Minutes of the Fifth Meeting of the Technical Resource Group on PPTCT/EID

05 December 2016 Ç€ 10:00 hrs – 13:30 hrs

Venue: UNICEF- CB Room, 73 Lodhi Estate | New Delhi

The meeting was chaired by Dr K. Satyavathi,

Meeting began with welcome address by Dr. K.S Sachdeva, DDG (BSD) followed by opening remarks by the Chairperson.

Chairperson in the opening remarks mentioned that while things were moving in the right direction since inception of the programme and the expansion of PPTCT services but still there is huge gap in testing of pregnant women in some states. This needs immediate remedial action looking at the elimination of MTCT goals by 2020. A concerted effort needs to be made, besides formal IEC programs, to focus on community education. NACO needs to enhance HIV testing of spouses, male partners, families and children. FOGSI, IMA and other such well-established societies may facilitate this activity.

Members of the Technical Resource Group on PPTCT/EID discussed on the following agenda items under the chairpersonship of Dr. K. Satyavathi:

• Progress of the PPTCT and EID programme in the country
• Operational and service delivery challenges in PPTCT and EID
• Preparation for sub-national validation of EMTCT in five states
• Private sector engagement in HIV and syphilis testing of pregnant women
• Discussion on new WHO/UNICEF 2016 infant feeding guidelines and ARV prophylaxis

Discussion point	Suggested  follow-up
Progress of the PPTCT and EID programme in the country
The programme has advanced efforts to increase early HIV and syphilis detection among pregnant women, facilitate early linkage to treatment, and prevent new HIV infections among babies in 2016-17 However, a lot more needs to be done to achieve the goal of eliminating mother to child transmission of HIV and syphilis in the country.	Collaborative effort and joint strategic action by all partners is critical, including with NHM, regional institutes, medical colleges, private sector, UN and development partners, etc. Focus on EMTCT at the policy / strategy level can be reinvigorated, with focus particularly on those states where coverage can be expanded. Key response measures for tackling the main 2-3 challenges can be identified per state.

AGENDA 1: ACTION TAKEN ON RECOMMNEDATIONS BY 4TH TRG

Context:

Action taken report on the fourth TRG meeting of PPTCT/EID held on Sep 2015 was perused by members. All action points completed except for decentralization of ART services to LAC Plus and then to all LAC for pregnant women. A corrigendum on case scenarios as suggested by Dr Anju Seth will be circulated to all ARTc.

Discussion point

Suggested follow-up

There are currently 12 states / union territories where ART coverage of HIV positive women detected is over 95%, but in remaining states there are gaps between testing and those on treatment. Decision has been taken to further decentralise ART services to LAC Plus and then all LAC. At the field level, all doctors, especially those in the private sector may not be aware of the updated treatment guidelines and some may be cautious is taking up HIV positive cases.

Training of ICTC Medical Officers to be conducted for roll-out of ART services at LAC Plus and then LAC. At least one printed copy of the guidelines should be sent to all centres. Additionally, they should be made easily accessible at all key websites. FOGSI and IMA are encouraged to upload them. FOGSI sub-committee on women’s health encouraged to get actively involved in PMTCT efforts and sensitise private sector doctors. Systematic efforts to reduce Stigma &Discrimination  among health care providers need to be built in through various mechanisms including trainings, with private sector involvement

 

AGENDA 2: Overview of the National PPTCT and EID Programme

Discussion

HIV testing has become more decentralised due to introduction of FICTCs and PPP-ICTCs as screening centres. Going forward programme hopes for more screening load shifting to these facilities. Testing has been scaled up, 45% of the pregnant women (PW) who register at ANC clinics (95% of estimated PW) were tested for HIV in 2015-16 leading to identification of 35% of the estimated HIV positive PW.

It was pointed out that even in states where testing coverage is high there are gaps between estimated and identified infected PW. The gap between ANC registrations and HIV testing was due to the unavailability of screening facilities at all ANC registration points.92% of the women identified as HIV positive were put on treatment in 2015-2016. There has also been a high observed sero-discordance between PW and their partners who have undergone spouse testing.

The launch of the New National HIV Counselling  and Testing Guidelines by the Hon Health Minister of GoI and its  rolled-out was discussed.  Issue of diminished  coverage of  HIV testing among pregnant women in northern states was discussed.

The problems related to fear/ignorance amongst private sector healthcare providers for conducting  deliveryof HIV positive pregnant women and the challenges in reporting of private sector was discussed.

In light of the above discussions, TRG members recommended the following:

• NACO need to increase HIV testingat the PHC / sub-centre and VHND, particularly in those states where testing coverage is less.
• Hard copy of new HIV testing guidelines to be made available at all centres and to be rolled-out even at PHC / sub-centres.

