PMTCT in Action: 2017/03/09. PMTCT cascade. Improving PMTCT for mother-infant pairs in the Tshwane District UTE FEUCHT

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1 Tshwane District: Working smarter, not harder PMTCT in Action: Improving PMTCT for mother-infant pairs in the Tshwane District UTE FEUCHT UNIVERSITY OF PRETORIA & TSHWANE DISTRICT HEALTH SERVICES DATE: 3 MARCH 2017 Children in the Tshwane District PMTCT cascade HIV-exposed but uninfected child Antenatal care Delivery Malnutrition Clinical care, including HIV test Maternal ART Infant birth PCR test Infant ART prophylaxis Repeated HIV tests Maternal HIV care HIV & HIVexposure Social risks HIV-infected child Confirmatory HIV test Urgent ART Maternal HIV care TB Long road Mom & baby Various health facilities Tshwane District: Paediatric HIV case surveillance WBOT & Family Medicine Health facilities (Test, trace, treat) MCWH & HAST NHLS DCST PMTCT cascade: 1 st Prong: Preconceptual Keeping women HIV-negative Planned pregnancies FPD Data systems M&E HIV Prevalence in South Africa, by age and sex (2012) 1

2 PMTCT cascade: Pregnancy Tshwane District: Antenatal 1 st visit before 20 weeks rate Early ANC booking HIV-testing at first ANC visit HIV-negative: Retesting every 3 months (pregnancy & BF) Consent process to include future testing New HIV+: Counselling Include adherence, transmission risks and infant testing Immediate : FDC Contra-indications to FDC: High-risk pregnancy Start AZT immediately and refer for 3 single ART drugs VL after 3 months / % 61.7% 60.5% 49.0% Quarter 1 Quarter 2 Quarter 3 Quarter / % 60.8% 57.2% Antenatal client HIV re-test rate Tshwane District: 2016/ Antenatal client initiated on ART rate Tshwane District: 2016/ % 95.4% 97.9% Antenatal client HIV re-test positive rate Tshwane District: 2016/ Infant given NVP within 72 hours after birth uptake rate Tshwane District: 2016/ % 96.0% 98.2% Maternal Viral loads! Documentation! Labour and delivery If VL does not come down!! Women on ART: Continue regular ART (Re-)Test all HIV-negative women presenting in labour Should there be any exceptions to this rule?? ART prophylaxis (if not on ART): 2

3 Number of respondents Infant PMTCT Prophylaxis We know: Breastfeeding is best! But what about HIV-transmission? Clinical scenario Infant prophylaxis Mother on lifelong ART NVP x 6w <4w of maternal ART NVP x 12 w (if BF, otherwise 6w NVP) Maternal VL >1,000 NVP & AZT x 6w Unknown maternal HIV NVP within 72h, then x 6w Imminent change (new EDL) Low risk: Mother on lifelong ART Infant prophylaxis NVP x 6w High risk: NVP & AZT x 12 w 14 Breastfeeding & HIV: Paradigm shifts From HIV transmission to HIV free survival ART to either mother or infant makes BF a safe option! Move to a public health approach for infant feeding in the HIV context If 100 HIV-infected women breastfeed until their children are two years old, how many children will be infected at age 2 years? (no ART to mother or child) Options: A) 0-20 B) C) D) E) Don't Know Number of infants infected Correct answer ~14 Chopra and Rollins, Arch. Dis. Child Infant feeding options: WHO 2010 National (or sub-national) authorities to decide on infant feeding practice for HIV+ mothers to be promoted and supported by Maternal and Child Health services: ----BF with ART prophylaxis, OR ----Avoidance of all BF as the strategy that will most likely give infants the greatest chance of HIV-free survival. Taking into account: Socio-economic and cultural context Availability and quality of health services Main causes of maternal and child under-nutrition Main causes of infant and child mortality in settings where national authorities decide to promote & support BF + ART Which BF practices and for how long? HIV+ mothers: EBF for first 6 mo Then introduction of appropriate complementary foods Continue BF for first 12 mo of life BF only to stop once nutritionally adequate & safe diet without BM can be provided 3

