. Guidelines to support PMTCT National Infant feeding policy Guidelines for the care of HIV infected women Guidelines on the use of anti-retroviral drugs

18. IEC materials to support PMTCT Posters to be used within the health facility and at community level Take home brochures to help women initiate discussion on PMTCT Flip charts with detailed information to help the health worker provide accurate information Badges for counselors to help clients identify who they can approach for information Video to be used in antenatal clinic Counseling cards on infant feeding

19. Tools for monitoring PMTCT at health facility level Modified antenatal card Modified institutional registers –Antenatal register –Laboratory register –Delivery register –Bin cards –Drug registers (maternity, MCH, pharmacy) New register –Counselors register Weekly summary sheets

20. Steps in implementing PMTCT at facility level Advocacy with the staff Needs assessment to –Determine the existing resources and gaps –existing package of services being provided Development of training materials Training of health workers Establishment of appropriate client flow Carrying out monitoring and evaluation

21. Factors affecting uptake of testing Counseling case load Prevalence of HIV Counseling strategy – –Group versus one-one counseling –Opt-in versus opt-out approach to testing Client flow –one-stop service provision versus production line approach

22. Uptake of HIV-test results and ARV’s

23. Content of Health education & counseling before and 9 months after a PMTCT program in Karatina

24. Content of Health education & counseling before and 9 months after a PMTCT program in Homa Bay

25. Quality of HIV testing in Homa Bay District Hospital

26. Quality of HIV testing in Karatina District Hospital

27. Counseling Environment

28. Communication Skills in HIV counseling sessions (1)

29. Communication Skills in HIV counseling sessions (2)

30. CHALLENGES Sustaining the consumables – HIV Test kits, IEC Materials Providing essential package of services such as syphilis screening, and antenatal multivitamin supplements Improving uptake of test results and intervention among HIV infected women.. Providing standardized messages and ensuring quality of counseling.

31. Partnerships Joan Kreiss Grace John Barbrar Richardson Julie Overbaug Dana Pantaleef Christine Rousseau Population Council Family Health International Ruth Nduati Dorothy Mbori- Ngacha J Ndinya Acholla J Bwayo Anthony Mwatha James Ochieng