Issues for Policy decision options

Health policy makers need further guidance on the following policy issues:

1. When and where to introduce Nevirapine?

Potential criteria:

· Incidence of MTCT

· Knowledge of safety/adverse effects and need for further research

· Experience with large-scale implementation of ARV regimens already in place (short/long regimen of ZDV)

· Replacement of AZT short regimen by Nevirapine among breastfeeding women

· Affordability verses health budget

· Operational feasibility: capacity of health system to implement VCCT, deliveries attended, and capacity of systems to reach women/children after the delivery

· Nevirapine procurement

· Role of the private sector in offering treatment

2. Implication for counseling on infant feeding?

Instead of AZT and replacement feeding, potential criteria for exclusive breast-feeding and Nevirapine with or without a postnatal component:

· Under 5 mortality

· Affordability of replacement feeding

· Marginal cost-effectiveness of adding AZT or NVP during the exclusive breastfeeding period to the short regimen of NVP

· Present Breast-feeding patterns, notably exclusive breastfeeding

· Stigma associated with replacement feeding

3. Implications for relevance of VCCT

Potential criteria:

· Is it already in place?

· Discrimination/stigma linked to HIV positive test results

· Access and quality and effective use of MCH services

· Other potential benefits to intervene: development of user-friendly services, primary prevention among women of reproductive age

Potential operational packages for countries of East Asia and Pacific

Countries of the East Asia and Pacific Region can be grouped in function of the particular context including health system development and resources available. Within each group, different packages can be developed in function of the prevalence and incidence of HIV in specific areas.

	Group A (Thailand, Malaysia)	Group B: Myanmar, Cambodia/PNG	Group C: Vietnam, China, Philippines/Indonesia
High prevalence areas	Full package PMTCT: VCT-ARV-IFC + PREVENT and SUPPORT	Improve access MCH + trigger response to HIV + test full package PMTCT	Test full package PMTCT+ Improve quality MCH
Low prevalence/high incidence areas	VCT-ARV-IFC + PREVENT	Improve access to MCHPREVENT package Exclusive BF	Improve quality MCHPREVENT package Exclusive BF
Low prevalence/low incidence areas	VCT-ARV-IFC	Exclusive BF	Exclusive BF

Some countries already identified the key packages to be implemented in their own context. The tentative packages for Vietnam, Myanmar and Cambodia are presented below as national managers developed them.

1 Vietnam

The Vietnam approach proposes to implement several different packages into the UNICEF country program within existing health care services. Four main packages are proposed. The most comprehensive is to be implemented in three provinces (Quang Ninh, An Giang, Kien Giang) and two cities (HCMC, Haiphong)

	Package 1	Package 2	Package 3	Package 4
		Community Based Monitoring Project	Safe Motherhood & Community Based Monitoring	Pilot three districts and two cities
	Everywhere	14 districts	18 districts	3 districts &2 cities
Phase alpha		Condom promotion	- Life skills - Condom promotion	- Life skills - Condom promotion - STIs
Phase 1: Inform		STI management	- RH Counselling - STI management	- HIV testing & counselling in women’s health services - STI management - Syphilis screening and treatment
Phase 2: Prophylaxis		-Safe delivery practices-Universal precautions	- Safe delivery practices - Universal precautions	- ARV treatment - Safe delivery practices - Universal precautions
Phase 3: Care	Exclusive breastfeeding up to 4 months	Exclusive breastfeeding up to 4 months	Exclusive Breastfeeding up to 4 months	Infant feeding & counselling
Phase omega				- PCP prophylaxis - TB diagnosis and treatment - Social support - Home based care - Acceptance raising
Opportunity				- Existing Counselling capacity in HCMC and Hanoi
Additional Benefit	Reinforcement of exclusive breastfeeding	Reinforcement of exclusive breastfeeding	Integration of condoms and life skills within safe motherhood	Development of a Vietnamese approach for counselling within reproductive health services

2 Cambodia

Four different groups of health facilities providing antenatal and obstetric services were identified in which activities to prevent Mother To Child Transmission of HIV could be implemented. A specific package of activities was developed for each of these groups. (see tables 1 and 2 below). The groups were the following: MCH Hospitals which are to represent quality standards in public services: the National MCH center and the Calmette hospital

· Hospitals to represent standards of care in the private sector (not for profit and for profit)

· A pilot district (including hospital and satellite health centers) in which the full package of improved reproductive health and enhanced response to HIV (including prevention in high risk groups and care) is to be offered and a model tested for future extension on a national scale.

