PMTCT-Projects Migori/Kenya, Mbeya/Tanzania and Western Uganda Sector Project Prevention of Mother-to-Child Transmission of HIV

PMTCT
Prevention of Mother-to-Child Transmission of HIV in Kenya, Tanzania and Uganda

Gundel Harms, Angelika Mayer and Heiko Karcher

Published by: Deutsche Gesellschaft fr Technische Zusammenarbeit (GTZ) GmbH Dag-Hammarskjld-Weg 1-5 65760 Eschborn Contact Addresses International Coordination Office GTZ PMTCT - Project PD Dr. Gundel Harms, Angelika Mayer, Heiko Karcher Institut fr Tropenmedizin und Medizinische Fakultt Charit, Humboldt-Universitt zu Berlin Spandauer Damm 130 14050 Berlin, Germany Tel: +49-30-30162741/3 Fax: +49-30-30162742 e-mail: pmtct.gtz@t-online.de Division 4300 Health, Education, Social protection Sector Project Prevention of Mother-to-Child Transmission of HIV Dr. Sybille Rehmet Gesellschaft fr Technische Zusammenarbeit GTZ Dag-Hammarskjld-Weg 1-5 Postfach 5180 65726 Eschborn, Germany Tel: +49-6196-791274 Fax: +49-6196-791366 e-mail: sybille.rehmet@gtz.de Text and graphics: Gundel Harms, Angelika Mayer, Heiko Karcher Photos: Gundel Harms, Gabriele Poggensee, Heiko Karcher Layout: Jeanette Ausmann, konzept & design Printed by: Henrich Druck + Medien GmbH September 2003

Kenya

Tanzania

Uganda

Table of Contents
Foreword Background The PMTCT Pilot Project PMTCT Project Sites Approaches and Achievements 1. Sensitisation and awareness-raising 2. Training 3. Improvement of infrastructure 4. Drug administration 5. Regular Monitoring and Evaluation Antiretroviral Treatment Programme Research Infrastructure and organisation of services Awareness and knowledge of mother-to-child transmission Infant feeding practices Impact of intervention Feasibility of antiretroviral treatment Methods for monitoring of CD4 cell counts Organisational Design Bibliography and Relevant Documents Project Addresses 5 6 7 8 9 9 10 11 14 15 17 19 19 20 22 23 23 23 24 25 26

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Abbreviations
AIDS ANC ART CDC GTZ HAART HIV IEC MoH MTCT NGO PMTCT STD TBA VCT Acquired Immune Deficiency Syndrome Antenatal Care Antiretroviral Treatment Centers For Disease Control and Prevention Gesellschaft fr Technische Zusammenarbeit Highly Active Antiretroviral Treatment Human Immunodeficiency Virus Information, Education, Communication Ministry of Health Mother-To-Child Transmission of HIV Non-Governmental Organisation Prevention of Mother-To-Child Transmission of HIV Sexually Transmitted Disease Diseases Traditional Birth Attendants Voluntary Counselling and Testing

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Foreword
The HIV/AIDS epidemic has had a disastrous economic, social, and physical impact on individuals, communities and nations in the poorest countries of the world, particularly in sub-Saharan Africa. Beyond sexual transmission and transmission by injecting drug use, the transmission of the HI virus from mother to child - or rather from parent to child - is now also a frequent transmission route in high prevalence areas. The prevention of virus transmission to the unborn child must, of course, begin with a commitment to primary prevention of the infection through information on the modes of transmission of HIV, on safe sex practices, on counselling and voluntary testing. Ensuring the availability and affordability of contraceptives for dual protection against unwanted pregnancy and unwanted sexually transmitted infections, such as male and female condoms, are a vital component of every HIV prevention programme. Primary prevention also means reaching out to groups at particular risk, such as sex workers and intravenous drug users, but also to all young girls and women, who are at particular risk of becoming infected due to gender inequity in negotiating the conditions of sex. In all this, health promotion services, the media, schools and the health services themselves have a vital role to play. In high prevalence settings where 30 percent or more of pregnant women are HIV positive, however, primary prevention is not enough to keep the infection from being passed on to newborns. Thanks to technological and scientific developments, drugs and interventions have become available which can effectively and cheaply protect the health of a newborn. Different regimens of antiretroviral drugs, some as simple as one dose for the mother and one for the newborn, can reduce transmission by about 50 %. By combining with cesarean section and by not breastfeeding, a further reduction of transmission is achieved. Sometimes, due to the conditions of health services, cesarean sections are not routinely possible, and there is no alternative to breastfeeding - there drugs alone can still have a significant impact. Long-term antiretroviral treatment of mothers and affected family members further increases the chances of newborns and their families living with HIV/AIDS to survive. In this book, we review the experiences gathered in informing the population on the availability of services, in encouraging them to join the programme, and in ensuring that the interventions are carried out by well trained health personnel in appropriately equipped settings. We thank the pharmaceutical sector for the readiness to make some of the necessary drugs available free of charge for the communities needing them most. We hope that the documentation provided will be useful to countries in supporting more and more health services in providing comprehensive programmes to reduce mother-to-child transmission of HIV, and useful to multi- and bilateral agencies wishing to provide support. We wish to thank all those who contributed their knowledge and energy towards the initial success of this programme. Dr. Assia Brandrup-Lukanow Head of Department of Health, Education and Social Protection

