XV International AIDS Conference, Bangkok, July 2004 The Odessa +PMTCT+ Model: A Replicable Reorganization of the Healthcare Delivery System for the Effective Prevention of HIV Transmission to Infants in Resource-limited Settings in Eurasia S. Posokhova,1 N. Nizova,2 G. Tyapkin,1 N. Gozhenko,1 Z. Shabarova,2 J.P. Smith,2 K. Schecter2 1Odessa Oblast Hospital, Odessa, Ukraine; 2American International Health Alliance (AIHA), Washington, DC, USA providers, and local NGOs to establish open lines of commu- BACKGROUND 100% 100 97% nication and effective referral and patient flow systems. This 100% Baseline Group 100 Baseline Group 97% 95% (1997– 1999) HIV infection is growing rapidly component of the Odessa +PMTCT+ Model is designed to PMTCT PMTCT 80 79% in Ukraine; by 2010 it is predicted strengthen service delivery, proactively reach women in high- (2001–2003) 76% 80 that 1.44 million people (3% of risk groups, and improve the early identification of HIV+ 69% 65% the total population, 48.4 million pregnant women to ensure complete case management, 60 60 55% in 2001) will be infected with the continuum of care, and on-going participation in the program. 56% virus.1 Currently Ukraine has the Percentage 40% 40 40 highest HIV prevalence rate in the UKRAINE This single institution approach was supported by the Odessa region, estimated at 1% of the Oblast Health Administration (OOHA) who issued a special Odessa Receiveing ServicePercentage of Women 20 20% adult population.2 From 1998 to order in May 2002 legislating the referral pattern: 20 2002, the number of new HIV 10% 2% 3% 2% 2% cases reported in pregnant • On-going Support and Follow-up Services: The Odessa Actual number 28 233 20 158 1 236 1 246 Actual number 1 236 5 133 34 111 9 3 31 88 Neonates HIV+ status First visit to OOH before Women appropriately ARV therapy Delivered by Birth canal Episiotomy Ruptured membrane who received known 2nd trimester treated with ARV before and/or C-section cleansing for less than 4 hours Ukrainian women rose from 686 +PMTCT+ Model provides ongoing social and medical care ARV prophylaxis before delivery prophylaxis regimen during to 2,022.3 Currently two-thirds of all children born to HIV+ to HIV+ women and their families. To this end, in June 2003, delivery Increased capacity for early Increased capacity to deliver comprehensive Of those who delivered vaginally 4 out of 45; out of 111 mothers in WHO’s European Region are delivered in Ukraine. OOH opened a satellite clinic that offers follow-up medical identification of HIV+ pregnant women preventive and curative services In 2002, in Ukraine, 1,379 children were born to HIV+ women care and social service referral. For the first time, HIV+ indi- Table 1. Selected delivery improvement results. Table 3. Labor/delivery. a 90% increase from the 727 cases reported in 2000.5 viduals in Ukraine can receive care at a facility located within a conventional, multi-profile hospital rather than at a specially- Baseline Group PMTCT In Ukraine, the Odessa Oblast (pop. 2.4 million in 2001) and designated AIDS Center. The creation of the clinic at OOH 100% 100% 100% 100% 98% 100% 96% 96% its principal city of Odessa (pop. 1.1 million in 2001) have also helps combat the stigma associated with HIV/AIDS. 100 the highest prevalence rates of HIV (361.3 per 100,000 oblast 95% 96% 96% 80% wide) in the country.6 • Training and Developing Health Professionals: In addi- Baseline Group 80 PMTCT tion to providing medical care and social service referrals 80 for HIV+ women, OOH staff are committed to training 60 PROJECT DESCRIPTION 65% 60 others in the region. To this end and with AIHA support, 56% In 2000, the Odessa Oblast Hospital (OOH) implemented a OOH and its partners 42% 40 40% 40% program for the prevention of mother-to-child transmission • in June 2003, opened the South Ukrainian AIDS Education 40 Percentage Receiveing Service (PMTCT) of HIV based on a comprehensive strategy endorsed Center (SUAEC), a PMTCT training center located within 20 7 20 by WHO, UNICEF, and UNAIDS. The Odessa PMTCT Project the OOH Maternity Hospital, to provide practical, skills- Receiveing Service Percentage of Women is supported in part by the American International Health based training to healthcare professionals throughout baseline Alliance (AIHA) and builds upon more than a decade of pro- Eastern Europe and Eurasia. SUAEC offers courses in all 2% unknown Actual Number 20 158 28 233 20 235 21 235 Actual number 1 24648 246 48 24440 240 244 Registered for HIV-test results Received pre- and Received vitamin A, Neonates given Neonates Mothers received Mothers received Mothers and neonates grammatic activity funded by USAID that uses partnerships facets of the Odessa +PMTCT+ Model, including integrat- prenatal care available before post- HIV-test iron, and ARV given post-delivery counseling post-delivery referred for during 1st delivery counseling folic acid therapy replacement on newborn family planning follow-up support trimester supplements feeding care/feeding counseling to a clinic between Ukrainian