4 PMTCT guideline change for infant testing (1 June 2015) 2016 WHO GUIDELINES: - NOT YET ADOPTED IN SA - HARMONISING DURATION OF BF (2 YRS) - NB: With ART + VL suppression - GUIDANCE ON MIXED FEEDING - Any BF is better than no BF HIV testing protocol for all HIV-exposed infants: Birth PCR for all HIV-exposed infants 10w PCR: All infants who tested negative at birth 18w PCR: All infants on extended 12w NVP PCR 6w post cessation of BF Rapid HIV test at 18m Symptomatic testing at any stage Implementation of birth PCR testing: Practical implications Why did we move to birth PCR testing? CHANGING EPIDEMIC RELIABILITY OF TESTS SYSTEM WEAKNESSES HIGH RISK INFANTS EARLY ART Identification of infants (24/7/365) Including BBAs, emergency deliveries, etc Consent Why not before baby is born? Staff to perform PCR testing New cadre of staff involved Need for Baby facility registration numbers Recordkeeping NB: Tracing information Treat the newborn as a new patient Laboratory data on PCR tests: Tshwane November 2016: Total: 2386 (59 PCR+) <7d: 1018 (10 PCR+) 7d-2m: 124 (3 PCR+) 2-6m: 751 (20 PCR+) 6-18m: 357 (20 PCR+) >18m: 136 (6 PCR+) 4

5 # HIV PCR Tests Tshwane District: Birth HIV PCR coverage Apr Jun % EID in weeks of life (Tshwane District July 2016) Age in Weeks Weeks of Life Negative Positive Indeterminate Other 26 Closing the loop: Weekly HIV PCR results from laboratory Facility Ward Folder No Surname Name DOB Address Tel No Age Taken Date Reviewed Date Episode No Atteridgeville Clinic Ward Not Stated Mathama Molebogeng 07-NOV months 13 days 20-AUG AUG-2016 MG Positive Bronkhorstspruit Hospital Unknown UNKNOWN Chauke Suzan b/t 21-AUG day 21-AUG AUG-2016 MG Positive Dr George Mukhari Hospital Paediatric Opd GT Modau Thapelo 03-SEP months 13 days 16-AUG AUG-2016 MA Positive Dr George Mukhari Hospital Ward 30 GT Suthu Khensani 17-AUG day 18-AUG AUG-2016 MA RTHB2136FBCD Positive Dr George Mukhari Hospital Ward 22a High Care GN Mogashoa Thato 21-OCT months 28 days 18-AUG AUG-2016 MA Positive Dr George Mukhari Hospital Paediatric Opd GP Boikanyo Bokang 10-JUL month 13 days 23-AUG AUG-2016 MA Positive Dr George Mukhari Hospital Paediatric Opd GT Shoniwa Sesi 13-AUG days 23-AUG AUG-2016 MA Positive Gazankulu Clinic Arv Clinic 6390 Lebea Keitumetse 14-MAY months 8 days 22-AUG AUG-2016 MG Positive Jubilee Hospital Ward Mahlare Letlhogonolo 25-MAR year 4 months 24 days 18-AUG AUG-2016 RC Positive Kalafong Hospital Ward Skhosana Nhlanhla 21-AUG day 21-AUG AUG-2016 RH Positive Kgabo Health Centre Clinic Not Applicable Madikizela Pearl 19-MAY months 28 days 16-AUG AUG-2016 RG RTHB3796EBCD Positive Kgabo Health Centre Clinic Not Applicable Vilakazi Bathabile 22-AUG days 20-AUG AUG-2016 RG RTHB6823CBCD Positive Laudium Community Health Centr Unique ID RTHB No HIV Arv Clinic UNKNOWN Baby to myo Bridget 17-AUG day 17-AUG AUG-2016 MG RTHB4465CBCD Positive Lotus Gardens Clinic Arv Clinic Selemane Rorisang 21-JAN months 28 days 18-AUG AUG-2016 MG Positive Mamelodi Hospital Post-natal Ward 7 GT Segogela B/t ennie 18-AUG day 18-AUG AUG-2016 RE RTHB9597BBCD Positive Mamelodi Hospital Neonatal Ward GT Boseka Katlego 19-JUL month 6 days 25-AUG AUG-2016 RE Positive Mamelodi West Clinic Ward Not Stated Malebana Omphile 12-DEC-2015 Maria Rantho Clinic Arv Clinic Masalesa Koketso 03-AUG SECTION K MAMELODI WEST GPZA BLOCK L SOSHANGUVE PCR Result 8 months 11 days 23-AUG AUG-2016 MG Positive 1 year 16 days 19-AUG AUG-2016 MA Positive Pretorius Park Clinic Arv Clinic Boseka Katlego 19-JUL days 18-AUG AUG-2016 MG Positive Pretorius Park Clinic Arv Clinic Boseka Katlego 19-JUL PLASTIC VIEW month 5 days 24-AUG AUG-2016 MG RTHB0607EBCD Positive Soshanguve Clinic 3 Arv Clinic 1080 BLOCK FF Seema Bokamoso 12-OCT BLOCK FF SOSHA 10 months 4 days 16-AUG AUG-2016 MA Positive Stanza Ii Clinic Ward Not Stated Ndou Pfumulani 12-JUL month 11 days 23-AUG AUG-2016 MG RTHB0689DBCD Positive Dr George Mukhari Hospital Ward 23 GT Maretela Naledi 01-JAN-1800 Unknown 18-AUG AUG-2016 MA Indeterminate Dr George Mukhari Hospital Ward 23 GT Maretela Naledi 30-MAY months 24 days 23-AUG AUG-2016 MA Indeterminate Eersterus Clinic [hammanskraal] Not Applicable 3693 Masango Betty 23-AUG years 11 months 30 days 22-AUG AUG-2016 MA Indeterminate Jubilee Hospital Labour Ward Mhlaola Tebogo 21-AUG day 21-AUG AUG-2016 RC Indeterminate Suurman Clinic Not Applicable Ramolobeng Tumisang 14-JUL year 1 month 2 days 16-AUG AUG-2016 RC Indeterminate Minimizing missed opportunities in access to care Tracing: How to find the infected babies? Linking to Ward-based Outreach Teams (WBOTs) NB: Babies from difficult psycho-social backgrounds Retention in care: Counselling Information: If mothers understand the process they are more compliant with follow-up Issues: Language, finances, travelling, support structure, fear Linking of data systems Tshwane District: The unique RTHB identifier The RTHB is a constant factor and now it has a unique number in order to identify and trace children! 5