Background
In Africa, especially in the countries of eastern and southern Africa most severely affected by the HIV/AIDS epidemic, the transmission of the HI virus from mother to child during pregnancy, birth and during the period of breastfeeding is by far the most common way of HIV infection in children. It is believed that in sub-Saharan Africa each year more than 500,000 women who live with HIV/AIDS become pregnant and give birth. In December 2002, around 3.2 million children were infected with the virus around the world, 90% of them in Africa. Since the survival time, the period from infection to the development of AIDS and consequent death, is much shorter for children than for adults, 20% to 25% of them will die within the first two years of life and 60% to 70% before reaching their fifth birthday. The prevalence of transmission from the mother to the child in developing countries is about 30%, the highest risk of infection being at the time of birth. Since in numerous countries of eastern and southern Africa, 20% to 30% of pregnant women are HIV positive, up to 10% of all infants here are born with HIV or acquire it from breast milk within the first weeks and months of life. The most important approach for avoiding mother-to-child transmission of HIV is still the primary prevention of HIV infection in young women through education, counselling, STD treatment, condom use, etc., within the scope of comprehensive multisectoral HIV/AIDS control programmes. For some time now drug interventions have been available that can drastically reduce the likelihood of infection by the virus before and during birth. With a single dose of the drug nevirapine to the mother during labour and of nevirapine syrup to the child within the first 72 hours following birth, the probability of HIV transmission is reduced by about 50%.

The PMTCT Pilot Project

To contribute to the worldwide approach for the control of HIV, the German government (Ministry of Economic Cooperation and Development) through the German Agency for Development and Technical Cooperation (GTZ) supports a project on the prevention of mother-to-child transmission of HIV (PMTCT) in different African countries. Since the Germany based manufacturer, Boehringer Ingelheim, offers nevirapine (brand name: Viramune) free of charge for the indication of PMTCT for a period of five years to all developing countries who meet certain conditions, a collaboration was established. A comprehensive PMTCT - Project using nevirapine was started in 2001 in selected sites in Kenya, Tanzania and Uganda. The Project includes the implementation of an antiretroviral treatment programme for mothers participating in the PMTCT - Programmes, their children and partners. The PMTCT - Project is meant to assist the partner countries in establishing the necessary infrastructure to offer low-cost measures for reduction of mother-to-child transmission of HIV. The Programmes are strictly integrated into the existing health services. All activities are conducted in accordance with the national PMTCT strategies and under information exchange with international and national organisations and institutions active in PMTCT interventions.

Major Components of the PMTCT - Programmes

Sensitisation of the general and the target population Continuous support and training of the health personnel Improvement of infrastructure in the intervention sites Implementation of voluntary counselling and testing services (VCT) Procurement of reagents, supplies, test kits, drugs Offer of nevirapine, infant feeding counselling and replacement feeding, if wanted. HAART for mothers, their children and partners (WHO quality) Implementation of a monitoring and evaluation system Accompanying research

PMTCT Project Sites

In KENYA the PMTCT - Programme is implemented in Migori and Kuria Districts, Nyanza Province. The Programme is offered at the two District Hospitals, Migori and Kehancha, at Ombo Mission Hospital in Migori District and at Isebania Health Centre in Kuria District. About 9.000 pregnant women attend antenatal care services of the four sites annually. The HIV prevalence among pregnant women is about 26%. In TANZANIA, the PMTCT - Project collaborates with the GTZ - supported Comprehensive AIDS Control Programme in Mbeya Region. The PMTCT Programme sites are Mbeya Referral Hospital, Ruanda Health Centre, Igawilo Health Centre, all in Mbeya Town and District, and Vwawa Hospital in the neighbouring Mbozi District. The catchment area of these sites is about 2.2 million people. About 12.000 pregnant women attend the antenatal services of these sites annually. The HIV prevalence among pregnant women is about 15%. In UGANDA, the PMTCT - Project collaborates with the GTZ-supported Basic Health Services - Project in Western Uganda. The PMTCT - Programme is implemented at two urban sites, Buhinga Hospital and Virika Mission Hospital in Fort Portal in Kabarole District, and at three rural sites, Kibiito Health Centre in Kabarole District, Rukunyu Health Centre in Kamwenge District and Kyenjojo Health Centre in Kyenjojo District. The Uganda Kabarole, Kamwenge and Kyenjojo District facilities serve a population of about 1.8 million. The antenatal care services of these sites are attended by about 13.000 pregnant women annually. HIV prevalence among pregnant women is about 8%.

