Human Resource Constraints and Roll out of more efficacious regimens for PMTCT

The Zambian experience

Nande Putta MD MPHTechnical Assistant PMTCT & Paediatric HIV CareMinistry of Health

HIV in Zambia Prevalence rate of HIV is 16% (15-49 yrs) One in five pregnant women is HIV

positive (19% ANC seroprevalence) Estimated 150,000 children are living

with HIV Mother-to-child transmission accounts for

over 90% of childhood HIV infections Estimated 97,000 HIV infected pregnant

women (~~HIV exposed infants) Each year estimated 28,000-40,000

children acquire the virus from their mother

Zambia's Program Scale Up plan for pMTCT and Paed. ART

developed with clearly outlined objectives and strategies

Overall objectives for Zambia by 2010:

To provide comprehensive prevention of mother-to-child transmission services to at least 80% of pregnant women

To provide ART to at least 80% of HIV-positive children in need of ART

Progress in Service Provision

Steady progress from 74 sites in 2003 to 678 in 2007

0

100

200

300

400

500

600

700

2003-74

(6%)

2006-307

(24%)

2007-678

(53%)

# of Sites

Performance 2007

678 PMTCT sites (53% coverage)

Of estimated 500,000 annual pregnancies, 306,000 tested (61%)

Of estimated 97,000 HIV positive pregnant women, 52,800 identified (54%)

Of estimated 97,000 HIV positive pregnant women, 35,300 accessed ARVs (36%)

Performance 2007 contd. Of estimated 97,000 HIV exposed babies,

15600 accessed ARV proph. (16%)

Of estimated 97,000 HIV exposed babies, 11,900 receive Cotrimoxazole proph.(12%)

Of estimated 97,000 HIV exposed babies, 7600 received a virological test within 2 months (8%)

Performance 2007 contd.

0%

10%

20%

30%

40%

50%

60%

70%

PW tested HIV+ PWidentified

HIV+ PWrcv ARVs

HIV exp infrcv ARVs

HIV exp infrcv CPT

HIV+ expinf tested

2007

Progress over last 3 years (2005-2007)

050000

100000150000200000250000300000350000

PWtested

HIV+pw

HIV+PW rcvARVs

HIVexp

babiesrcv

ARVs

2005

2006

2007

Guidance for PMTCT regimens in Zambia

More efficacious regimens incorporated into revised pMTCT guidelines and training package

Adapted from the WHO guidelines Single dose NVP dispensed at first contact

to be taken at onset of labor AZT dispensed beginning at 28 weeks AZT/3TC given at onset of labor with NVP AZT/3TC given through labor and as a tail

for 7 days

Guidance for PMTCT regimens in Zambia

For baby Single dose Nevirapine soon after

birth 7 day tail of AZT (28 days if mother

received less than 4 weeks of ARVs)

Guidance for PMTCT regimens in Zambia as quoted from the guidelines

“At the first visit after confirming the mother is HIV positive, the woman can be given her single NVP dose to take home so she can take it at the onset of labour. Where blister packs are available she may be given the full course of drugs for her to take during antenatal, labour, delivery and in the postpartum period………

Guidance for PMTCT regimens in Zambia as quoted from the guidelines

………… How ever it needs to be emphasized that she will need to be seen every four weeks for review. At these visits assess adherence and other issues such as disclosure, side effects and testing of other family members…………

Guidance for PMTCT regimens in Zambia as quoted from the guidelines

…………These visits can also be used to reinforce messages such as infant feeding, family planning, early infant HIV testing and other aspects of continuum of care. She will also be given the babies NVP dose at the 32 week visit to be taken soon after birth and she should be advised on safe storage.”

Uptake of ARVs by Pregnant women for PMTCT

Of HIV positive women identified through ANC testing and counseling, 67% are taking ARVs for PMTCT

Of all estimated HIV positive women 36% are taking ARVs for PMTCT

Current estimates show about 25% of women taking ARVs are using more efficacious regimens (sdNVP and AZT)

Constraints contributing to low uptake of more efficacious regimens Late 1st ANC visit booking and low average

frequency of ANC visits Low institutional deliveries and postnatal

attendance Lack of holistic care within MCH Poor linkages to other facets of treatment and

care Poor reporting and recording Data tools not integrated and all inclusive Inadequate training of staff (refer to mapping

exercise) Inadequate community involvement

Constraints contributing to low uptake of more efficacious regimens Suboptimal logistic and supply

management at all levels (refer to mapping exercise)

Slow dissemination of guidelines Inadequate Monitoring and Evaluation

(mentorship, support supervision and feedback on these)

Inadequate or inappropriate staff Inadequate integration of PMTCT into

outreach visits

Human resource situation in Zambia

Human resource inadequacy is a huge problem facing the health sector

Staff attrition caused by job seeking outside the country, job seeking to private and non governmental sector and illness & death

Average estimate is that most health institutions are running at 50% capacity

Some health facilities being run by unqualified staff

Human resource situation in Zambia in PMTCT care provision

High turn over of trained staff with inadequate compensatory training of staff

Inadequate retraining or updating of staff trained when single dose Nevirapine was standard of care

Human resource retention strategies in place though competing with time to provide universal access for PMTCT (rural retention scheme, direct entry midwifery training)

Effect of Human Resource inadequacy on roll out of more efficacious regimens Poor quality of counseling and care Poor reporting and recording Suboptimal logistic management at

facility level Inadequate follow up of clients Inadequate performance self

assessment

Possible solutions to Human Resource inadequacy and roll out of more efficacious regimens

Task shifting Involvement of the community in mother baby

tracking Involvement of peer support through initiatives

like Mother2mother Easier delivery mechanisms such as blister

packs Strengthen Supervision, mentoring and

feedback mechanisms Over and above – “Health Systems

Strengthening” to cope with evolution of Scientific based recommendations

Thank YouZikomo

Natotela

Any Questions?