· All the other health centers/antenatal clinics throughout the countries in which a minimum package to respond to HIV among the population of reproductive age is to be offered

	All health centers	One pilot district including hospital and satellites health centers	Public Hospital		Private Hospital
Site chosen		Battambang	National MCH,	Calmette
Phase Alpha: reducing HIV+ pregnancies	100% condom policy in commercial sex places Life Skills STIs treatment Family Planning	100% condom policy in commercial sex places Life Skills STIs treatment Family Planning	Counseling in Treatment of STIs Information	Family Planning
Phase 1: Inform in ANC	Anaemia prophylaxis Treatment of STIs in pregnant women	Treatment of STIs Counseling inTreatment of STIs Information VCCT Improved ANC Syphilis Partner’s information Partner’s testing	VCCT Improved ANC STIs SyphilisPartner’s information Partner’s testing		Idem
Phase 2: Prophylactic treatment	UP SOP BCC	ARV UP SOP BCC	HIV+ mothers: ARVUPSOPBCC	HIV - and unknown status UP SOP BCC	Idem public
Phase 3: Care of children and mothers	Exclusive Breastfeeding up to 6 months Complementary feeding as off 6 months IMCI	Infant feeding counseling IMCI	HIV+ mothers: Infant feeding counseling for HIV+ mothers: BMS or EBF, early cessation and complementary food IMCI	HIV - and unknown status mothers Infant feeding counseling for EBF 6 months and complementary food IMCI	Idem public
Phase w		Communication for Acceptance raising Home based Care PCPP TB	Home based Care PCPP TB

3 Myanmar

In Myanmar activities of prevention of Mother To Child Transmission of HIV are proposed to be mainstreamed in the existing IMMCI program and in the HIV/AIDS project areas. In addition several pilot districts (districts with high HIV prevalence) are to implement the full package of prevention including ARV.

Myammar	IMMCI	HIV AIDS project areas	Pilot 3 districts
Phase Alpha: Prevent		Life Skills Condom Promotion STIs	Life Skills: in out-of school Condom promotion STIs FP
Phase 1: Inform	Quality ANCSTIs		VCT STIs
Phase 2: Prophylaxis	Safe delivery UP		ARV Safe delivery UP
Phase 3: Care	Exclusive BF 6m IMCI	Exclusive BF 6m	Infant feeding counseling
Phase Omega: Support			TB Spiritual support Acceptance raising

Conclusion: Crosscutting issues for scaling up

1. There is now a large range (figure 11) of potential interventions, which are effective for PMTCT. In this menu of interventions each country is to choose the intervention most appropriate to its own epidemiological, economic, and health system situation.

2. Although the intervention regimens are still not fully defined, there is enough information about ARV and VCCT to move towards to scaling up. VCCT and ARV are cost-effective strategies that reduce MTCT regardless of the mode of infant feeding.

3. As illustrated in Phayao Province, Northern Thailand, 1998: 97% of pregnant women had ANC, 94% were tested for HIV, of which 4% tested positive; 95% of these returned for confirmation, 76% initiated ARV treatment and 71% finished the treatment. This implies that in large-scale PMCT programs, VCCT and ARV effectively covered 69% of the estimated total number of HIV+ mothers.

4. In contrast, current knowledge points to the dangers of going to scale with replacement feeding in contexts where women will have low education, low access to water, low economic means, and strong cultural pressures to breastfeed. Emphasising replacement feeding in those contexts may fuel the mixed feeding practice for mothers who will have no other choice than breastfeeding, yet will try to follow the recommendations to replacement feed.

5. Regimens combining ARV during delivery, exclusive breastfeeding with ARV prophylaxis in children followed by early cessation of breastfeeding are likely to prove very cost-effective in reducing MTCT on a population basis and may even prove more effective in improving child survival than replacement feeding plus ARV.

6. The approach to envisioning implementation is to be discussed: are women to be recipients or stakeholders? VCCT can be seen as an empowering long-term oriented strategy, whereas ARV is an outcome oriented emergency strategy. Should both progress at the same pace or should we phase the implementation of emergency measures and capacity building measures along different time and space schedules?

7. A core package (or several options of core packages to depend on the country context) to be offered to HIV+ pregnant women and their families is to reduce not only MTCT but also overall U5 mortality rate. What is the right balance for scaling up between ARV only and a full package (life skills, condoms, VCCT, ARV, replacement feeding) with support to HIV affected families including orphans?

8. There is a need to scale up in order to broaden health economic studies beyond the cost-effectiveness of alternative regimens to address MTCT in isolation (well established now and of little concern to countries) to analysis of cost-effectiveness in terms of child survival, allocative efficiency, and affordability. This includes:

· Analysis of the costs and benefits in terms of both child survival and decrease of the HIV epidemic from the full package of MCH services to be offered to HIV+ pregnant women

· Analysis of the opportunity costs of investing in this intervention as compared to investing in other activities to decrease child and maternal mortality as well as the spread of HIV

· The development of financing scenarios taking into account government, household (identifying the demand of women), and donor contributions

Acronyms

ARV:	anti-retrovirals
BCC:	Birth Canal cleansing
BF:	Breastfeeding
BMS:	Breast-milk substitutes
EBF:	Exclusive breastfeeding
IFC:	Infant Feeding Counseling
IMCI:	Integrated Management of Childhood Illnesses
SOP:	Safe Obstetric Practices
STIs:	Sexually transmitted infections
UP:	Universal Precautions
VCCT:	Voluntary Counseling and testing

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