ICAP News - June 2008

ICAP Advances Vision for Comprehensive Prevention of Mother-to-Child Transmission Programs at HIV/AIDS Implementers’ Meeting in Uganda
With nine posters and oral presentations describing country experiences with the implementation of comprehensive prevention of mother-to-child transmission (PMTCT) programs, ICAP outlined its new vision for PMTCT programming at the fifth annual HIV/AIDS Implementers’ Meeting, June 3-7, in Kampala, Uganda.

“We have re-conceptualized PMTCT from the traditional approach of a simple intervention with limited effectiveness into a comprehensive program that uses the best strategies to achieve optimal outcomes for both mothers and their children,” said Elaine Abrams, MD, director of ICAP’s MTCT-Plus Initiative and architect of ICAP’s PMTCT and pediatric programs.

ICAP's vision for PMTCT programs was detailed in depth by ICAP Director Wafaa El-Sadr, MD, in a meeting session titled “Effective Ways to Integrate Prevention, Care and Treatment.” In her presentation, El-Sadr argued for the integration of programmatic components of PMTCT services into Maternal Child Health (MCH) services. “The MCH platform can catalyze a transformation of PMTCT,” said El-Sadr.

View presentation (pdf format)

In other presentations, ICAP staff detailed success stories from Ethiopia, Lesotho, Mozambique, Rwanda, Swaziland, and Tanzania about the integration of PMTCT into MCH services, increased availability of CD4 cell counts assays for pregnant women, growing use of multi-drug PMTCT regimens, use of expert clients to provide patient support services to women participating in PMTCT programs, and identification of HIV-infected women and HIV-exposed infants through immunization clinics and provision of follow-up care, including access to early infant diagnosis and cotrimoxazole prophylaxis.

ICAP-Lesotho Country Director Raphael Ntumy, MD, reported on a capacity-building and performance improvement initiative to allow for access to highly active antiretroviral therapy (HAART) and PMTCT services in the MCH settings. In support of this initiative at five healthcare facilities, ICAP and its partners led on-site MTCT-Plus workshops and HIV/AIDS medical education meetings, provided intensive clinical mentorship, while working at the same time with staff to realign job responsibilities. Nurses and nurse clinicians were supported to initiate HAART, which enabled the doctors to focus on complex medical cases and supportive supervision. Between January and December 2007, a total of 236 providers participated in the initiative. In the same period, a total of 375 HIV-infected pregnant women initiated HAART and 426 women received the multi-drug PMTCT regimen consisting of AZT administered from week 28 of pregnancy and single-dose nevirapine at delivery. Despite the fact that Lesotho faces severe human resource shortages, Ntumy demonstrates how large numbers of women can be initiated on HAART during pregnancy in the MCH through concerted efforts.

View presentation (pdf format)

• ICAP-Tanzania Country Director Amy Cunningham presented results of a pilot project to integrate PMTCT services, as well as HIV care and treatment, into the Reproductive and Child Health Clinic at Tumbi Regional Hospital. Introduction of this “one-stop shop” model resulted in increased uptake of all PMTCT regimens among women testing positive. Between July 2007 and March 2008, the number of HIV-positive pregnant women receiving any PMTCT regimen increased from 20 to 93. Newly diagnosed women receive immediate access to care and treatment at the clinic. Their partners are also notified and enrolled into care and treatment, if indicated. 

View presentation (pdf format)

• Landry Tsague, ICAP-Rwanda PMTCT program manager, reported on the successful migration from single-dose nevirapine to multi-drug PMTCT regimens at 19 ICAP-supported sites. In support of the revised national PMTCT guidelines, ICAP worked with district health authorities and teams at the facilities to implement new procedures for rapidly assessing immunological status of pregnant women newly diagnosed with HIV through CD4 cell count assays and enrolling eligible women into care and treatment. District laboratories were also equipped with new CD4 cell count machines to facilitate timely access to CD4 cell testing. In addition to providing extensive clinical training and mentorship, ICAP worked with the sites to build strong linkages to ART clinics to ensure that newly diagnosed women obtain prompt care and ART. By the end of 2007, the clinics provided CD4 testing to 96 percent of pregnant women testing positive. At the same time, 94 percent of HIV-positive pregnant women were receiving a multi-drug ART regimen.

View presentation (pdf format)

Photo caption: Landry Tsague, ICAP-Rwanda prevention of mother-to-child transmission of HIV program manager, during a clinical mentoring visit at an ICAP-supported PMTCT site.

• Isabelle Yersin, ICAP-Mozambique PMTCT model centers program manager, examined the successful adoption at 13 ICAP-supported PMTCT sites of the multi-drug PMTCT regimen of AZT initiated at week 28 of pregnancy and single dose nevirapine at delivery. Yersin and her colleagues demonstrated that implementation of this regimen is highly feasible in antenatal clinic settings (ANC), even at rural health facilities, and laboratory testing should be integrated into ANC to facilitate increased use of the regimen. Between January 2007 and March 2008, nearly one-third of all patients received the multi-drug regimen at the 13 sites.

View poster (pdf format)

• Joris Vandelanotte, MD, ICAP-Swaziland senior clinical officer, presented findings on an ICAP-supported initiative to increase access to PMTCT and HIV services for pregnant women through decentralization of these services from ICAP-supported Mankayane Hospital to Luyengo clinic, a primary care facility. Before decentralization took place, pregnant women who were eligible for HAART could only access treatment at ART centers. In support of decentralization, ICAP provided a range of technical support to both facilities to establish systems for pregnant women to rapidly initiate HAART during pregnancy at the Luyengo clinic. In 2007, 72 out of 144 pregnant women eligible for treatment began it at the clinic. The outcome suggests it is feasible to initiate HAART during pregnancy at decentralized lower-level health facilities.

