Women and Children and the Economics of HIV/AIDS

FILIPINO WLHIV

Helen V. Madamba, MD MPH-TM FPOGS FPIDSOGCaraga Regional Hospital

Philippine Gateway Hotel, Surigao City

1 September 2017

OBJECTIVES

• To discuss the WHO consolidated guideline on sexual and reproductive health and rights of women living with HIV and to relate this to local guidelines

• To identify the available resources in the management of WLHIV

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UNAIDS 2016 Estimates

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Philippines is one of nine countries with increasing prevalence >25%.

Others are Bangladesh, Guinea-Bissaue, Georgia, Indonesia, Kazakhstan, Kyrgyzstan, Republic of Moldova, and Sri Lanka.

PHILIPPINES NOW

• MSM

• IV drug use

• gender-based violence

• teenage pregnancy

• single mothers

• new cases of HIV

• AIDS-related deaths

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HIV 101HIV is a virus that attacks the

immune system.

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HIV 101

2. As the viral load increases, the CD4 lymphocyte count decreases.

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HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

The age group with the biggest proportion of cases has become younger!

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15-24 year age group:

• 25% in 2006-2010

• 29% in 2011-2017


HIV among FemalesHVMADAMBA2017


HIV+ Pregnant Patients

• In June 2017, 11 cases of pregnant women with HIV were reported. 3 cases from Region 7.

• Median age was 23 years old

• Age Range: 15-31 yo

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VSMMC HIV TREATMENT HUBHVMADAMBA2017

PLHIV alive on ART 1,395

male 1,116

female 279

PMTCT cases 74

Pedia cases 10

• Primary prevention of HIV infection for key populations has to start in adolescence mainly because infections now occur at a younger age.

• On average, the initiation to sex and drug use is between 14 and 19 years old.

http://www.unicef.org/philippines/hivaids.html

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HIV Modes of Transmission

25-40% the risk of perinatal acquisition without intervention

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HIV/AIDS EPIDEMIC TRENDS IN THE PHILIPPINES

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HIV in 6 PH cities may reach 'uncontrollable' rates – DOH

Prevalence rate among males who have sex with males

http://www.rappler.com/nation/89412-hiv-6-philippine-cities-uncontrollable-rates

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Framework of WHO

recommendations and good practice

statements to advance the sexual and reproductive

health and rights of women living with

HIV

CREATING AN ENABLING

ENVIRONMENT

Healthy Sexuality across the life course

Integration of SRHR and HIV services

Community Empowerment

Healthy sexuality across the life course

Recommendation Strength of Recommendation, quality of evidence

Adolescent-friendly health services should be implemented in HIV services to ensure engagement and improved outcomes.

Strong recommendation, low-quality evidence

Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva: World Health Organization; 2017.


In generalized epidemic settings, anti-retroviral therapy should be initiated and maintained in eligible pregnant and postpartum women and in infants at maternal and child health care settings, with linkage and referral to ongoing HIV care and ART, where appropriate.


Integration of SRHR and HIV service



Sexually transmitted infections (STI) and family planning services can be integrated with HIV care settings.

Conditional recommendation, very low-quality evidence

Integration of SRHR and HIV service


Protection from violence


Women who disclose any form of violence by an intimate partner or sexual assault by any perpetuator should be offered immediate support. Healthcare providers should, as a minimum, offer first-line support when women disclose violence.

Strong recommendation, indirect evidence


Protection from violence


Care for women experiencing intimate partner violence and sexual assault should, as much as possible, be integrated into existing health services rather than as stand-alone service.

Strong recommendation, very low-quality evidence


Community empowerment


Introduce new, or reinforce existing, policies that prevent discrimination against health workers with HIV or TB, and adopt interventions aimed at stigma reduction among colleagues and supervisors.

Strong recommendation, moderate quality evidence


HEALTH INTERVENTIONS

Sexual Health Counselling and Support

Violence against Women Services

Family Planning and Infertility Services

Antenatal care and maternal health services

Safe abortion services

Sexually transmitted infection and cervical cancer services

Sexual health counselling and support


WHO recommends that for WLHIV, interventions on self-efficacy and empowerment around sexual and reproductive health and rights should be provided to maximize their health and fulfill their rights.

Strong recommendation, low quality evidence




WHO recommends that policy-makers and service providers who support WLHIV who are considering voluntary HIV disclosure should recognize that many fear, or are experiencing, or are at risk of intimate partner violence.

