Charles S. Kiptemas, MBChB, MPH

Director

South Rift Valley HIV Care & Treatment Program

Kenya Medical Research Institute/Walter Reed Project

Track 1 Partners Meeting; Willard Intercontinental Track 1 Partners Meeting; Willard Intercontinental Hotel, Washington, DCWashington, DC August 11-12, 2008

Integration of ART Into MCH:Experience from Kericho District

Hospital One Client: Multiple Needs

Kenya National PMTCT Goal

• By 2005:

50% of all pregnant women should access PMTCT services.

Reduce proportion of infants infected with HIV by 20%.

• By 2008:

80% of all pregnant women should access PMTCT services.

Reduce proportion of infants infected with HIV by 50%.

Models of Providing HIV Care to Pregnant Women

• HIV counseling, testing, staging (clinical and immunological), care and treatment including PMTCT at MCH,

or

• HIV counseling, testing, staging (clinical and immunological), non ART care including PMTCT at MCH and referral for ART on/off site,

or

• HIV counseling, testing, and PMTCT at MCH and referral for care and treatment on/off site.

Rationale for Integration

• Maternal-child health clinics are often the point of entry to care for HIV-infected women and children.

• In Kenya over 90% of pregnant women seek antenatal care at least once.

• PMTCT program has been successfully integrated within the MCH framework.

• Enhances follow up of the mothers and the exposed infants since they are served under one roof.

• To support accelerated scale-up of HIV prevention, care, and treatment in resource-constrained settings.

The South Rift Valley PMTCT Program

• Started in August 2001

As a collaboration effort between USMHRP and EGPAF

• To date approximately 200, 000 pregnant women have

been counseled

• Because of the maturity of the PMTCT program at

Kericho District Hospital (KDH), the hospital was

selected to pioneer the integration of ART in MCH.

26,442 New ANC Clients

26,869 Counseled

24,477 (91%)Tested

23,510 (96%)Results

695 (90%)Mothers

519 (67%)Infants

772 (5%)HIV+ nevirapine

South Rift Valley PMTCT ProgramCounseling & Testing

andNevirapine Prophylaxis

(Jan 08- May 08)

Implementation of ART in MCH

• HIV clinic for pregnant women started in MCH due to: Loss to follow up, Poor uptake of more efficacious regimens, and Poor access to care and treatment.

• Run by clinical officers and nurses. Runs 5 days a week. Peer educators used to support the service.

• A file is opened for each patient. HIV care and PMTCT counseling provided by the clinical officer. Clinical Staging and blood for baseline evaluation that includes

CD4 cell count done in MCH. NVP for baby and mother given at first contact.

Implementation of ART In MCH, cont.

• HIV Care and PMTCT ARV prophylaxis initiated at next visit(s):

Prescriptions written in MCH and drugs dispensed from central pharmacy.

• Women encouraged to bring members of her family for HIV diagnosis.

• Mother and baby followed up in MCH till child is 18 months old:

Early HIV Infant Diagnosis by PCR done at 6 weeks.

Septrin prophylaxis provided to both infant and mother.

Recommendations for Initiating ARV Treatment in HIV Infected Pregnant Women

WHO clinical

stage

CD4 testing not available

CD4 testing

available

1

Do not treat

(Efficacious Prophylaxis)

Treat if CD4 <350* cells/mm3

2

3

Treat Treat4

* * CD4 >250/mm3 and <350/mm3 use PI based..

MCH Care of HIV Infected Pregnant Women: Kericho District Hospital (KDH)

(Jan 05-June 08)

17061543

1454

227

0

200

400

600

800

1000

1200

1400

1600

1800

HIV +ve Evaluation HIV care ART

Nu

mb

er o

f C

lien

ts

Uptake Of More Efficacious Regimen (KDH)

(Jan 08- June 08)

112 112

40

9

0

20

40

60

80

100

120

HIV +ve NVP-Mother AZT-Mother ART

Nu

mb

er o

f C

lien

ts

Male Involvement: Kericho District Hospital

(Aug 05-June 08)

1301

16367

0

200

400

600

800

1000

1200

1400

CT Male Partners HIV +ve ART

Nu

mb

er o

f C

lien

ts

Challenges & Issues

• Integrating ART into MCH with improved uptake of services in high volume sites is possible.

• Increased workload for the MCH/FP health care providers.

- Task shifting: auxiliary staff, peer counsellors.

• Requirement of additional & training of health care providers.

• Additional services will require additional resources that may include clinic space and furniture, diagnostic test, and ARV drugs.

• Disclosure issues.

Anticipated Challenges/Issues

• Maintaining quality services against the many facility

limitations and competing needs.

• Supervision, monitoring and evaluation.

• Early initiation of ARV's in pregnancy remains a challenge

(roll out of dual therapy).

• Health worker buy-in/motivation critical.

• Supply chain management.

Acknowledgements

Kenya Ministry of Health

• Dr. John Odondi

• KDH Staff

Kenya Medical Research Institute/Walter Reed Project HIV Program

• Leonard Soo

• Fredrick Sawe

United States Military HIV Research Program

• Dr. Tiffany Hamm

• Dr. Nelson Michael

• Ms. Lisa Reilly

• Dr. Doug Shaffer

Sponsors

• Kenya Ministry of Health

• Kenya Medical Research Institute

• United States Military HIV Research Program

• Presidents Emergency Plan for AIDS Relief

Asantenina

Karibuni Kericho, Kenya!

Women Presenting Below 38 Weeks Gestation Women Presenting Below 38 Weeks Gestation With Less Advance Disease With Less Advance Disease

• WHO clinical stage I or II with CD4 cell count > 350/mm3 OR

• WHO clinical stage I or II no CD4 cell count done– HB ≥7g/dl OR no clinical features of anaemia– AZT 300mg BD from 28 weeks

• At onset of labour– Administer Nevirapine 200mg and AZT 300mg stat and,

Combivir one tab BID to mother.• Post partum

– Give Infant sd Nevirapine 2mg/kg within 72 hours of birth and AZT syrup 4 mg/kg BD for 4 weeks.

– Give mother AZT300 mg / 3TC 150 BID for 7 days