View presentation (pdf format)

• Xoliswa Keke, ICAP-Swaziland psychosocial and adherence advisor, reported on an innovative ICAP-supported activity that uses expert clients at PMTCT service sites to help pregnant women better understand and access HIV/AIDS services. ICAP worked closely with its partners to support extensive trainings for 52 expert clients, who are themselves enrolled in care and treatment programs and/or PMTCT programs at the sites where they work. The expert clients serve as integral members of multidisciplinary teams and provide an array of patient support services, including adherence counseling and assistance with referrals. They also lead both individual and group counseling sessions. On average each month, a single expert client leads group counseling sessions for more than 700 people and individual counseling sessions for more than 200 individuals.

View poster (pdf format)

Photo caption: An expert client leads a group counseling session.

• Getachew Tizazu, ICAP-Ethiopia clinical advisor, reported that immunization clinics which offer provider-initiated counseling and testing (PIHCT) can serve as entry points to HIV care and treatment services for both women and children. Tizazu examined rates of PIHCT between April and November 2007 among 1,430 women of unknown HIV status who presented with their infants at the immunization clinic in ICAP-supported Dil-Chora Referral Hospital. Nearly 78 percent of the women agreed to take an HIV test, of whom 5 percent tested positive. All women testing positive and their infants were immediately enrolled into HIV care and treatment at the hospital. In a country like Ethiopia with low rates of antenatal care and health facility delivery, Tizazu concluded that immunization clinics can feasibly provide HIV testing and access to care and treatment for women and their children.

View poster (pdf format)

Photo caption: Mothers wait outside the child immunization clinic at Dil-Chora Referral Hospital.

• ICAP Mozambique Senior Project Officer Matthew Rosenthal, on behalf of ICAP-Mozambique PMTCT Model Centers Program Manager Isabelle Yersin, described the integration of PMTCT services within MCH clinics at 18 ICAP-supported PMTCT sites focusing on the follow-up and care of HIV-exposed infants (HEI), including provider-initiated counseling and testing, early infant diagnosis, and cotrimoxazole prophylaxis. In 2007, 85 percent of HEI visiting the clinics received their first dose of cotrimoxazole and 77 percent of HEI accessed early infant diagnosis services, where available. In addition, providing care for HEI within the MCH setting was demonstrated to be more effective than referring infants to off-site clinics. Rosenthal concluded it is highly feasible and effective to identify and engage HEI in care in MCH.

View presentation (pdf format)

• Charles Mugizi, ICAP-Lesotho clinical advisor, detailed preliminary findings on the impact of multi-drug antiretroviral PMTCT regimens at ICAP-supported Queen Elizabeth II Hospital. DNA PCR testing was used to determine HIV infection in samples from 580 HIV-exposed infants (HEI). Mugizi reported that women with advanced HIV disease were rapidly initiated on HAART, while those who were not eligible received standard PMTCT regimens (single dose nevirapine initially, AZT at 28 weeks of pregnancy, and nevirapine at delivery). Greater than 90 percent of HEI whose mothers had received a PMTCT intervention tested HIV negative. At six weeks of life, only 2.5 percent of infants born to women with the most advanced HIV disease and treated with HAART during pregnancy were determined to be HIV infected. The transmission rate for infants born to healthier women who initiated AZT during pregnancy (with single dose nevirapine at delivery) was also very low at 2.8 percent. Mugizi called for more widespread use of multi-drug PMTCT regimens in resource-limited countries and highlighted the importance of early infant diagnosis programs as essential first steps in providing care and treatment to HEI.

View presentation (pdf format)

Lesotho Training Focuses on Strengthening Pediatric HIV Care and Treatment
In a week-long training in May supported by ICAP Lesotho, 45 healthcare workers, laboratory technicians, and expert patients from ICAP-supported Quthing District Hospital and health centers within the district expanded their knowledge about the elements of strong pediatric HIV care and treatment programs. The training, which included morning preceptorship sessions followed by afternoon didactic sessions, examined topics such as approaching pediatric patients, early infant diagnosis, feeding practices, growth and nutrition, adherence, and psychosocial support for children and their caretakers. ICAP continues to work closely with the participants from Quthing District Hospital, providing both clinical mentoring and supportive supervision.

For more about ICAP Lesotho, visit here.

U.S. Ambassador to Cameroon Lauds Breadth of MTCT-Plus Services During Tour of ICAP-Supported Site
On May 14, US Ambassador to Cameroon Janet Garvey toured the ICAP-supported Nkwen Cameroon Baptist Convention Health Board site in the country’s Northwest Province where she praised the scope and quality of HIV services offered and discussed plans for expanding services at the facility.

The Nkwen clinic, among five ICAP-supported facilities in Cameroon, provides comprehensive HIV services, primarily for pregnant women and their families, based on the MTCT-Plus model of care. In the last year, patient enrollment at the clinic has doubled through a community outreach partnership that utilizes support groups and peers to link services for patients.

Photo caption: From left to right, Nkwen Medical Director Dennis Palmer, MD, Nkwen Health Services Director Pius Tih, MD, US Ambassador Janet Garvey, Reverend Charles Tangwa, and MTCT-Plus Initiative Senior Project Officer Patricia Toro, MD.

For more about ICAP Cameroon, visit here.