Transcript Document

Launching of National PMTCT Action Plan, Accelerating for Reducing
MMR and Maternal Health Pocket Book, Jakarta; Indonesia
September 26, 2013
The PMTCT Cascade:
Scaling up HIV and Syphilis Testing in ANC and
community-based programs in Cambodia
Mean Chhi Vun, MD, MPH
National Centre for HIV/AIDS, Dermatology and STD (NCHADS)
National Centre for Maternal and Child Health (NMCHC)
Ministry of Health of Cambodia
Profil Kamboja
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Populasi: 14,2 juta
Urban: 20%; Rural: 80%
GDP: US$ 830 per kapita
Life expectancy:
– Laki-laki: 57 tahun
– Perempuan: 65 tahun
Total Fertility Rate: 3.0
AK Bayi: 45/1.000
AK Balita: 54/1.000
AK Ibu: 206/100.000
Cakupan ANC: 89% th 2010
(80% th 2005)
Source: Cambodia Demographic and Health Survey, 2010
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Infrastruktur Kesehatan
• 8 Rumah Sakit Nasional
• 23 Provinsi (23 Rumah Sakit)
• 81 Operational Districts (OD)
(79 OD Hospitals / RSUD)
• 1.024 Health Centers th 2012 (ANC,
Delivery, diagnosis dan pengobatan
TB, testing HIV dan sifilis using finger
prick,…)
• Masing-masing mencakup 12.000
sampai 15.000 jiwa
Tren Epidemi HIV di Kamboja
Source: Conceptual Framework for Elimination of New HIV Infections in Cambodia by 2020 (NCHADS, 2012)
Cara Penularan HIV di Kamboja: 1991 – 2015
25000
Ibu ke anak
Mother
to child
Berbagi jarum
suntik
Needle
sharing
20000
Lelaki seks dgn
Male-male
sexlelaki
Seks dgn pasangan
Casual
sex
15000
tidak tetap
Wife->husband
Isteri  suami
Suami  isteri
Husband->wife
10000
Pekerja
Sex
workseks
Total 1.210
5000
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
0
5
Cascade Layanan PMTCT di Kamboja, Sebelum th 2013
(PMTCT Option B)
Paket dan Peranan Layanan
Kunjungan ANC K1
Ditawarkan Tes HIV
Diagnosis dan Pengobatan
TB (NTP)
Dites HIV
Menerima hasil Tes HIV
Penentuan CD4
Setuju ARV profilaksis
Patuh ARV profilaksis
Persalinan
Ibu yg diketahui
HIV+ kemudian
hamil dirujuk ke
ANC (KIA)
Patuh ARV profilaksis pd bayi
Tes HIV pd bayi
“Linking Model”
2000 PMTCT TWG (’99)
PMTCT pilot (’01)
PMTCT GL: SD-NVP (’02)
2005 PMTCT GL rev: Dual prophylaxis (’05)
2010
PMTCT Review (’07)
Linked Response (’08)
SOP and Joint Agreement
(Role and responsibility)
PMTCT GL rev: Option B (’10)
2013 SOP on Boosted LR (2013)
• Universal ANC testing for HIV and
syphilis
• Option B+
TB-HIV Sub-committee (‘99)
TB/HIV Framework (’02)
TB/HIV pilot (’03)
Joint Statement: Role &
Responsibility (’03)
SOPs PITC in TB cases (’06)
CAMELIA and ID-TB/HIV results (’09)
SOP, Joint Statement: 3I’s (’10)
3I’s Role Out (’11)
5I’s has been implemented (’12)
Kesepakatan antara NCHADS dan NMCHC
NCHADS
Community
based support
• Layanan tes dan konseling HIV
(HTC: VCT, PITC, C/PITC)
• Layanan Pre-ART dan ART
(Konfirmasi utk HIV)
• Layanan “Pediatric AIDS Care”
(EID)
• Supply chain:
- tes kit rapid HIV dan sifilis,
- obat IO dan ARV
- bahan habis pakai
• Laboratory service: CD4, VL
PCR-DNA (EID)
NMCHC
• Paket Layanan ANC :
- kegiatan ANC
• Birth spacing - tes HIV dan sifilis (finger prick)
•Training
• Delivery Service:
• Monitoring
- tes HIV saat persalinan dan ARV
• Supervision
- NVP untuk bayi terpajan
•Reporting
• Rujuk ps hasil HIV Reactive ke ART
• Resource
• Advise on immunization
shared
Joint Action Plan for
common activities
Linking Model (2008 onward):
Fasilitasi perluasan PMTCT dan TB/HIV
Referral and Follow-up
HCBC Team/NGO
Satellite
VCCT
HC
+
Referral and Follow-up










Community
+
Referral and Follow-up
HC
HCBC Team/NGO
HC
Referral and Follow-up
Health worker/NGO
+
RH (Hub)
HCBC Team/NGO
VCCT
VCCT
Expansion of Testing in All Health Centers
HTC 2.0: 2008 to 2012
HTC 1.0: 1995-2007
Referral Hospital
Pre-ART/ART (<12%)
Referral Hosp with VCT/ART
Pre-ART&ART (>60%)

