Feature: PMTCT Policy – A Comprehensive Document

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Examining key??statements contained in the??policy document on the Prevention-of Mother-To-Child Transmission, launched today at the UN House, Hastings Christ Church, are (from back left): UNICEF Representative in Barbados, Tom Olsen; Senior Medical Officer of Health (Communicable Diseases),??Dr. Anton Best; (at front) : Minister of Health, Donville Inniss and Consultant Paediatrician at the Queen Elizabeth Hospital,??Dr. Anne St. John.

Barbados’ development of a policy on the Prevention of Mother-to-Child Transmission (PMTCT) of HIV has been regarded as necessary to harmonise and standardise efforts related to PMTCT across the island.

This is the view of Senior Medical Officer of Health, Dr. Anton Best, who is also responsible for the Ladymeade Reference Unit. He believes that despite overwhelming success in the area of PMTCT, a few gaps still remain to be addressed.

"We needed to raise the bar and achieve universal access and so we set a policy framework to which all health care providers in Barbados would adhere for PMTCT," Dr. Best noted.

He pointed out that there was concern that the country needed to reach "as close as possible to 100 per cent of women, who are pregnant being tested for HIV", since currently, the proportion of women tested for HIV in Barbados ranges from 90 per cent to 95 per cent."

The programme on PMTCT, which was started in Barbados in 1995, has been linked to a substantial reduction in the rate of mother-to-child transmission from 27.1 per cent, prior to 1995, to 2.5 per cent in 2008.?? With the advent of the policy, launched last year at United Nations House and comprising comprehensive strategies, the continuum of prevention to care is expected to result in an even further reduction.

The first strategy in the policy document addresses the area of Primary Prevention of HIV, which, according to Dr. Best, "takes a general look at the entire population on the island, whether they are HIV positive or not and seeks to encourage

testing and screening for sexually transmitted infections". It recommends the use of behavioural communications interventions: the Abstinence, Be Faithful and Condomise (ABC strategies) and other initiatives likely to prevent HIV.??

The second strategy is the Prevention of Unintended Pregnancies in HIV Positive Women, which essentially involves the use of family planning methodologies. Caution, however, must be taken to ensure that interventions for the prevention of mother-to-child transmission are done in the context of comprehensive maternal child health services. "Antiretroviral prophylaxis, as well as counselling for safe infant feeding and obstetrics practices must be optimal for the prevention of mother-to-child transmission," Dr. Best warned.

Strategies which address Care and Support for parents and families were considered by the physician "as the more comprehensive approach". He said: "This is where we are just not treating a medical problem, but we’re treating a mother, father, a child…treating the families. So, there is also a role for your community-based organisations."

The key aim of the national policy on PMTCT is to guide the health sector of Barbados in effectively implementing a comprehensive programme for the prevention and control of HIV from parent to child. Its four main components are HIV Testing in Pregnancy; Referral System for HIV Positive Pregnant Women; Treatment and Prevention.

Under HIV Testing in Pregnancy, the policy objective is to determine the HIV status of all pregnant women. This speaks to the need for the pregnant woman to be

offered a test at the time she visits her health care provider and says she is pregnant. "This is referred to as booking," the Senior Medical Officer said, adding that the client should also be offered a repeat test between 30 and 34 weeks (that is, if she were negative the first time around).

Pointing out that the PMTCT policy respects the rights and privileges of the woman, who is HIV positive, the health professional stated: "The methodology of HIV which we use is what we call the opt-out testing where the health-care provider tells the woman we are going to do an HIV test on you. However, we must always respect the rights of the patient. The pregnant woman has the right to refuse the test if she doesn’t want it.

"Notwithstanding this, the results should be clearly documented in the woman’s antenatal records so that all health-care workers involved in her case know what her status is."

He stressed: "The health sister or the midwife at the polyclinic is responsible for managing the pregnancy of the patient. In other health-care settings, HIV testing is the responsibility of the midwife or nurse, the private obstetrician or family physician attending to that pregnant patient.

"In a situation where a woman arrives at the Labour Ward but has never accessed antenatal care or HIV testing, either at booking or during the 30 to 34 weeks, the hospital would offer a rapid test."

Accepting that there may be some areas to strengthen within the health system, with respect to this issue, Dr. Best added: "Maybe, she did book but the HIV test was not clearly documented in her notes and right now this is the only setting in which we offer rapid testing for HIV."

The second policy objective seeks to ensure that all HIV positive women have joint care by HIV specialists, obstetricians and paediatricians for the purposes of PMTCT via an effective Referral System.

The point was made by Dr. Best that the HIV positive pregnant woman should be referred to all physicians and health-care providers that would be involved in her care, whether it is the antenatal clinic at the Queen Elizabeth Hospital, the Ladymeade Reference Unit, or a private facility.?? "An HIV positive pregnancy is regarded as [a] high-risk pregnancy, and, thus should receive specialised obstetric care. Women who have high blood pressure, diabetes and severe anaemia in pregnancy are all referred to special obstetric care and HIV is regarded in this light as well," he explained.

The Medical Practitioner further disclosed that all HIV positive pregnant women should be referred for management of their disease, whether they needed anti-retroviral therapy for their own health, or simply for the purposes of PMTCT. And, Dr. Best stressed: "At all times, effective and highly confidential communication of health care providers involved in the care of the patient is advised to ensure she follows through from one referral to the other. Specialist HIV physicians, seeing HIV positive pregnant women, should make clear and concise written entries in the antenatal notes of the patient; and these should follow the confidentiality guidelines in the policy document."

The third policy component is Treatment:?? Its objective is to reduce the risk of mother-to-child transmission through the use of anti-retroviral therapy. It recommends

that all HIV pregnant women, who have a positive status, should be adequately counselled on the HIV infection, as well as the benefits and risks of antiretroviral drugs.

"The woman should be offered antiretroviral therapy whether for prophylaxis or treatment and both of them speak to PMTCT. It is also important to make sure that all foreign nationals residing here receive anti-retroviral treatment. Irrespective of a woman’s nationality, this is the policy of the Government of Barbados," Dr. Best pointed out.

The final component, Prevention, speaks to the reduction of mother-to-child transmission through interventions, including the prevention of HIV transmission, in the first place to the mother, and the avoidance of unintended pregnancies.?? The document recommends that strategies be employed to prevent HIV in the first place and women who are HIV positive, along with their spouses, be counselled on safer sexual practices and the island’s comprehensive family planning options.

"An HIV positive woman still has the right to have children if she so desires," Dr. Best affirmed, adding that prevention included other interventions to stop the child acquiring HIV from its mother. He stressed: "It is already the policy of the Government of Barbados that breast feeding is not advised. The Ministry of Health supports alternative breast feeding and the mothers should be counselled accordingly."??????????

In 2005, the Caribbean HIV/AIDS Regional Training (CHART) network initiated the evaluation of existing PMTCT programmes in the entire Caribbean with a view to scaling up these services. From this particular endeavour regional guidelines for PMTCT were compiled in 2006 and later adapted to the Barbadian setting. This resulted

in the policy framework now known as the Prevention of Mother-To-Child Transmission of HIV in Barbados.

Additionally, CHART (Barbados) developed the PMTCT Training curriculum which was piloted in September 2008 and its final document published in November 2009.

jgill@barbados.gov.bb

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