6 No. RTHBs Captured NHLS lab request form with RTHB identifier placed on top right-hand side Laboratory result look-up: Alternate Ref No field on TrakCare WebView The consistent use of the RTHB identifier will ensure that health facilities will be able to trace previous laboratory tests with ease, irrespective of where these tests were performed. RTHB Identifiers Captured at Birth % 52% % % 21% 25% 37% RTHBs at Birth Reducing stigma Even if page 7 of RTHB is missing, the child s HIV PCR results can still be obtained using the RTHB Unique Identifier % May June July August September October November December 2016 Other advantages: No IT infrastructure needed at time of issuing of the unique RTHB Nr Linkage to other health system identifiers can be done at any stage Fast-tracking HIV+ babies into care Clinical tool for HIV PCR + children Gauteng DoH Confirmatory HIV DNA PCR Refer infant to nearest centre for neonatal ART Doctor-initiated, currently at large ART sites Investigate gaps in PMTCT cascade PCR positive tool to be completed Avoid creating sense of maternal guilt Some do everything correctly but still their infant is positive Some encounter significant barriers (access to care/adherence) Full support with rapid 6

7 City of Tshwane Boekenhout Clinic Not Applicable 30-MAR-2016 UNKNOWN 2 days 01-APR APR-2016 RG Positive City of Tshwane Mandise Shiceka Clinic Ward Not Stated 22-OCT-2015 UNKNOWN 5 months 10 days 01-APR APR-2016 RC Positive City of Tshwane Gazankulu Clinic Arv Clinic 31-AUG-2015 UNKNOWN 7 months 4 days 04-APR APR-2016 MG Positive City of Tshwane Gazankulu Clinic Arv Clinic 01-MAY-2015 UNKNOWN 11 months 4 days 05-APR APR-2016 MG Positive City of Tshwane Kt Matubatse Clinic Arv Clinic 06-DEC-2014 UNKNOWN 1 year 3 months 30 days 05-APR APR-2016 MA Positive City of Tshwane Jubilee Hospital Labour Ward 06-APR-2016 UNKNOWN 1 day 06-APR APR-2016 RC Positive City of Tshwane Soshanguve Clinic 3 Arv Clinic 30-MAR-2016 UNKNOWN 1 day 30-MAR APR-2016 MA Positive City of Tshwane Soshanguve Clinic Jj Arv Clinic 22-DEC-2015 UNKNOWN 3 months 8 days 30-MAR APR-2016 MA Positive City of Tshwane Jubilee Hospital Labour Ward 31-MAR-2016 UNKNOWN 1 day 31-MAR APR-2016 RC Positive City of Tshwane Kt Matubatse Clinic Arv Clinic 06-DEC-2014 UNKNOWN 1 year 3 months 25 days 31-MAR APR-2016 MA Positive City of Tshwane Laudium Clinic Arv Clinic 19-JAN-2016 UNKNOWN 2 months 12 days 31-MAR APR-2016 MG Positive City of Tshwane Kalafong Hospital Medical Opd 17-FEB-1977 UNKNOWN 39 years 1 month 12 days 29-MAR APR-2016 RH Indeterminate City of Tshwane Soshanguve Clinic T Arv Clinic 09-MAR-2015 UNKNOWN 1 year 22 days 31-MAR APR-2016 MA Indeterminate Why is neonatal ART management different? PMTCT cascade Antenatal care Delivery HIV-exposed but uninfected child Neonates, who are <28 days old and weigh >2.5kg, will be initiated on AZT, 3TC, NVP Clinical care, including HIV test Maternal ART Infant ART prophylaxis Repeated HIV tests Maternal HIV care LPV/r (Kaletra ) is not safe for neonates <14 d of age/ <42 w gestation ABC can only be given once an infant weighs over 3kg HIV-infected child For premature babies (<35 weeks gestation) or babies weighing <2.5kg the options are even more limited Premature/low birth weight babies with a positive birth HIV PCR require urgent and management by a