Strong recommendation, low- quality evidence




Children of school age should be told their HIV positive status and the status of their parents or caregivers; younger children should be told their status incrementally to accommodate their cognitive skills and emotional maturity, in preparation for full disclosure.



Family planning & infertility services


Anti-retroviral therapy (ART) should be initiated in all adults living with HIV regardless of WHO clinical signs and at any CD4 cell count.

Strong recommendation, modoerate-quality evidence




The correct and consistent use of condoms with condom-compatible lubricants is recommended for all key populations to prevent sexual transmission of HIV and sexually transmitted infections (STIs).

Strong recommendation, moderate-quality evidence




Women living with asymptomatic or mild HIV clinical disease can use the following hormonal contraceptives without restriction: • Combined oral contraceptive pills• Combined injectable contraceptives• Contraceptive patches and rings• Progestogen-only pills, progestogen-only injectibles• Norethisterone enenthate and levonorgestrel and

etonorgestrel implants

Strength of recommendation is indicated by MEC category




Women living with severe or advanced HIV clinical disease should generally not initiate use of the LNG-IUD (MEC Category 3 for initiation) until their illness has improved to asymptomatic or mild HIV clinical disease.

Moderate- to very low-quality evidence




Women who already have an LNG-IUD inserted and who develop severe or advanced HIV clinical disease need not have their IUD removed (MEC Category 2 for continuation).

LNG-IUD users with severe or advanced HIV clinical disease should be closely monitored for pelvic infection.

Moderate- to low-quality evidence


ANTENTAL CARE AND MATERNAL

HEALTH SERVICES

pregnant women living with HIV

*since 2010 to June 2017

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5%• Only five per cent of HIV-positive

pregnant women have received antiretroviral medicines to prevent mother-to-child transmission.

• Very few of those at-risk have taken an HIV test, with the number at zero for those under 18 years.

http://www.unicef.org/philippines/hivaids.html#.V2yW-_l95rQ

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Philippine Obstetrical and Gynecological Society (Foundation) Inc Clinical Practice Recommendation on

Prevention of Mother to Child Transmission of HIV Infection

November 2015

• HIV Screening

• Antiretroviral Drugs

• Management of Delivery

• Infant Feeding

• Contraception

POGS Clinical Practice Recommendations on PMTCT

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HIV ScreeningPreliminary Counselling Dialogue

Providers of obstetric care should

inform the patient that an HIV

screening test will be performed as

part of the recommended routine

antenatal package of tests of

infections (HBsAg, RPR/VDRL,

rubella IgG, papsmear, urine

culture)


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HIV ScreeningPreliminary Counselling Dialogue

Key Message:

The fact that you are pregnant is an evidence of unprotected penetrative

sexual contact which is a mode of transmission for HIV.


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Anti-retroviral (ARV) DrugsEligibility for ARV Prophylaxis

• Option A: maternal AZT + infant ARV prophylaxis

• Option B: maternal triple ARV prophylaxis until delivery or if breastfeeding, until 1 week after all exposure to breast milk ended

• Option B+: start triple ARVs as soon as diagnosed and continued for life


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Anti-retroviral (ARV) DrugsAdvantages of Option B+

• Earlier treatment for woman’s health and avoiding risks of stopping and starting triple ARVs especially in settings of high fertility

• Simple message to communities

“once ARV started, it is taken for life.”


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MODE OF DELIVERY

Management of DeliveryRole of Cesarean Section

Cesarean delivery should be scheduled at completed 38 weeks age of gestation: Have no prenatal consults

Have not received anti-HIV medications during pregnancy

Have a viral load greater than 1,000 copies/mL at 36 weeks AOG

Have unknown viral load near the time of delivery

POGS Clinical Practice Recommendations on PMTCT of HIV Infection, 2015.

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Management of DeliveryRupture of Membranes

If there is spontaneous rupture of amniotic bagof less then 4 hours, perform an emergencycesarean section, unless delivery is imminent.

*the risk of vertical transmission increased by 2% for everyincrease of 1 hour in the duration of ruptured membranes


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Management of DeliveryRole of Vaginal Delivery

Vaginal delivery may be performed when the risk of mother-to-child transmission of HIV is low

Take anti-HIV medications during pregnancy

Have a viral load less than 1,000 copies/mL near the time of delivery

If ever membranes rupture, the time elapsed should not be more than 4 hours to delivery.


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Management of DeliveryEssential Intrapartum Newborn Care (EINC)

Thoroughly dry newborn infant

× vigorous suctioning

Skin to skin bonding should be encouraged

×Delayed clamping of umbilical cord is NOT recommended. Minimize infant’s and health provider’s exposure to blood.