Kenya Migori and Kuria District

Tanzania Mbeya and Mbozi District

Approaches and Achievements

1. Sensitisation and awareness-raising Knowledge about HIV - transmission and with it awareness and openness towards preventive measures are crucial for the compliance of the pregnant women, acceptance and support by the health personnel and, very important, support by the communities. The involvement of males, particularly the husband or partner, is a major challenge. Community sensitisation is necessary not only at the beginning of the programme but needs to become a continuous activity. Therefore, IEC-material such as posters and leaflets are designed, radio spots are transmitted, drama and theatre groups established and peers educated.

Peer education for HIV/AIDS and PMTCT in Mbeya, Tanzania

Drama group performance on PMTCT in Mbeya, Tanzania

2. Training Health personnel is continuously trained in antenatal counselling with particular attention to mother-to-child transmission of HIV, in performing HIV rapid tests and in postnatal counselling comprising infant nutrition, growth monitoring, STD management and family planning. In order to establish the level of knowledge about HIV transmission from the mother to the child, assessments of awareness and knowledge were done in the population, in health workers and TBAs before the preparations for the PMTCT - Programmes were started (see research). fvdv The availability and access to voluntary HIV - counselling and HIV - testing are a prerequisite for the drug intervention component of the programme. Ideally, each and ervery pregnant woman attending an ANC clinic would be counselled and tested for HIV. Rapid HIV-tests (two tests based on different, complementary methodology) are used in the PMTCT - Programmes in order to have test results immediately available.

Capillus HIV rapid test

Positive HIV rapid test

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3. Improvement of infrastructure Infrastructure regarding space for health talks, for HIV-counselling and HIV - testing, for ANC examination, delivery and for postnatal care are often inadequate. Upgrading of facilities, modifications or sometimes even reconstructions are therefore necessary. At several sites shaded waiting areas for ANC clients were established to provide space for health talks and group counselling.

Group counselling at Rukunyu Health Centre, Uganda Group counselling on PMTCT is often used to reach the huge number of ANC clients in a first approach. Thereafter, individual counselling is offered to all clients, before they decide to be tested. Post - test counselling is always done individually.

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At Migori Hospital, Kenya, a new MCH - unit was established comprising an ANC registration and waiting area, counselling and examination rooms, the family planning unit, the STD clinic and the PMTCT coordinators office. A laboratory was integrated in the new complex where all ANC - related investigations and the necessary laboratory investigations for the monitoring of antiretroviral therapy are performed.

Old ANC clinic at Migori Hospital, Kenya

New ANC / MCH clinic at Migori Hospital, Kenya

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Renovations and provision of equipment were also necessary in the maternity wards. Patients often had to bring their own mats and had to deliver on the floor.

Maternity ward, Rukunyu Health Centre, Uganda

Old delivery room in Migori Hospital, Kenya Necessary equipment to ensure a safe delivery comprises delivery sets, episiotomy sets, suctions machines, and sometimes delivery beds. Test kits, laboratory reagents, drugs for opportunistic infections and symptomatic HIV treatment, STD drugs, condoms, contraceptives, gloves and other protective wear are some of the supplies that should be regularly available.

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4. Drug administration Nevirapine may be administered to the HIV-positive pregnant woman once she has been counselled, agreed to HIV testing and to participate in the programme. In most sites the nevirapine tablet is given to the future mother at about week 36 of the pregnancy. This is practised because most women, in particular multiparae, will not be able to reach the health facilities in time in order to receive nevirapine at the onset of labour. In this case they will have to come to the health unit within 72 hours after delivery so that the nevirapine syrup can be administered to the newborn.

Woman receiving nevirapine tablet from counsellor in Uganda

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5. Regular Monitoring and Evaluation A monitoring and evaluation programme is applied to continuously assess programme indicators. Different monitoring forms are applied in the different stages of the programme. This monitoring and evaluation concept also serves to assess the infection status and infection-relevant parameters of children as well as costs of the PMTCT - Programme. Figure 1 shows the total number of ANC clients assessed during the period of April 2002 to July 2003 in the different stages of the PMTCT - Programme.

Figure 1: PMTCT - Programme Indicators April 2002 - July 2003

Between April 2002 and July 2003 28,164 new ANC clients were documented in the health services in the project areas in Kenya, Tanzania and Uganda.