specialist Continuum of care is absolute crucial! Confirmatory HIV test Urgent ART Maternal HIV care Sub District Facility Ward Folder No Surname Name DOB Address Tel No Age Taken Date Reviewed Date Episode No Unique ID HIV PCR Result Use of data to optimize patient follow-up WBOT Records Weekly name based reports based on NHLS report: Positive PCR: Repeat PCR testing & Indeterminate PCR / No result PCR: Tracing for repeat PCR testing Negative PCR: Ensure follow-up testing as per protocol Clinic / medical Records NHLS / Laboratory Results Electronic birth register (Home affairs) Department of Social Development If electronic birth register: Weekly report on all HIV infected moms who gave birth, highlighting HIV-exposed babies without birth PCR Cohort monitoring But how do we do this?? Database & Application Tshwane: 1 March 2017 What happened??? Induced traffic jam!! HIV positive Woman HIV positive Mother It is all about (up-to-date) information! HIV exposed Infant HIV Diagnosis HIV Diagnosis Birth PCR Monitoring Symptomatic testing 10w PCR 6 weeks post +/- 18w PCR breastfeeding Monitoring Monitoring 18m rapid/ ELISA Monitoring You WANT to use Google maps! You WANT to LEARN to use Google maps! Positive HIV-test: Confirmatory PCR 7

8 Birth Linking of data systems: HIV positive Woman HIV positive Mother HIV Diagnosis Detectable VL HIV exposed Infant Symptomatic testing 10w PCR 6 weeks post HIV Diagnosis Birth PCR +/- 18w PCR breastfeeding Confirmatory PCR Monitoring Monitoring AR Monitoring initiation Positive HIV-test: Confirmatory PCR Individualized patient care Consolidated reports M&E! 18m rapid/ ELISA Monitoring PMTCT cohort monitoring ANC E-Health record Register baby Link mom & at birth baby Labour ward Electronic birth register Clinical care (mother & baby), including Clinic visits E-Health record (repeated) Immunizations Hospitals DHIS Health Information Exchange Norms & Standards -centered registration (HPRS) Electronic Health record ID Nr M&E from capturing of clinical activities Outcome data Maternal mortalities, PPIP, Child PIP WBOTs WBOT db Laboratory HIV results TB programme & ETR HIV programme Tier.net care (repeated; also negative) MCWH module (including pregnancies and maternal VL) Integration of vertical programmes by using a similar data linking approach to achieve longitudinal cohort monitoring Clinic database: Electronic Health Record Linking of data systems: Child cohort monitoring ANC E-Health record Register baby Link mom & at birth baby Labour ward Electronic birth register Clinical care (mother & baby), including DHIS Health Information Exchange Norms & Standards -centered registration (HPRS) Electronic Health record ID Nr M&E from capturing of clinical activities WBOTs WBOT db Electronic growth monitoring Other departments (DSD, SASSA, Agriculture) Laboratory HIV results TB programme & ETR HIV case surveillance Other laboratory tests Immunizations Clinic visits E-Health record (repeated) Immunizations Hospitals Outcome data Maternal mortalities, PPIP, Child PIP HIV programme Tier.net care (repeated; also negative) MCWH module (including pregnancies and maternal VL) PMTCT: Way forward Working smarter, not harder Maternal New infant prophylaxis regimen Infant HIV testing (cohort retention) Safe breastfeeding Early infant ART Cohort monitoring Thank you! 8