• NACO need to disseminate the new testing guidelines among private sectorthroughFOGSI and IMA,for country wide implementation.

• Institutions like IMA, IAP, FOGSI etc. need to  drive mandatory reporting of HIV testing by private practitioners to public health systems.

• Reporting in SIMS could be opened for private practitioners with minimum crucial indicators which will help in bridging the gap in ANC HIV testing coverage.

AGENDA 3: Operational & Service Delivery Challenges in the PMTCT & EID Programme

1. PMTCT Programme

Discussions

There are four prongs to the PPTCT program – a) Primary prevention of HIV, b) Prevention of unintended pregnancies, c) Prevention of MTCT and d) Care, Support and Treatment. The program has undertaken several initiatives for Adolescents like YUVA and Red Ribbon club under Prong 1 but as of now, there are no proactive family planning measures under prong 2. For Prong 3 the programme has increased testing but currently only ~45% of the total pregnant women registered at ANC were tested for HIV in 2015-16. Recently the program adopted universal HIV testing of pregnant women in order to improve testing coverage and reduce transmission of HIV to the babies. With the adoption of Option B+, all identified pregnant women will be initiated on ART immediately irrespective of their CD4 count to reduce the probability of transmission. However, the program still needs to further improve the reach and reduce linkage losses due to operational inefficiencies to achieve the aim of elimination of MTCT of HIV.

Among adolescents the age of consent is 18 while mean age of high risk behavior is 14 years of age.Unless laws are reformed to change age of consent, effective initiatives for adolescents would be difficult to implement.

It was highlighted that in the current SIMS format, HIV testing data among adolescents is not available. It is possible that a large section of the population may be missed, especially in the public sector, due to the need for parental consent if the person is a minor.

It was observed that Spouse Testing among general individuals need to improve ,based on the programme data presented. The idea of universal spouse testing of HIV negative pregnant women could be explored where HIV prevalence is high.

Most pregnant women go to multiple windows to access ANC package services which can be inconvenient from a beneficiary’s perspective.

The  recommendations of  paediatric ART TRG regarding HIV exposed babies  being initiated on ART based on presumptive diagnosis, regardless of PCR test results, was appreciated.

In light of the above discussions, TRG members recommended the following:

NACO to capture the data of HIV testing in adolescents in SIMS

More innovative ideas for reaching out to adolescents need to be considered, to strengthen the coverage of various interventions.

Spouse / partner testing are a key intervention for positive prevention.  Differentiated strategies based on geographies could be explored. ART centres could be leveraged for Partner testing if feasible as patients arrive every month to collect ARVs.so spouse testing may not be limited to ICTC.

Models for single window PMTCT services to be documented, which could be replicated.

1. EID Programme

Discussions

Early Infant Diagnosis (EID) is used to diagnose HIV infections in infants and children less than 18 months of age. Since the mortality rates in HIV infected infants are very high with ~33% dying by first year and 50% by the second, it is critical to ensure prompt delivery of test results and rapid initiation on treatment. The infants of 85% of detected PW were tested under EID programme, implying only 30% coverage of EID services. In FY16, the median turnaround time (TAT) for infants, who were tested by PCR, between sample collection at ICTC and result dispatch from the PCR laboratory was ~62 days. 19 days out of 62 days were spent between collecting a sample at ICTC and dispatching it to the lab. The time taken to dispatch samples after collection at ICTC has increased over the years.

Moreover, ~50% of the infants who had a positive screening test did not come for a confirmatory PCR test in 2015-16. LFU has also shown an increasing trend over the years.

It was highlighted that in the FY 16, the median turnaround time (TAT) for infants, who were tested by PCR, between sample collection at ICTC and result dispatch from the PCR laboratory was ~62 days.

In light of the above discussions, TRG members recommended the following:

• NACO to plan action towards reducing turnaround time in PCR Labs and ensureprompt delivery of PCR results through email to ICTC can be done
• District AIDS Prevention &Control Unit be leveraged to reduce LFU and fast track the process

AGENDA 4: Validation of Elimination of Mother to Child Transmission (EMTCT) of HIV in 5 states in India

Discussions

Mother-to-child transmission of HIV is the primary route of HIV transmission among infants. Out of the estimated 2.1 Million PLHIV in the country, nearly 35,255 (estimated) pregnant women with HIV would require PPTCT services each year.

