# Presentation: 764281

## President’s PMTCT Initiative

- Nathan Shaffer, MD
- PMTCT Team Leader
- Perinatal HIV Prevention Meeting
- June 10, 2003

## Why Focus on Mothers and Babies?

-  720,000 new mother-to-child HIV infections in 2001
- 2,000 new infections each day
- Erasing child survival gains
- Transmission risk can be reduced by at least 50%
- Feasible, affordable in low-resource settings
- Opportunities for primary prevention, access to partners, family care and treatment

* **	**Clinical trials have proven the efficacy of *
*   **low-cost, simplified PMTCT interventions*
*	*
*	**PMTCT programs can be important gateway to primary prevention and clinical care*
-  	*However, major challenge remains how to:*
*implement effective PMTCT programs in resource-poor countries*
*how to scale-up national programs*

## International Support for PMTCT

- 1998:  UNICEF pilot programs
- 1999:  EGPAF Call to Action program
- 2000:  Boerhinger-Ingelheim NVP drug donation
- 2000:  WHO recommends PMTCT as standard MCH
-            care
- 2001:  UNGASS:  50% access to PMTCT by 2005;
- 		  80% access, 50% decrease PMTCT by 2010
- 2002:  MTCT-PLUS (PMTCT plus family ARV
-            treatment; Rockefeller and Columbia U.)
- 2002:  Global Fund
- 2002:  President’s Initiative for PMTCT

## Objectives for the Initiative

- Reach up to           1 million women annually
- Reduce mother-to-child HIV transmission by    up to 40% among women treated

*WHO/P. Virot*

## Key Program Elements

- Performance-based
- Coordinated USG activities (CDC/ USAID)
- “Twinning”
- Volunteer Medical Corps
- Support for NGO sector
- Support for faith-based organizations

## Designated Countries in the President’s Mother-to-Child Initiative

_**Africa**_
- Botswana
- Côte d’Ivoire
- Ethiopia
- Kenya
- Mozambique
- Namibia
- Nigeria
- Rwanda

- South Africa
- Tanzania
- Uganda
- Zambia
_**Caribbean**_
- Guyana
- Haiti
- 15. CAREC / Caribbean Region

**Notes:**
The Administration selected these 14 countries based on 
the burden of HIV/AIDS, particularly as indicated by ANC data, 
the level of infrastructure to support targeted efforts to prevent mother-to-child HIV transmission, 
the individual country governments’ commitment to preventing HIV and treating those infected.

## Why These Countries?

- High HIV burden
- Strong USG country offices (GAP and USAID)
- Commitment to PMTCT
- Likelihood of success

## Baseline Assessment Findings: Antenatal HIV Prevalence in PMTCT Initiative Countries

## Funding for PMTCT Initiative

- $500 million, 5 years, appropriated over 2 years
- FY ’03
- $40M HHS (CDC/GAP)
- $100M USAID
- FY ’04 (expected)
- $150M HHS (CDC/GAP)
- $150M USAID

## President’s Emergency Plan for AIDS Relief[Proposed for FY ’04,  $15 billion, 5 years]

- Prevent 7 million new infections  (60% of  projected new infections) *Large-scale prevention efforts, supported by treatment*
- Treat 2 million HIV-infected people** **** ***First global effort to provide advanced ARV treatment on large scale in poorest, most afflicted countries*
- Care for 10 million HIV-infected individuals and AIDS orphans  *Range of care, including support for AIDS orphans*

**Notes:**
$15B over 5 years, including $10B new money

PMTCT initiative seen as a model for this effort; same 14 countries:
In Africa:
Botswana
Cote d’Ivoire
Ethiopia
Kenya
Mozambique
Namibia
Nigeria
Rwanda
South Africa
Tanzania
Uganda
Zambia and, 
in the Caribbean,
Guyana
Haiti

## EPAR Management: State DepartmentCoordinator for International HIV/AIDS 

- Appointed by the President
- Confirmed by the Senate
- Rank of Ambassador
- Report directly to the Secretary of State
- Responsible for overseeing all U.S. international HIV/AIDS assistance within Initiative and coordinating efforts of various implementing agencies and departments

## PMTCT Core Program Elements

- Counseling and testing services at ANC and labor and delivery (routine, opt-out)
- Short-course ARV  prophylaxis for HIV+ mother-baby pairs
- Counseling and support for safe infant feeding practices
- Counsel_i_ng and/or referral for family planning

## Expanded Program Elements for the Presidential PMTCT Initiative

- Prevention strategies for pregnant HIV- negative women
- Integration of PMTCT services into MCH services
- Palliative care, psychosocial support
- Community mobilization to enhance PMTCT/ MCH activities, decrease stigma
- Strengthen health, family planning, and safe motherhood programs
- PMTCT-PLUS demonstration sites

## Elements of PMTCT Program Logic Model

**Activities**

**Core Monitoring Indicators**

** ****% of sites meeting quality standards**
**# of technical assistance visits**

## Implementation Strategies and Partners

- _CDC_
- Cooperative agreements with MOH
- In-country contracts and agreements
- Central cooperative agreements (eg. UTAP, other)
- _USAID_
- Existing cooperating agencies
- New partnerships (eg. Elizabeth Glaser)

## PMTCT UTAP Partners

- University of North Carolina at Chapel Hill
- Baylor College of Medicine
- Columbia University
- Harvard Medical School
- Johns Hopkins University

- Tulane University
- University of Maryland
- Howard University
- University of Medicine and Dentistry of New Jersey
- University of California, San Francisco

## Coordination Across USG Departments and Agencies

- Steering Committee
-      White House Office of National AIDS Policy, Dept. of Health and Human Services, CDC, HRSA, USAID, State Department, Office of Management and Budget
- 5 Work Streams
- Program Services
- Procurement
- Human Resources
- Monitoring, Evaluation, and Operational Research
- Budget

## Country Program Planning Process

- Joint USAID/CDC in-country planning process
- Countries will complete/ have completed :
- Baseline Assessment 		March ‘03
- Initial Program Proposal (IPP) 	April ‘03
- Initial Obligation Plan (IOP)	April-May ‘03
- Receive initial funding		May/June ’03
- Implementation Plan (IP) 		October ’03
- Receive remaining ’03 funds  Sept/Oct ’03
- Annual IP’s				September

## M&E Indicator Matrix

| 
Planning/Inputs |  Services
Available | 
Outcomes | 
Impacts |
| --- | --- | --- | --- |
| National
Guidelines exist | # Volunteers to field | Service Uptake         (# / %):
- CT
- Results
- ARV to              prevent MTCT | # Infections
Averted |
| Steering
Committee exists | # Workers Trained |  | % Reduction
in MTCT |
| Program. Expansion
Plan exists | # PMTCT Sites |  |  |
| # Twinning
Programs | # PMTCT+ Sites | % PMTCT-ARV Prophylaxis |  |
| Commodities
Dist./Mon. System  |  |  |  |

## CDC Technical Areas of Interest

- PMTCT training curriculum
- National PMTCT monitoring system
- M&E Capacity-building
- Operational research/ program evaluation
- Laboratory
- Other

**Notes:**
The purpose of this system is to:

## PMTCT Program Challenges 

-  Training
-  Program management
-  Community support/access to
-   male partners
-  Simple monitoring systems
-  Infant feeding
-  National scale-up
-  PMTCT services outside of facilities

## Summary

- PMTCT Initiative new paradigm for USG international HIV/AIDS programs
- Tremendous challenge and tremendous opportunity
- Will provide framework for new and larger initiatives
- Profound impact on CDC/GAP