ELIMINATION OF VERTICAL HIV TRANSMISSION ARE WE READY?

BY SHAARI NGADIMAN,
MD, MPH, EIP, AM

MINISTRY OF HEALTH MALAYSIA

drshaari@moh.gov.my

CURRENT SITUATION - GLOBAL

1. 2. 3.

Each day 1,500 under 15 infected with HIV Majority due to vertical transmission 25 30 % dies before their 1st birthday

4 ways to minimise infant HIV

UNGASS Declaration of Commitment, June 2001 Prevention of HIV in women of reproductive age Prevention of unintended pregnancy in HIV+ women
1. 2. 3.

PMTCT of HIV through

a) b)

antiretroviral therapy (ART) during pregnancy safer delivery practices

NEXT BEST

c)
4.

counselling and support on infant feeding methods

FALL-BACK POSITION

Care, treatment and support to HIV-infected parents, infants and families

Definition of terms
9

eMTCT of HIV
Number

of new child HIV infections <10% of 2009 value MTCT <5% IN BF, or MTCT<2% in NBF Screening HIV ANC > 95% PMTCT ARV >95%

TO ACHIEVE THE GOAL OF ELIMINATION

COUNTRY NEED: 1. Put priority to eliminate pediatric HIV 2. Allocate adequate resources 3. To build capacity

4. 5.

Training staff Development of guidelines

6. 7.

To improve coverage and quality of antenatal care To ensure regular supply of lab reagents for diagnosis and drug for treatment including pediatric prophylaxis Have a policy of infant feeding To establish a system for surveillance, monitoring and evaluation

Target of NSP on AIDS 2011-15

80% MARPs reached prevention programmes 60% of MARPs use condoms consistently. 60% of IDUs use clean injecting equipment. Able to eliminate vertical HIV transmission 80% ARV coverage for eligible PLHIV,

ANTENATAL HIV SCREENING (MOH)1998 - 2012

600,000

No

56

89

85

79

141

177

138

110

170

190

200

171

239

309

270

0.500

500,000

0.400

400,000

0.300 300,000

200,000

0.200

100,000

0.100

0
1998 1999 2000 2001 2002 2003 2004 2005 2006
384027 377735 0.044

0.000
2007
380346 381686 0.050

2008
394673 396951 0.051

2009
403287 410980 0.042

2010
413862 415427 0.057

2011
443453 443453 0.070

2012
449013 458213 0.060

Screened 161,087 275,640 286,390 343,030 387,208 361,152 377,016 349,922

ANC % positif 162960 0.035 323902 0.032 347979 0.030 394534 0.022 393173 0.036 374388 0.047 388037 0.035 365352 0.031

No of HIV positive mothers No of babies positive for HIV

2012 Rate of HIV vertical transmission to newborn baby = 1.1% 12 HIV antenatal screening coverage 2012= 98%

% positive

eMTCT in the context of Malaysia

STRATEGIES FOR Prevention Mother To Child HIV Transmission -PMTCT

14

Services at Private Clinics / Hospitals Close monitoring of positive cases Miss opportunity labour rooms Quality assurance
Enhanced towards ELIMINATION BY 2015

Objectives
15

To compile existing data/indicators on MTCT of HIV and syphilis in Malaysia To select and test the eMTCT criteria/ indicators/ process for validation of eMTCT of HIV and syphilis To test the flowchart for diagnosing congenital syphilis To discuss on assessment of eMTCT of HIV and syphilis, availability of data and data quality, and data gaps to validate eMTCT To document process of validation of eMTCT, identify issues and challenges and make recommendations To summarize lessons learned and make recommendations for the global guidance

Conceptual framework of PMTCT in Malaysia

16

Methodology
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Study location: Study sites were chosen based on highest , middle and lowest percentage of HIV+ mothers in 2011 .as well as logistic reasons

Site 1: AIDS/HIV Section, Primary Care, Surveillance Unit, MOH, Putrajaya Site 2: Selangor, medium percentage of HIV+ mothers in 2011 Site 3: Negeri Sembilan, with one of the lowest HIV+ mothers in 2011 Site 4: Kelantan, highest percentage of HIV+ mothers in 2011 Site 5: IMR, the national referral centre for confirmation of HIV+ for babies through PCR

Methodology
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Data collection methods:

Records, discussions with program managers and implementors at sites

Data collection process

Qualitative and quantitative Verification of data via performa

in Likert scale data at sites and MOH

Verification of work process as from CPG, Evaluation and monitoring process Discussions with stakeholders

Team criteria validated

Program definition Data flow and management Screening tests Defaulter tracing Contact tracing Treatment of mothers with ARV Treatment of babies with ARV timely Subsequent management of mother and baby

Innovative mechanism Management infrastructureIdentified overall manager/coordinator Involvement of private practices Involvement of NGO/ societal

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FINDINGS OF VALIDATION PROCESS

FINDINGS : Strength
21

Most of teams criteria were fulfilled Good program coverage for HIV Coordinated, integrated Regular monitoring and evaluation at different levels The coverage of PMTCT, including HIV screening, ARV for PMTCT, non-breast feeding, high across the country in 2011 There are policies, guidelines and integrated of PMTCT implementation at different levels in the country

FINDINGS : Strength
22

Most of teams criteria were fulfilled National AIDS Registry

Good system built in with ways to monitor the data as well as the staff at the end users, clear, coordinated Reminders

Verifiable and well-functioning data flow for services of ANC, HIV screening, treatment and prophylaxis and follow up from community to health centers up to the state and national level Some data not within control of MOH Makes periodic reporting complicated

FINDINGS : Strength
23

Clinical Practice Guidelines, SOPs are in place to ensure proper treatment and follow up Regular updates/discussions between clinicians in the management of the HIV+ mothers and children Checking of flow is possible at various points with accountable personnel Screening facilities
Available Free

at all KKs A designated laboratory for Confirmatory PCR at IMR

FINDINGS : Treatment of mother and child

24

Up to date Following guidelines Available Free Efforts to home deliver

FINDINGS : Gaps
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Discordant data at states with IMR

o

The HIV + babies results from IMR are as follows:

A total of 39 positive babies reported in 2011

o o o

28 captured from the missed opportunities (non-PMTCT) 8 carry forward from 2010. 3 from PMTCT

Rate of PMTCT could be different if the IMR data is considered.

Vertical transmission rate (VTR) n from

PMTCT: non PMTCT is then (3/228: ?28/228+28); 228 are HIV+ mothers from NAR VTR then 1.32% or 10.93% TOTAL VTR 12.1%

The effectiveness of PMTCT is considered good.

Number of mothers who did not participate (non-PMTCT) is also big resulted with the number of children under this category (missed opportunity) about 28.

Findings :Gaps
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Illegal immigrants: The service and data gap is another barrier for PMTCT in Malaysia. The service to illegal immigrants is an issue within a bigger picture, given the size and complexity, mobility of this population, and potential threat to the HIV prevention and care programme in the country in general, and to PMTCT of HIV and syphilis in particular. Immigrant: Legal - data captured may have inaccuracy(. Usually Is verified at private clinics under FOMEMA) and monitoring is always difficult due to the size and mobility. Illegal immigrant no data on the previous status and they are not obliged to follow the government procedures. currently we have, stillbirths are not diagnosed with causes, in particular to those (especially the immigrants) loss to follow up a big issue

Gaps
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Smart partnership with NGOs the active participation of communities through intensified information campaigns. No feedback mechanisms/targets given to them?

Conclusion
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Utilizing the existing National PMTCT Programme, it appears that Malaysia has great potential to reduce and ultimately eliminate PMTCT in 2015.

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