Prevention of Mother to Child Transmission of HIV (PMTCT) in northern Uganda

Presentation AIDS 2012, XIX International AIDS Conference,

Washington DC, USA

Dr Lawrence Ojom and Ketty Opoka

AVSI Uganda• In 1984 AVSI started

working in Uganda in the health sector and home based care for persons with AIDS

• In 2002 the AVSI PMTCT program started, supporting the government’s program initiated in 2001

• In 2011 the PMTCT program covered 24 health facilities

Northern Uganda• 22 years of conflict between Lord’s Resistance Army (LRA) and the Government of

Uganda• Estimated 66,000 children/youth were abducted during the conflict• Approximately 10,000 killed, thousands more mutilated during the conflict• Relative stability has allowed most people to return to their villages of origin

Northern Uganda• 24 health

facilities received PMTCT activities from AVSI in collaboration with the Ministry of Health in northern Uganda throughout and after the conflict

AVSI’s method in PMTCT • Centrality of the Person: the mother, father,

child, and family• Starting From the Positive: which strengths does

this person have, what are the opportunities in our setting

• Partnership: working with the ministry, district offices, hospitals, health centers and community based organizations in the region

• Development of Intermediate Bodies and Subsidiarity: build capacity in partners and create networks

• Doing with: work together, hand in hand, not alone, following a bottom up rather than top down process.

AVSI PMTCT Program Activities• Community sensitization• Staff support and capacity building• ANC and PMTCT services at health facilities• Provision of medical equipment and supplies• Logistic and administrative support • Nutritional education and support• Follow up and home based care • Family Support Groups• Data management• Coordination, monitoring and evaluation

Indicators PMTCT activitiesANC attendance 136,300Pregnant women counseled 129,298Pregnant women tested for HIV 128,325Pregnant women tested HIV+ 8,030Partners tested for HIV 41,078Partners tested HIV+ 2,824Women received prophylaxis 5,663Deliveries in health facilities 65,659HIV+ deliveries in health facilities 4,503Infants given NVP 4,251Children tested 3,737Children tested HIV + 243

T

ANC attendance in AVSI PMTCT sites

0

5000

10000

15000

20000

25000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

ANC Attendance Women

ANC Attendance Partners

• In total 136,300 women attended Ante Natal Care services from 2002 – 2011. Increase in attendance of women till 2007, then a decrease due to population returning

• Partner involvement increased drastically over the years from 296 in 2002 to 10,723 in 2011. In 2011 73.6% of the women attended ANC with their partner.

Male involvement

• Partner involvement increased drastically over the years from 5.9% in 2002 to 73.6% in 2011, supporting the family to have children born FREE from HIV

• Nationally male testing only reached 12.3% in 2009/10 (PMTCT annual report, Ministry of Health)

Mothers waiting for ANC services

• Acceptance for testing was 93.9% for women and 99.5% for attending men in the AVSI PMTCT sites.

• The HIV prevalence over the 10 years is 6.4% for women, and 8.5% for partners. The national prevalence (UAIS 2011) is 7.3%, and 8.3% in the north.

HIV prevalence in AVSI PMTCT sites

0.0%2.0%4.0%6.0%8.0%

10.0%12.0%14.0%16.0%18.0%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

HIV prevalence ANC women

HIV prevalence ANC partners

Women with their partners at the ANC

• Of the women who were tested positive (8,030) in AVSI PMTCT sites in total 6,033 were started on prophylaxis for PTMCT, while 697 were started on ART (triple therapy).

• ART became freely available in Uganda in 2004, however stocks of sufficient supplies in remote conflict affected areas such as northern Uganda delayed till 2006. In 2011 the ART uptake increased to 30%, similar to the national proportion of HIV positive pregnant women receiving ART.

Women started on prophylaxis and ART in AVSI PMTCT sites

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

% of ANC positive womenstarted on prophylaxis

% of ANC positive womenstarted on ART

• In total 65,735 of the 136,300 ANC women over the 10 years delivered in a health facility (48.2%). Of the women who delivered in a health facility, 4,605 were HIV positive (7.0%).

• The reduction in deliveries in health facilities in 2007 can be attributed to women moving back to their villages of origin, away from the internally displaced camps, and thereby often further away from health services.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

2004 2005 2006 2007 2008 2009 2010 2011

Percentage of (HIV+) deliveries in AVSI PMTCT sites

% ANC women deliver in AVSIPMTCT sites

% HIV deliveries of all deliveries

• If an HIV+ pregnant woman does not receive prophylaxis, the chances she delivers an HIV+ baby are 1 out of 3.

• Over the years only 6.8% of the babies of HIV positive mothers who received PMTCT services were tested positive.

• The variation in prevalence can be attributed to the small number of children tested, especially in the early years (no data available for 2002 and 2003)

HIV prevalence in children under 18 months in AVSI PMTCT sites

0.000

0.020

0.040

0.060

0.080

0.100

0.120

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Elimination of Mother of Child Transmission of HIV (EMTCT)

• Between 2004 and 2011, the HIV prevalence in PMTCT infants declined significantly from 10.3% to 5.0%

• The government target of virtual elimination of < 5% of MTCT by 2015 was achieved in the AVSI supported sites.

Feeding practices

From replacement feeding to breastfeeding using prophylaxis

Infant and Young Child Feeding (IYCF)

- food demonstration using local foods - nutrition education about good feeding practices

Family Support Groups• Family support groups have been created to support families. They started at community level with drama groups in 2004, and evolved into support groups of mothers and their partners over the years.• The groups are facilitated by AVSI, Meeting Point, and health workers and provide education, information sharing, psychosocial, and economic support

Meeting Point Kitgum

• Meeting Point Kitgum is a community based organization which started operating in Kitgum in 1990

• AVSI and Meeting Point started their partnership in 1991• Provided home based care, educational and

psychosocial support to persons living with HIV/AIDS (PLWHA), when no treatment was available.

• Facilitates follow up of mothers and children in collaboration with Health facilities in their activities.

• Meeting Point supports approximately 260 AVSI PMTCT mothers per year in Kitgum district.

Meeting Point Kitgum PMTCT in communities

Community Dialogue Music and dramaSharing experiences

Home visits by Meeting Point staff

• Counseling• Health education: ANC

attendance, adherence, delivery

• Promote Breastfeeding and Infant and Young Child Feeding

• Medical care and referral• Male and family

involvement• Reducing stigma• Provision of home based

care kits

Lessons learned• Collaboration with the government,

districts, community organizations• Community involvement, peer education

through men and community groups, Village Health Teams, and family support groups contributed to high ANC attendance, acceptance of PMTCT uptake, and male involvement and children being born FREE from HIV

Plans for EMTCT activities in AVSI Uganda

• Research collaboration with Makerere University John Hopkins University & University of San Francisco California on primary prevention of HIV in pregnant women

• Continue on job mentoring and health system strengthening through UNICEF supported ALIVE program in the 7 Acholi districts

• Continue lobbying for funding for EMTCT and pediatric HIV/AIDS programs for 2012 and consecutive years to support the GoU program

• Include HIV/AIDS as a cross-cutting component in all programs (health, education, livelihoods, protection, disability)

AVSI calls for continued support and collaboration for EMTCT

from the Government of Uganda, the US Government,

PEPFAR/USAID, UNICEF, and other donors

Apwoyo MatekThank you

Grazie mille