Patient
Referral if (+)
HIV +
HC with VCCT
1st and confirmatory test (17%)

ANC
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



Health Center with VCT
HIV 1st Test, Confirmatory Test
Syphilis rapid test (confirmatory at STD) (>80%)
Sample
referral
1st Test
Result
Patient
Referral if (+)
Health Center without VCT
Blood Taking
HTC 1.0 in One Operational District
20 HCs have only 2
VCCT sites,
1 OI/ART services
VCCT
HTC 2.0: Linking Approach in One Operational District
14 HC refer blood
samples to 6 VCCT
New PMTCT
New
New PMTCT
New VCCT
New PMTCT
New PMTCT
Linking Model Demonstration Results (2007-9)
100%
90%
90%
80%
80%
85%
79%
74%
70%
Percentages
88%
70%
68%
60%
55%
50%
40%
30%
20%
10%
3%
0%
Q1
8%
6%
Q2
Q3
2007
11%
7%
Q4
Q1
Q2
Q3
Q4
2008
Per quarter and year
HIV testing coverage
Q1
Q2
Q3
2009
Syphilis testing
* Pengenalan tes sifilis pada kuartal I th 2009
** Percentase bumil dites HIV/sifilis pada ANC dari jumlah perkiraan bumil
Q4
85%
Cakupan “PMTCT Cascade” Lebih Baik
Tantangan
 Transport (pengiriman) sampel dari Health Center satelit ke VCCT:
Biaya dan waktu
 Beban kerja tenaga kesehatan dengan gaji yang sangat rendah di
VCCT
 Hasil tes terlambat dikembalikan ke klien (dalam 7 hari)
 Kesenjangan (gap) dalam PMTCT service cascade
Streamlining prosedur HTC dan rujukan
HTC 2.0
HTC 3.0
Referral Hosp with VCT/ART
Pre-ART&ART
Referral Hosp with VCT/ART
HIV Confirmatory Test at Pre-ART/ART
Syphilis confirmatory at STD
Pasien
Dirujuk jika (+)
Health Center with VCT
1st Test, Confirmatory Test
Rujuk
Sample
Hasil
Tes 1st
Pasien
Dirujuk jika (+)
Pasien
Dirujuk jika (+)
Health Center without VCT
Blood Taking
Every Health Center and Hospital
(ANC)
First Test with Finger Prick
(HIV and Syphilis Rapid test)
HTC 4.0: Setelah 2015
Kapan kasus baru HIV menjadi sangat kecil, pendekatan
baru apa untuk HTC pada ANC?
•Melanjutkan skrining HIV untuk semua bumil datang
ANC?
•Fokus pada daerah beban HIV tinggi?
•Fokus pada orang yang paling berisiko (mis. EW dengan 7
pasangan atau lebih per minggu)?
Virtual elimination of new HIV infections by 2020
e-MTCT
(Boosted LR)
Ibu hamil dan
Pasangan seks
MARP Prevention and Links
to Health Service
(Boosted COPCT)
MARP dan Sex Partners
Manajemen kasus
IMS
Boosted CoC
VCCT,
PITC (TB, ANC)
Community Peer Initiated TC
Pasangan ODHA
ODHA dlm Pre-ART
Immediate
ART (CD4≤500)
ART as Prevention
Eliminasi Penularan HIV dari Ibu ke Anak pada 2020
(Manajemen Kasus Aktif dan PMTCT Option B+ mulai 2013)
OD
+
-HIV or MCH District Officer
(CMC)
- One Assistant to CMC
OD Referral Hospital
Health
HC Center
ANC (tes HIV dan
sifilis secara
universal,
menggunakan finger
prick)
+
Reactive test result referred to
Community support / NGO
• Pre-ART/ART dengan HTC
• Delivery service (labor testing)
CMP
• Pediatric AIDS Care (EID)
• Laboratory service
CMP
Outreach HTC (15%)
(Finger testing)
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
 
Community
Note:
- Case Management Coordinator (CMC)
- Case Management provider (CMP)
Kesimpulan
• Pendekatan vertikal diperlukan pada fase awal respons
• Jejaring berjalan, apabila peranan/tugas dan tanggung
jawab jelas pada setiap sisi dan tingkatan layanan
• Desentralisasi tes dan konseling HIV ke jenjang layanan
kesehatan primer dapat meningkatkan cakupan tes HIV
• Menyederhanakan/meluruskan (streamlining) prosedur
dengan teknologi baru diharapkan dapat meminimalkan
“lost-to-follow-up” (LTFU) dari Layanan Tes dan Konseling
HIV ke Layanan Pra-ART (pengobatan HIV)
• Retensi di seluruh rangkaian cascade berpengaruh untuk
eliminasi infeksi HIV baru
• Integrasi/linkage merupakan strategi “Win-Win” untuk
meningkatkan kedua program