kuantan fms elimination vertical transmission 060713
TRANSCRIPT
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ELIMINATION OF VERTICAL HIV TRANSMISSION
ARE WE READY?
BYSHAARI NGADIMAN,
MD, MPH, EIP, AM
MINISTRY OF HEALTH MALAYSIA
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1. Each day 1,500 under 15 infected with HIV
2. Majority due to vertical transmission
3. 25 30 % dies before their 1st birthday
CURRENT SITUATION - GLOBAL
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4 ways to minimise infant HIVUNGASS Declaration of Commitment, June 2001
1. Prevention of HIV in women of reproductive age
2. Prevention of unintended pregnancy in HIV+ women
3.
PMTCT of HIV through a) antiretroviral therapy (ART) during pregnancy
b) safer delivery practices
c) counselling and support on infant feeding methods
4. Care, treatment and support to
HIV-infected parents, infants and families
NEXT
BEST
FALL-BACK
POSITION
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Definition of terms
eMTCT of HIV
Number of new child HIV infections
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COUNTRY NEED:
1. Put priority to eliminate pediatric HIV 2. Allocate adequate resources 3. To build capacity
Training staff Development of guidelines
4. To improve coverage and quality of antenatal care 5. To ensure regular supply of lab reagents for diagnosis and
drug for treatment including pediatric prophylaxis6. Have a policy of infant feeding 7. To establish a system for surveillance, monitoring and
evaluation
TO ACHIEVE THE GOAL OF ELIMINATION
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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,
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1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Screened 161,087 275,640 286,390 343,030 387,208 361,152 377,016 349,922 384027 380346 394673 403287 413862 443453 449013
ANC 162960 323902 347979 394534 393173 374388 388037 365352 377735 381686 396951 410980 415427 443453 458213
% positif 0.035 0.032 0.030 0.022 0.036 0.047 0.035 0.031 0.044 0.050 0.051 0.042 0.057 0.070 0.060
0.000
0.100
0.200
0.300
0.400
0.500
0
100,000
200,000
300,000
400,000
500,000
600,000
ANTENATAL HIV SCREENING (MOH)1998 - 2012
HIV antenatal screening coverage 2012= 98%
56 89 85 79 141 177 138 110
%p
ositive
3 3 15 5 8 2 5
No of babies positive for HIV
No of HIV positive mothers
170
3
2012 Rate of HIV vertical transmission to newborn baby = 1.1%
190
9
200 171 239
5 9 7
No 309
3 3
270
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eMTCT in the context of Malaysia
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STRATEGIES FOR Prevention Mother To
Child HIV Transmission -PMTCT
Services at Private Clinics / Hospitals
Close monitoring of positive cases
Miss opportunitylabour rooms Quality assurance
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ELIMINATION BY 2015
Enhanced towards
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Objectives
To compile existing data/indicators on MTCT of HIV andsyphilis in Malaysia
To select and test the eMTCT criteria/ indicators/ processfor 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 tovalidate 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
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Conceptual framework of PMTCT in
Malaysia
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Methodology
Study location:
Study sites were chosen based on highest , middle and lowestpercentage of HIV+ mothers in 2011 .as well as logisticreasons
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 in2011
Site 4: Kelantan, highest percentage of HIV+ mothers in 2011
Site 5: IMR, the national referral centre for confirmation of HIV+ forbabies through PCR
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Methodology
Data collection methods:
Records, discussions with program managers andimplementors 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
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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 infrastructure-
Identified overallmanager/coordinator
Involvement of privatepractices
Involvement of NGO/
societal
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FINDINGS OF VALIDATION PROCESS
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FINDINGS : Strength
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
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FINDINGS : Strength
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
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FINDINGS : Strength
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
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FINDINGS : Treatment of mother and child
Up to date
Following guidelines
Available
Free
Efforts to home deliver
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FINDINGS : Gaps
Discordant data at states with IMR
The HIV + babies results from IMR are as follows:
o A total of 39 positive babies reported in 2011
o 28 captured from the missed opportunities (non-PMTCT)
o 8 carry forward from 2010.
o 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.
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Findings :Gaps
Illegal immigrants:
The service and data gap is another barrier for PMTCT in Malaysia. Theservice to illegal immigrants is an issue within a bigger picture, given thesize and complexity, mobility of this population, and potential threat to theHIV prevention and care programme in the country in general, and toPMTCT of HIV and syphilis in particular.
Immigrant: Legal - data captured may have inaccuracy(. Usually Isverified at private clinics under FOMEMA) and monitoring is alwaysdifficult due to the size and mobility.
Illegal immigrantno data on the previous status and they are not obligedto follow the government procedures.
currently we have, stillbirths are not diagnosed with causes, in particular tothose (especially the immigrants)
loss to follow up a big issue
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Gaps
Smart partnership with NGOs
the active participation of communities through
intensified information campaigns.
No feedback mechanisms/targets given to them?
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Conclusion
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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