Towards eliminating perinatal transmission of HIV, syphilis and hepatitis B in Yunnan A case study, 2005–2012 Yunnan AIDS Prevention and Control Bureau Towards eliminating perinatal transmission of HIV, syphilis and hepatitis B in Yunnan A case study, 2005–2012 Yunnan AIDS Prevention and Control Bureau WHO Library Cataloguing-in-Publication Data Towards eliminating perinatal transmission of HIV, syphilis and hepatitis B in Yunnan: a case study, 2005-2012 1. HIV infections – prevention and control. 2. Hepatitis B. 3. Syphilis, Congenital. I. World Health Organization Regional Office for the Western Pacific. ISBN 978 92 9061 696 2 (NLM Classification: WC 503.6) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, fax: +632 521 1036, e-mail: [email protected] The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Photo cover: ©UNICEF Table of Contents Acknowledgements iv Abbreviations v Executive summary vi Introduction 1 Initial challenges 2 HIV PMTCT programme strategy and implementation (phase I), 2005–2009 4 National iPMTCT implementation protocol summary (phase II), 2010–2012 9 Results in 2010–2012 12 Coverage of testing for HIV, syphilis and hepatitis B 12 HBV, syphilis and HIV infection rates in pregnant women 14 Scaling up triple ARV prophylaxis during pregnancy 15 Testing and follow up of HIV-exposed infants 16 Coverage of interventions for infants born to HBV-positive mothers 16 Free testing and catch-up vaccination for partners of HBV-positive women 18 Coverage of interventions for syphilis-positive women and syphilis-exposed infants 18 Achievements and challenges 19 Follow up of HBV-exposed children: a heavy workload 19 Syphilis testing: need for additional training to improve testing quality 19 Improving the cascade of services to ensure elimination of MTCT 19 Lessons learnt 20 Annex 1: Integrated HIV, syphilis and HBV PMTCT interventions during ANC, labour 21 and delivery, and post partum in China Annex 2: Integrated interventions for the follow up of HIV-, syphilis- or HBV-exposed 22 infants in China iv Acknowledgements This eight-year programme on the prevention of mother-to-child transmission (PMTCT) of HIV required the efforts of many dedicated teams of health professionals in Yunnan, and the generous support of various national and international organizations, as well as individual donors. Initiation of the project in 2005 would not have been possible without the generous donation from Tony Yeung and his Gracious Glory Buddhism Foundation. Other donors for the early phase of the project include the JT Tai Foundation, Oscar and Kevin Tang, Walter and Shirley Wong, and Miranda Wong Tang. Both funding and technical support from the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) was critical from 2007 to 2009, when the project expanded capacity-building to the township and village levels. Funding from Rotary International during this period filled the gap in supply of HIV rapid test kits. Initially, the Hong Kong ZeShan Foundation made donations to the programme in 13 counties during 2005–2009, and supported the integration of PMTCT of hepatitis B and syphilis in six of those 13 counties during 2009-2010. During 2009-2010, the Foundation supported further expansion of the programme to 26 counties. The report was written by Zhou, Zengquan: Yunnan AIDS Care Center, Yunnan AIDS Initiative; Kathrine Meyers, Aaron Diamond AIDS Research Center; Qian, Haoyu: Aaron Diamond AIDS Research Center; Lao, Yunfei: Yunnan AIDS Care Center; Chen, Qingling: Yunnan AIDS Care Center; Dong, Xingqi: Yunnan AIDS Care Center; Li, Huiqin: Yunnan AIDS Care Center; Wang, Yu: Yunnan AIDS Care Center; Yang, Yiqing: Linxiang Maternal and Child Hospital; Gao, Liping: Linxiang Maternal and Child Hospital; Jiang, Chengqin: Mangshi Maternal and Child Hospital; Guo, Yunsong: Dehong Prefecture Maternal and Child Hospital; Zhang, Yan: Yunnan Provincial Maternal and Child Hospital; Li, Wei: Yunnan Provincial Maternal and Child Hospital; Seguy, Nicole: WHO China Office; and Zhang, Lan: WHO China Office. Ying-Ru Lo, WHO Regional Office for the Western Pacific, coordinated the finalization of the English version of the