CONCEPT NOTE

GROUP III: PREVENTION OF MOTHER TO CHILD HIV TRANSMISSION.

Theme: « COUNT DOWN TO 2015 FOR CHILDREN AND HIV – ACHIEVING MILLENNIUM DEVELOPMENT GOAL (MDG) 6 »

Theme: « QUALITY PMTCT SERCIVES FOR ALL: TOWARDS AN HIV FREE    GENERATION »

1.    Context and Justification

Every day in the world, approximately 1,200 new infections with HIV occur in children below 15 years of age. Mother to child transmission (MTCT) represents the main mode of infection (>90%). In Rwanda, HIV prevalence is estimated at 3% in the general population (DHS III, 2005) and 4.3% among pregnant women. The total fertility rate is 5.5 (National Institute of Statistics of Rwanda, 2008); infant mortality and under 5 mortality rates are respectively 103/1000 and 62/1000 (NISR, RIDHS, on 2008).

It is estimated that 7 700 new HIV infections in children would occur every year in Rwanda if nothing is done to prevent MTCT. A national programme for prevention of MTCT (PMTCT) was established in 2002 following a pilot project in 1999. The comprehensive package of PMTCT service in Rwanda includes routine HIV testing of pregnant women and their partners in antenatal clinic (ANC), evaluation of CD4 count in HIV + pregnant women, antiretroviral prophylaxis in HIV+ pregnant women and their newborn children, counseling on safe infant feeding, enrolment in care and treatment for HIV+ women and their partners, antiretroviral therapy (HAART) for eligible women, psychosocial support and support for adherence, facility-based assisted delivery, follow-up package for children born to HIV+ mothers (routine immunization, prophylaxis with Cotrimoxazole,  early/later HIV diagnosis, growth surveillance, nutritional support), integration of family planning services, referral of infected children for a comprehensive care and support management.

The geographical coverage of PMTCT program increased from 28% (120/420) to 76% (362/476) between January, 2005 and June, 2009. The proportion of HIV+ pregnant women who received ART prophylaxis in PMTCT program increased from 53.7% in 2005 to 94.8% in June 2009 as well as children born to HIV+ mothers (93% June 2009). Early Infant Diagnosis (EID) of HIV is effective in 86.5% (313/362) of all PMTCT sites with a cumulative number of 1 077 children infected (VIH+) from 2005 to 2008. In 2008, the prevalence of HIV among exposed infants was 6.9% at 18 months.

2.    WHY TO CHOOSE THIS THEME?

Although these results provide a strong rationale for Rwanda to aim for elimination of MTCT by 2015; major challenges remain including:
•    Prevention of HIV in women at childbearing age (prong1) who remain almost 3 times more infected than men counterpart
•    Prevention of unintended pregnancy among women infected with HIV (prong 2), the uptake of effective contraceptives methods remains low.
•    Prevention of HIV transmission from a woman living with HIV to her infant (prong 3):
o    Access to CD4 assessment during pregnancy is not optimal. Despite the increase in number of CD4 machines at the national and district level from 13 to 31 (2007 to June, 2009), only 72% of district hospitals have them and they are still insufficient to server all the health facilities in the Country. The CD4 count in pregnant women still has some operational constraints (distance, coordination between PMTCT and Care and Treatment services, etc.).  
o    Ensuring effective ARV prophylaxis with more efficacious regimens in the context of decentralization and limited skilled human resources is a major challenge. About one-third (98/362) of PMTCT site do not yet implement the national PMTCT ARV guideline, irregular doctors’ visits to PMTCT sites at health centers level lead to a delay in HAART initiation for eligible pregnant women; the task shifting policy is not yet available. About one-third of PMTCT sites are not qualified as ART sites, leading to weak referral and follow up system between PMTCT and ART services
o     Access to nutritional support for women and exposed children remains inadequate (only 50.4 % of PMTCT sites).
o    Access to services for early infant diagnostic of HIV remains a challenge.
o    Guidelines and tools for follow-up are insufficiently disseminated and not yet standardized as well as monitoring indicators
o    Guidelines for the follow-up and care and treatment of discordant couples, as well as the psychosocial support for HIV+ women in PMTCT is not available.
This theme “QUALITY PMTCT SERCIVES FOR ALL: TOWARDS  AN HIV FREE GENERATION” of this 5th Pediatric conference, was chosen to highlight achievements and discuss about strategies, and mobilize various stakeholders to address the gaps toward an HIV free generation in Rwanda.

3.    EXPECTED RESULTS
At the end of this session, participants will be able to:
•    Identify key achievements and challenges in implementing the comprehensive PMTCT package services to all
•    Formulate strategies and recommendations to improve on the implementation challenges.
•    Identify needed resources and secure commitments from all stakeholders to implement the proposed recommendations.