Latching on is done ONLY IF breastfeeding has been chosen.


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Antenatal Care and Maternal Health Services


WHO recommends that elective cesarean section should not be routinely recommended to women with HIV.





Late cord clamping (performed approximately 1-3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care.



1. In planning for child delivery, the benefits and risks of different modes of delivery should be discussed by the health care providers (e.g. obstetrician) to women living with HIV, including vaginal delivery, elective and non-elective C-section while being adherent to ART.

2. For risks of mother to child transmission of HIV to be significantly reduced, especially during child delivery, the pregnant WLHIV should be initiated and fully adherent with ART as early as possible in pregnancy.

3. Pregnant WLHIV need not be isolated during labor and delivery because of their HIV status. Health facility staff must perform standard precautions and infection control in all patients regardless of their patients’ HIV status.

4. Elective cesarean section (C-section) should not be routinely recommended to women living with HIV. C-sections should only be performed for standard obstetric indications.

5. When elective cesarean section is medically indicated, it shall be offered and should be scheduled at 38 weeks.



Anti-retroviral therapy (ART) should be initiated in all pregnant and breastfeeding women living with HIV, regardless of WHO clinical stage and at any CD4 cell count, and continued lifelong.



INFANT FEEDING

Infant Feeding

Avoid all breastfeeding in women who are HIV positive.

HIV infection is in the shortlist of medical conditions where replacement feeding may be permanently justified.

POGS Clinical Practice Recommendations on PMTCT of HIV, 2015.

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Infant Feeding

Option A: where ARVs are available, mothers known to be HIV-infected are recommended to breastfeed until 12 months of age

Option B: total avoidance of all breastfeeding

Guidelines on HIV and Infant Feeding. 2010. Principles and Recommendations for Infant Feeding in the

context of HIV and a Summary of Evidanee. World Health Organization, Geneva, Switzerland, 2010.


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Infant Feeding

OPTION B (avoidance of breastfeeding) is the strategy that may give Filipino infants of HIV (+) mothers the greatest chance of HIV-free survival.

Breastfeeding is staunchly supported and practiced

Formula feeding is similarly widely accepted, available and practiced in situations where breastfeeding cannot be sustained


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Infant Feeding• continuing ARV medications

• replacement feeding:

Acceptable

Feasible

Affordable

Sustainable

Safe (AFASS)• risks, follow up and other options for replacement feeding

• relieve breast engorgement


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Mothers living with HIV should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer while being fully supported for ART adherence.

Strong recommendation, low-quality evidence for 12 months, very low-quality evidence for 24 months


Mothers living with HIV are strongly recommended to exclusively breastfeed their infant in the first 6 months of life. Thereafter, complementary foods must be introduced and may continue breastfeeding for up to 24 months or longer while being fully supported for ART adherence.

Infant Feeding

PATIENT’S CHOICEINFORMED CONSENT

NO MIXED FEEDING

EXCLUSIVE breastfeeding or

AFASS replacement feeding

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Sexually transmitted infection (STI) and family planning services can be integrated within HIV care settings.

Conditional recommendation, very low-quality evidence




WHO recommends the human papilloma virus (HPV) vaccine for girls in the age group 9-13 years.

No details on strength or quality found, but recommendation is based on the GRADE approach


Primary prevention of HIV among women of child-bearing age

• A – abstinence

• B – be faithful

• C – check your status

• D – don’t do drugs

• E – educate yourself and others

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“HIV will end with me!”HVMADAMBA2017

FILIPINO WLHIV

Helen V. Madamba, MD MPH-TM FPOGS FPIDSOGCaraga Regional Hospital

Philippine Gateway Hotel, Surigao City

1 September 2017

Registration Rates:Pre-registrationConsultants: P1200 Residents/Paramedical: P800On-site: Consultants: P1500 Residents/Paramedical P1000*DEADLINE OF PRE-REGISTRATION: September 8, 2017.

Payment Details:1.Pay directly to Dr. Alcantara’s secretary, Ms. Catalina Daclison at Room 314, Chong Hua Medical Arts Bldg.3 (M-F: 3-6 pm, Sat: 12nn-4pm), landline: (032) 4120965.2.Deposit your payment through BDO (Clarita B. Alcantara, Account No. 2310468009) and email validated deposit slip to [email protected] Chief Residents until September 4, 2017

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Women and Children and the Economics of HIV/AIDS

Healthcare

Transcript of Women and Children and the Economics of HIV/AIDS