report. Nicole Seguy and Zhang Lan, WHO China Office coordinated the development and implementation of the case study. Dr Gui Xi’en, AIDS Clinical Advisory and Training Center, Wuhan, Hubei, China was part of the Aaron Diamond AIDS Research Center’s early efforts on PMTCT. We wish to thank the Yunnan Bureau of Health (BoH), which gave its full support to the programme in the beginning, and continued to champion the project through all these years. We also thank all the health professionals at our sites who took part in the programme, including leaders of the local doctors from each China Centers for Disease Control and Prevention (CDC), antiretroviral (ARV) clinic, Maternal and Child Health (MCH) hospital, township health centre and village clinic. Finally, we wish to convey our appreciation to all the women and families that participated in our programme. It was only with their trust that we were able to carry out our work. The Chinese names start with Family name followed by first names whilst the European names start with first name followed by family name. v Towards eliminating perinatal transmission of paediatric HIV, congenital syphilis and viral hepatitis B in Yunnan: a case study, 2005–2012 Abbreviations ADARC Aaron Diamond AIDS Research Center ANC antenatal care ART antiretroviral treatment ARV antiretroviral drug AZT zidovudine BoH Bureau of Health CCDC China Centers for Disease Control and Prevention EID early infant diagnosis EPI Expanded Programme on Immunization HBIG hepatitis B immune globulin HBsAg hepatitis B surface antigen HBV hepatitis B virus iPMTCT integrated prevention of mother-to-child transmission L&D labour and delivery MCH Maternal and Child Health (programme) MoH Ministry of Health MTCT mother-to-child transmission NCAIDS National Center for AIDS/STD Prevention and Control NVP nevirapine PCR polymerase chain reaction PLHIV People Living with HIV PMTCT prevention of mother-to-child transmission RPR rapid plasma reagin TRUST toluidine red unheated serum test WHO World Health Organization YACC Yunnan AIDS Care Center YAI Yunnan AIDS Initiative vi Executive summary China began to implement services for the prevention of mother-to-child transmission (PMTCT) of HIV in 2003. By 2012, the national programme was expanded to 1156 counties. In 2011, the national Maternal and Child Health (MCH) programme included prevention of congenital syphilis and hepatitis B and the programme was renamed “integrated PMTCT” or iPMTCT. Yunnan province, located in southwest China, is severely affected by the HIV epidemic. The national and provincial governments made HIV prevention and treatment a priority in Yunnan. We describe the evolving and expanding PMTCT programme in Yunnan province informing the national scale up of PMTCT. This case study is divided into two parts. The first part describes the HIV PMTCT programme from 2005 to 2009. These were important years during which the programme worked within the existing local health structure to build a solid foundation for implementing PMTCT services integrated with routine maternal and child health services. The second part of this case study describes the iPMTCT programme from 2010 to 2012. In these three years, the triple antiretroviral (ARV) drug regimen for PMTCT of HIV was scaled up, and HBV and syphilis counselling and testing were added to those for HIV. Over the project period, the use of triple antiretroviral prophylaxis for HIV-positive women was rapidly scaled up. In 2012 more than 85% of HIV-positive pregnant women received triple ARV prophylaxis, and 86% of the 205 syphilis-positive women who gave birth in 2012 received benzathine penicillin treatment during pregnancy. Infants born to mothers who had hepatitis B surface antigen were given a birth dose of hepatitis B vaccine and hepatitis B immune globulin. vii Towards eliminating perinatal transmission of HIV, syphilis and hepatitis B in Yunnan: a case study, 2005-2012 Introduction China began to implement services for the prevention of mother-to-child transmission (PMTCT) of HIV in 2003. During this decade of implementation, the services have gone through several rounds of expansion and evolution.