Human Resource Constraints
and Roll out of more efficacious
regimens for PMTCT
The Zambian experience
Nande Putta MD MPH
Technical Assistant PMTCT &
Paediatric HIV Care
Ministry of Health
HIV in Zambia
 Prevalence rate of HIV is 16% (15-49
yrs)
 One in five pregnant women is HIV
positive (19% ANC seroprevalence)
 Estimated 150,000 children are living
with HIV
 Mother-to-child transmission accounts
for over 90% of childhood HIV infections
 Estimated 97,000 HIV infected pregnant
women (~~HIV exposed infants)
 Each year estimated 28,000-40,000
children acquire the virus from their
mother
Zambia's Program
 Scale Up plan for pMTCT and Paed. ART
developed with clearly outlined objectives
and strategies
 Overall objectives for Zambia by 2010:

To provide comprehensive prevention of motherto-child transmission services to at least 80% of
pregnant women

To provide ART to at least 80% of HIV-positive
children in need of ART
Progress in Service Provision
 Steady progress from 74 sites in 2003 to 678
in 2007
700
600
500
400
300
# of Sites
200
100
0
2003- 2006- 200774
307
678
(6%) (24%) (53%)
Performance 2007
 678 PMTCT sites (53% coverage)
 Of estimated 500,000 annual
pregnancies, 306,000 tested (61%)
 Of estimated 97,000 HIV positive
pregnant women, 52,800 identified
(54%)
 Of estimated 97,000 HIV positive
pregnant women, 35,300 accessed ARVs
(36%)
Performance 2007 contd.
 Of estimated 97,000 HIV exposed babies,
15600 accessed ARV proph. (16%)
 Of estimated 97,000 HIV exposed babies,
11,900 receive Cotrimoxazole
proph.(12%)
 Of estimated 97,000 HIV exposed babies,
7600 received a virological test within 2
months (8%)
Performance 2007 contd.
70%
60%
50%
40%
2007
30%
20%
10%
0%
PW tested
HIV+ PW
identified
HIV+ PW HIV exp inf HIV exp inf HIV+ exp
rcv ARVs rcv ARVs
rcv CPT
inf tested
Progress over last 3 years
(2005-2007)
350000
300000
250000
200000
150000
100000
50000
0
PW HIV+ HIV+ HIV
tested pw PW rcv exp
ARVsbabies
rcv
ARVs
2005
2006
2007
Guidance for PMTCT regimens in
Zambia
 More efficacious regimens incorporated into
revised pMTCT guidelines and training
package
 Adapted from the WHO guidelines
 Single dose NVP dispensed at first contact
to be taken at onset of labor
 AZT dispensed beginning at 28 weeks
 AZT/3TC given at onset of labor with NVP
 AZT/3TC given through labor and as a tail
for 7 days
Guidance for PMTCT regimens in
Zambia
For baby
 Single dose Nevirapine soon after
birth
 7 day tail of AZT (28 days if mother
received less than 4 weeks of ARVs)
Guidance for PMTCT regimens
in Zambia as quoted from the
guidelines
“At the first visit after confirming the
mother is HIV positive, the woman can
be given her single NVP dose to take
home so she can take it at the onset of
labour. Where blister packs are available
she may be given the full course of
drugs for her to take during antenatal,
labour, delivery and in the postpartum
period………
Guidance for PMTCT regimens in
Zambia as quoted from the
guidelines
………… How ever it needs to be emphasized
that she will need to be seen every four
weeks for review. At these visits assess
adherence and other issues such as
disclosure, side effects and testing of
other family members…………
Guidance for PMTCT regimens in
Zambia as quoted from the
guidelines
…………These visits can also be used to
reinforce messages such as infant
feeding, family planning, early infant
HIV testing and other aspects of
continuum of care. She will also be
given the babies NVP dose at the 32
week visit to be taken soon after birth
and she should be advised on safe
storage.”
Uptake of ARVs by Pregnant
women for PMTCT
 Of HIV positive women identified through
ANC testing and counseling, 67% are
taking ARVs for PMTCT
 Of all estimated HIV positive women 36%
are taking ARVs for PMTCT
 Current estimates show about 25% of
women taking ARVs are using more
efficacious regimens (sdNVP and AZT)
Constraints contributing to low
uptake of more efficacious
regimens








Late 1st ANC visit booking and low average
frequency of ANC visits
Low institutional deliveries and postnatal
attendance
Lack of holistic care within MCH
Poor linkages to other facets of treatment and
care
Poor reporting and recording
Data tools not integrated and all inclusive
Inadequate training of staff (refer to mapping
exercise)
Inadequate community involvement
Constraints contributing to low
uptake of more efficacious
regimens
 Suboptimal logistic and supply
management at all levels (refer to mapping
exercise)
 Slow dissemination of guidelines
 Inadequate Monitoring and Evaluation
(mentorship, support supervision and
feedback on these)
 Inadequate or inappropriate staff
 Inadequate integration of PMTCT into
outreach visits
Human resource situation in
Zambia
 Human resource inadequacy is a huge
problem facing the health sector
 Staff attrition caused by job seeking
outside the country, job seeking to private
and non governmental sector and illness &
death
 Average estimate is that most health
institutions are running at 50% capacity
 Some health facilities being run by
unqualified staff
Human resource situation in
Zambia in PMTCT care provision
 High turn over of trained staff with inadequate
compensatory training of staff
 Inadequate retraining or updating of staff
trained when single dose Nevirapine was
standard of care
 Human resource retention strategies in place
though competing with time to provide
universal access for PMTCT (rural retention
scheme, direct entry midwifery training)
Effect of Human Resource
inadequacy on roll out of more
efficacious regimens
 Poor quality of counseling and care
 Poor reporting and recording
 Suboptimal logistic management at
facility level
 Inadequate follow up of clients
 Inadequate performance self
assessment
Possible solutions to Human
Resource inadequacy and roll out
of more efficacious regimens
 Task shifting
 Involvement of the community in mother baby
tracking
 Involvement of peer support through initiatives
like Mother2mother
 Easier delivery mechanisms such as blister
packs
 Strengthen Supervision, mentoring and
feedback mechanisms
 Over and above – “Health Systems
Strengthening” to cope with evolution of
Scientific based recommendations
Thank You
Zikomo
Any Questions?
Natotela