Integrating PMCT in RH / MCH services in Myanmar 6 November 2006 At Kuala Lumpur
Country profile 14 states and divisions, 63 districts, and 325 townships Population in 2005 was 55.40 million (estimated) 70% of the population resides in rural areas Population growth rate was 2.02 (2000)
Background RH/MCH Total Fertility rate- 2.21 (2003) Estimated number of births-1303800 (2003) ANC coverage- 63% (2005) Infant Mortality Rate- Urban-45.3/1000 live birth (2003) Rural- 47.1/ 1000 live birth (2003) U5 Mortality Rate- 62.1/1000 live births(2003)
HIV/AIDS SITUATION IN MYANMAR HIV +ve recorded = 64,478 (cumulative up to Dec. 2005) AIDS Cases (Reported) = 10,730 (cumulative up to Dec. 2005) Deaths due to AIDS (Reported) = 4,785 (cumulative up to Dec. 2005) PLWHA (estimates) = 338,911 ( 2004) Number 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 AIDS 0 0 0 6 41 142 286 618 690 554 517 802 816 668 1298 736 1747 1809 HIV 1 323 1034 2152 1641 2001 2361 2055 2971 3307 3689 5201 4717 8013 5567 7982 6862 4601
100 Trends of HIV prevalence among the Urban Institution-based subpopulation group of the HIV sentinel surveillance, Myanmar, 1992 through 2004 80 Percent(%) 60 40 20 0 92M 92S 93M 93S 94M 94S 95M 95S 96M 96S 97M 97S 98M 98S 99M 99S 00M 01M 02M 03M 04M Time IDUs M.STD F. STD MCH RECRT BLOOD DONOR CSWs
1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 12.5 10.0 1980 Estimate of national HIV prevalence trend and number of PLHA in Myanmar 1983 1986 1989 1992 1995 1998 1.3% in 2006 2001 2004 Number of HIV infected pregnant women 2007 2010 Thousands 400 350 300 250 200 150 100 50 Number infected with HIV 340,000 in 2006 Thousands 7.5 5.0 2.5 7, 000 in 2006 0 82 85 88 91 94 97 00 03 06 09 0.0 82 85 88 91 94 97 00 03 06 09
No of HIV infected children (0-14) 8,200 in 2006
Health service structure Department of Health P M C T Dis. Control NAP State/div Heath Department Pub. Health MCH R H / M C H National State/division AIDS/STD team Township Health Department Township Health centers Township & Station Hp
PMCT Programme 140 PMCT implementing areas 120 Number of townships 100 80 60 40 Cumulative number of hospital based PMCT Cumulative number of township PMCT 7 17 68 29 89 20 0 7 12 5 22 2001 2002 2003 2004 2005 2006 Year 36
Approach Phase 1(2000-2005) - Community based approach (focus on 70% of population residing at Rural area, 80% deliveries at home, 60% ANC at RHC) Phase 2 (2005-) township (Hospital) & Urban MCH based approach at the township level &Institutional (Hospital) based approach at tertiary and S/D level (Focus on case load & facilities, logistic ease, easy for M&S, high prevalence) To be start with areas where - potential of target population exist: evidenced by epidemiological data - existing infrastructure and manpower is feasible to implement the PMCT programme
Community based PMCT Model (up to Rural Health Centre level done by Basic Health Staff except testing) Pre-test Group routine ANC education includes PMCT Followed by individual counseling (Opt-in) Taking blood Send blood sample to urban lab (hospital, STD clinic) Post-test Post-test counseling NVP for preg women and/or midwife Safe Delivery either at home or hospital Infant feeding counseling Follow up, care and support
Community based PMTCT programme AN VCCT RHC Blood AN VCCT Post test coun Delivery ARV AN VCCT RHC Post test coun Delivery ARV Test result ARV drugs Blood Hospital/ AIDS/STD Clinic Testing Post test coun Delivery ARV
ANC education session with PMCT messages [Photo of RHC or Midwife working]
Results - Service utilization Proportion(%) PMTCT at a glance: service utilization rate increased, seroprevalence rate reduced 80 60 40 20 0 72 71.6 61.7 50.16 51.9 54 43.8 25.58 34.48 12.97 3.08 2.21 1.53 1.37 1.27 2001 2002 2003 2004 2005 Years VCCT HIV tested HIV positive
Results ARV therapy PMTCT at a glance: most of the deliveries of HIV infected pregnant women were covered by Nevirapine 100 96.15 88.46 85.91 90.76 90.76 93.7 95.8 91.6 93.5 Proportion(%) 75 50 25 77.85 mothers Babies 0 2001 2002 2003 2004 2005 Years
Lessons learned from Community Based PMCT Advantage Can cover home deliveries BHS s knowledge and experience of HIV Easy access to VCT for pregnant women Good follow up after delivery Challenge Logistical challenge Transport of blood samples/report Technical challenge Difficulty of supervision to large number of RHC - Difficulty in improving counseling skills of Midwifes (as low prevalence in rural area)
Future activities for comprehensive PMCT New things Regimen Cotrimoxazol Opt-out Lay counselor for individual pre-test information Continuum of care (support group, CHBC, ART) Strengthen linkage with RH/MCH CoC (as an entry point)
Integration of PMCT in RH/MCH services Implementing staff (Basic health staff/ midwife) HIV/PMCT information as a part of routine ANC Training (knowledge, theory) MCH training includes PMCT knowledge (PCPNC) Pre-service training includes PMCT knowledge
Future Plan Scale up PMCT up to nation wide coverage Limited funding is a bottleneck for scale up Township hospitals to provide comprehensive PMCT Identify modalities of PMCT to be a part of routine AN services Coordinated training Coordinated reporting (HMIS, HBMR) Strengthen coordination through regular coordination meeting among stakeholders