The Government of India is committed to the global target of eliminating new HIV infections among children by 2020 by eliminating parent to child transmission (ePTCT). However, WHO recommends that countries meet global minimum criteria before initiating ePTCT validation process. Countries must maintain these national level process targets for 2 years and impact targets for 1 year as evidence of achievement of EMTCT of HIV. The minimum EMTCT of HIV targets are:

• Impact Targets
  • A case rate of new paediatric HIV infections due to MTCT less than 50 per 100,000 live births
  • MTCT rate either <5% in breastfeeding populations or <2% in non-breastfeeding populations
• Process Targets
  • Antenatal care coverage (at least one visit) should be > 95%
  • Coverage of HIV and/or syphilis testing of pregnant women should be > 95%
  • ART coverage of the identified HIV positive pregnant women should be >95%

Data from Andhra Pradesh, Tamil Nadu, Karnataka, Mizoram and Maharashtra suggests that they may havereached the three process indicators for HIV EMTCT. It is thus essential to conduct regional validation for these 5 states. It is important to review their existing data and propose data quality improvement to prepare for WHO validation.

In light of the above discussions, TRG members recommended the following:

• Preparation for the National validation of EMTCT in Phase 1 states (Andhra Pradesh, Tamil Nadu, Karnataka, Mizoram and Maharashtra ) to be initiated.
• SOPs, including strategy, methodology, tools, etc. to be developed / finalised by the National Core Group on EMTCT and an implementation plan to be formulated.
• A key component of the pre-validation process would be data verification and impact assessment, in addition to programmes and services, lab services, etc. 
• Additional research studies can be considered to plug data gaps, strengthen assumptions or information on other parameters to better understand the local context and substantively help in explaining the gap between HIV positive women being detected in high ANC coverage states and those estimated. Private sector data could be looked at from this context.

AGENDA 5: Lessons from Cuba & Thailand Elimination efforts

Discussions

Every year, globally, an estimated 1.4 million women living with HIV become pregnant. Untreated, they have a 15-45% chance of transmitting the virus to their children during pregnancy, labour, delivery or breastfeeding. However, that risk drops to just over 1% if antiretroviral medicines are given to both mothers and children throughout the stages when infection can occur. As treatment for prevention of mother-to-child-transmission is not 100% effective, elimination of transmission is defined as a reduction of transmission to such a low level that it no longer constitutes a public health problem. There have been major efforts in recent years to ensure that women get the treatment they need to keep themselves well and their children free from HIV and syphilis. A number of countries are now poised to eliminate mother-to-child transmission of both diseases.

So far 5 countries have been validated by WHO – 1) Cuba (Dual elimination), 2) Thailand (Dual elimination), 3) Armenia (HIV MTCT elimination only), 4) Moldova (Syphilis MTCT only) and 5) Belarus (Dual elimination).

Lessons from Thailand

The following factors helped Thailand achieve HIV eMTCT

1. Strong commitment from the government to reach the last mile
2. Involvement of various partners in eMTCT initiative
3. Universal health coverage – universal access to PMTCT services was extended to undocumented migrant workers as well
4. Self-reliant budget
5. Capacity building of healthcare workers
6. Constant Monitoring of PMTCT
7. Quality data management systems

AGENDA 6: Strategies to strengthen Private Sector engagement for HIV & Syphilis testing in pregnant women to eliminate MTCT

Discussion

A presentation was made on the extent of private sector participation in providing ANC services. There are more than 150,000 facilities and 1.7 million providers in the private sector (according to a mapping exercise conducted by SAATHII). There is no other database available for this kind of information, They have therefore undertaken mapping in 235/295 districts in 12 states and 2 UTs.

1. 22% of unreported deliveries occurs in private setor
2. Out of total institutional deliveries (18.6 million), private sector account for 29% of institutional deliveries (5.4 Million) and 20% of total deliveries in the country.
3. Despite covering 90% of pregnant women, the positivity is less than .008%. This is a puzzling factor and needs further scrutiny

SAATHII to Engage FOGSI, IMAI, IAP, Indian association of microbiologists and pathologists, nurses, nursing homes, Ayush providers and laboratories and Rotary and Lions club at the national and state level

TRG members recommended the following:

• New HCTSg guidelines can made available on the portal of private associations
• EQAS  for PPP model of HIV testing in private sector facilities need to be developed by NACO
• Engage paediatricians and corporate chain of hospitals in the program

AGENDA 7: Discussion on WHO/UNICEF 2016 infant feeding guidelines and ARV prophylaxis

Dr. Anju Seth provided a detailed overview to the new guideline which addresses four aspects of infant feeding in the context of HIV

The current WHO 2016 Recommendations for infant feeding have the following three updates from previous guidelines –

1. Breastfeeding to be continued till 24 months of age even for HIV negative exposed infants if mother is on ART and her adherence is good
2. Mothers who would like to provide mixed feeding should be reassured that providing some breast feeding is better than never initiating breastfeeding at all
3. Mothers who do not plan to breastfeed tillthe baby is of 12 months of age should also be reassured that a shorter duration of breast feeding is preferable to never initiating breast feeding