and American medical professionals to ed case management; infection control procedures and and/or NGO(s) strengthen regional and national health systems and address occupational safety; effective drug therapy; safe delivery Table 2. Prenatal care. Table 4. Post-natal/follow-up care issues such as infection control, women’s health, neonatal practices; prenatal, follow-up, and pediatric care; patient resuscitation, and primary care.8 The Odessa PMTCT Project education; and social support services. SUAEC is an affiliat- was also made possible with the help of other local and inter- ed training center of the Regional Knowledge Hub for the • 95% had HIV test results available before delivery (vs. 56%) • Build support within the local health authority and national organizations such as Me´decins Sans Fronti`eres (MSF), Care and Treatment of HIV/AIDS in Eurasia, a project • 96% had pre- and post-test counseling on HIV (vs. 40%) medical community to implement new referral protocols, who donated critical supplies and several training components. supported by WHO and GTZ;10 • 96% received vitamin A, iron, and folic acid supplements effective resource allocation, and continuing PMTCT • published English- and Russian-language versions of (vs. 42%) education for healthcare workers. The Odessa Model integrates three basic components of an practical guides that address topics related to PMTCT, • Establish, when possible, a main care facility at a place that effective PMTCT program: such as family planning, the prevention and treatment of Labor/Delivery (see Table 3) provides easy access to the population(s) it aims to serve. • access to and the use of efficacious antiretroviral (ARV) STIs, infection control practices, counseling, prenatal • 97% of HIV+ pregnant women had antiretroviral therapy For example, OOH is located in the “Palermo” region of drugs in accordance with established protocols; care, delivery, infant feeding, pediatric care, primary (ART) before and/or during delivery (vs. 2%) Odessa, a neighborhood known for drug dealing, and the • outreach efforts to identify HIV+ pregnant women and healthcare, and laboratory testing;11 and • 54% delivered by elective C-section (vs. 10%) home of many IDUs. facilitate their access to PMTCT care; and • developed Russian-language training materials and • Of those who delivered vaginally, • Establish a satellite clinic to provide follow-up medical care • comprehensive healthcare delivery services specifically curricula that are currently used by SUAEC faculty to • 100% had birth canal cleansing (vs. 75%) situated in a location convenient for targeted client base(s) designed for HIV+ women and their newborns. educate health professionals and policymakers. • only 3% had an episiotomy (vs. 20%) and/or local high-risk populations. • 79% had duration of ruptured membranes <4 hours • Develop partnerships with international organizations, The Odessa Model is defined as +PMTCT+ because it EVALUATION METHODOLOGY (vs. 69%) healthcare institutions, local community organizations, and includes pre- and post-pregnancy follow-up care in addition NGOs to ensure continuous management of care for HIV+ to successfully integrating the three components described An on-going, case-controlled study compares and tracks the Post-natal/Follow-up Care (see Table 4) women and their babies. above. The Model’s main objectives are to: effectiveness of +PMTCT+ intervention integrated into • 100% of the infants born to HIV+ women had ART (vs. 2%) • prevent HIV among women of reproductive age and pro- maternal/child health and primary care services. • 100% had replacement feeding (vs. 96%) SUMMARY vide family planning to HIV+ women; • The baseline group consists of 50 pairs of HIV+ women • 100% of the women received counseling on newborn • provide specific PMTCT interventions designed to decrease and their (50) babies who received care prior to the estab- care/feeding practices after delivery (vs. 96%) Successful PMTCT programs combine efficacious treatment the likelihood of transmission of HIV from mother to child lishment by OOH of comprehensive PMTCT activities. • 98% received family planning counseling after delivery with a cohesive infrastructure that includes comprehensive during the prenatal, delivery, and postnatal periods; and • The PMTCT group consists of 244 HIV+ women and their (vs. 80%) healthcare delivery services and outreach programs. The • provide follow-up monitoring, physical care, and social sup- 246 babies who participated in the Odessa PMTCT Pilot • 100% of the women and their babies were referred for Odessa +PMTCT+ Model is one that not only meets these port to the women, their babies, and their families using a Project. follow-up support to a clinic and to NGOs for continuing criteria, but is particularly suited for replication in other primary care approach. All results, except the MTCT rate, are calculated for the support; data for the baseline group is unknown countries that have a similar healthcare infrastructures and PMTCT group as of March 30, 2004.