Vote of Thanks

Meeting ended with thanks to the chair

Annexure -1

Agenda for 5th Meeting of Technical Resource Group on PPTCT/EID

5 December 2016,

UNICEF-CB Room,Office, 73 Lodhi Estate, New Delhi

Time	Topic	Moderator
10.00- 10.10	Welcome Address	Dr. K.S Sachdeva DDG(BSD), NACO
10.10- 10.20	Opening Remarks & Objectives of the Meeting	Dr. K. Satyavati Chairperson TRG
10.20- 10.30	Action taken on minutes of last TRG held on 24th Sept 2016	Dr. AshaHegde, NPO ICTC
10.30– 10.50	Overview of the National PPTCT & EID Programme	Dr. K.S Sachdeva DDG(BSD), NACO
10.50- 11.10	Operational & Service Delivery Challenges in PPTCT/ EID	Dr. Naresh Goel, DDG- Lab services Dr. Asha Hegde, NPO ICTC
11.10- 11.30	Validation of EMTCT in 5 States	Dr. K.S Sachdeva DDG(BSD), NACO
11.30– 11.45	Experiences gained from Cuba and Thailand for Elimination of-MTCT	Dr. Sudha , UNICEF
Working Tea
11.45–12.15	Strategies to strengthen private sector engagement for HIV  & Syphilis testing in pregnant women to eliminate MTCT	Ms. Subashree, SAATHII
12.15-12.30	Discussion on new WHO/UNICEF 2016 Infant feeding guidelines and ARV prophylaxis	Dr Anju Seth, Dir PCOE, Delhi
12.30- 13.00	Any other issue with the permission of the Chair	All members & participants
13.00-13.15	Summary of discussion	Chair person
1.15-2.00 (Lunch)

 

Annexure -2

List of Participants of 5th TRG meeting on PPTCT

Sr. no
1	Dr. K. Satyavathi, Chairperson of TRG on PPTCT		Former Head of  Obstetrics and Gynecology, Osmania Medical College, Koti, Hydrabad, AP
2	Dr. K. S. Sachdeva		DDG-BSD, NACO
3	Dr. R. S. Gupta		DDG-CST, NACO
4	Dr. Ashok Kumar		Ex. Addl. DGHS, MOHFW/GoI
5	Dr. Asha Hegde		NPO-ICTC/NACO
6	Dr. DCS Reddy		Technical Expert
7	Dr. Sheela Godbole		Scientist E, NARI
8	Dr. Ramesh Bhosale		HOD- OBG, BJMC, Pune
9	Dr. Rajesh Kumar		HOD – School of Public Health,  PGIMER, Chandigarh
10	Dr. Preety Pathak		I/c ICTC/PPTCT, UPSACS
11	Dr. Manju Bala		Prof. of Microbiology Safdarjung Hospital, New Delhi
12	Dr. Anju Seth		Prof. of Pediatrics, and Prog. Director, PCoE, Kalawati Saran Children Hospital, LHMC, New Delhi
13	Dr. Sumitra Yadav,		Prof. of OBGYN, MGM Medical College, Indore
14	Dr. Oussama Tawil		Country Director, UNAIDS
15	Dr, Nalini Chandra		PO, UNAIDS
16	Dr. Nicole Seguy		Team Leader, CDS, WHO
17	Dr. Timothy Holtz		Director, HIV-TB, CDC India
18	Dr. Srilatha Sivalenka		Sr. Public Health specialist, CDC
19	Ms. Deepika Joshi		Public Health Analyst, CDC
	Dr. KK Aggrawal		National President, IMA
21	Dr. Ranjana Khanna		Vice President, FOGSI
22	Dr. Naina Rani		NC, PPTCT, WHO
23	Dr. Sudha Balakrishnan		Health Specialist UNICEF
24	Dr. SubhashreeRaghavan		President, SAATHII
25	Dr Rochna Mitra		Project Director, AHANA Project, Plan India
26	Ms. Mona Balani		Treasurer, NCPI+
27	Ms. Parul Goyal		Clinton Health Access Initiative (CHAI)
28	Ms. Yashika Bansal		Clinton Health Access Initiative (CHAI)
29	Dr. TLN Prasad		Team Leader, NTSU, NACO
30	Dr. Rajesh Deshmukh		PO (HIV/TB), NACO
31	Dr. Sunny Saravankar		PO (ICTC), NACO
32	Dr. Sujit P		TO (M&E), NACO
33	Dr. Jyoti		TO (HIV/TB), NACO
34	Mr. Tejas Mulik		Consultant (PPTCT), VHS CDC
35	Mr. Mubarak Ali		TO (PPTCT), NACO
36	Mr. Rajiv		AC (BSD), NACO
37	Dr. Shikha Handa		TO (Lab Services), NACO
38	Ashber Gaym		Health  Specialist UNICEF