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Out of these, 16,027 (56.9%) women were counselled about PMTCT and related issues. 10,356 (65%) agreed to be tested and 1,862 (18%) were HIVpositive; 22% in Kenya, 17.5% in Tanzania and 16.5% in Uganda, respectively. A total of 1034 women were enrolled in the PMTCT - Programme, 386 women already took nevirapine and 326 are under follow-up. Many enrolled women are in earlier stages of the pregnancy and did not yet deliver under nevirapine. Figure 2 shows an example of the monthly flow of the PMTCT Programme at one Tanzanian site. While in the beginning of the Programme the gap between the number of new ANC clients attending services and the number of clients HIV - counselled and accepting HIV - testing was rather large, these figures were narrowing at later stages of the Programme.

Figure 2: Uptake of PMTCT - Programme at Igawilo Health Centre, Tanzania

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Antiretroviral Treatment Programme

The Project supports the implementation of antiretroviral treatment in all project areas. A PMTCT-Plus approach is used, offering free long term treatment to participants of the PMTCT - Programme and their families. Prerequisites for an antiretroviral treatment - programme such as HIV - counselling and - testing capacities and facilities, adequate ante-, peri- and postnatal care and laboratory facilities have been implemented as part of the PMTCT - Programme. In Uganda, in a first step, an ART - clinic was established. Clinicians and nurses are continuously trained in ART - management. The laboratory was upgraded and tests performed include complete blood count and serum chemistry to monitor side effects of ART as well as analysis of CD4 cell counts to assess treatment indication and immunologic response. Determination of HI - viral load and resistance testing are done in a reference laboratory.

ART - clinic, Fort Portal Hospital, Uganda Safe drug management for antiretroviral and supportive drugs is essential for an effective programme. In Uganda, drug procurement, storage and provision are organised in cooperation with a Diocese pharmacy. Storage of antiretroviral and supportive drugs at Virika Pharmacy, Fort Portal, Uganda

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Treatment indication and drug regimens follow international and national guidelines. Pregnant women enrolled in the PMTCT - Programme are regularly screened for treatment indication. If indicated, treatment is started during pregnancy to achieve maximal benefit for the mother and the unborn child. Since disease progression in perinatally infected children are accelerated, the infection and treatment indication are established by PCR - technique in the first weeks of life. In Uganda, within a period of 6 months, 48 patients (27 female, 19 male, 2 children) were started on antiretroviral treatment. Figure 3: Uptake of the antiretroviral treatment programme in Uganda

A close monitoring and evaluation protocol for the Antiretroviral Treatment Programme was equally implemented. A good understanding of drug action and side effects is substantial for patient adherence and treatment success. Therefore, patients are thoroughly counselled before treatment is initiated and counselling is offered at each encounter. Patients are examined and laboratory parameters determined at a regular basis to assess treatment response, side effects, opportunistic infections and drug adherence. In addition, post exposure prophylaxis (PEP) for health care staff was introduced at all PMTCT - intervention sites. It is envisaged that, when GTZ support discontinues, the MoH will have established a mechanism to assure continuous procurement of drugs and supplies for the Antiretroviral Treatment - Programme.

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Research
The Project has a strong focus on accompanying research, operational and biomedical. In a comprehensive research approach, studies attempt to determine the impact of the intervention. For both, monitoring and research, cooperations with national and interntional institutions have been established. Cooperating institutions are: Kenya Medical Research Institute (KEMRI), Kenya, Makerere University, Uganda, CDC, Entebbe, Uganda, Muhimbili University, Tanzania. All research protocols have been approved by the research and ethical committees of the respective countries. Infrastructure and organisation of services As a first step, the use, infrastructure and organisation of ANC and maternity services in four future intervention sites in western Uganda were assessed. Figure 4: Average waiting time at first ANC visit (not including HIV counselling and testing)

Minutes

As one result, waiting times for a first ANC visit turned out to be between 3 and 4 hours, not including counselling and testing for HIV. These findings clearly indicated that the patient flow had to be re-organised.

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Awareness and knowledge of mother-to-child transmission Assessments on awareness and knowledge about mother-to-child transmission of HIV and preventive measures were conducted in the target and general population and in health personnel in Uganda and Tanzania. Acceptance of HIV - testing was high in both settings, 94% and 78,5%, respectively. Table 1 shows the active and passive knowledge of female and male health unit clients. Only 1.6% and 1.8% in Uganda and Tanzania, respectively, mentioned MTCT as a route of transmission. When directly asked whether HIV transmission is possible during pregnancy, delivery or through breastfeeding, a higher percentage of interviewees affirmed these routes of transmission.

Table 1: Knowledge of clients of health units about mother-to-child transmission of HIV

Female and male health unit clients

Uganda (n=679) female male

Tanzania (n=508) female male

Routes of transmission of HIV? MTCT HIV transmission possible during pregnancy/delivery? HIV transmission possible through breastfeeding? 59.4% 40.8% 86.1% 75.8% 67.1% 78.3 93.1% 93.9% 1.1% 2.5% 1.9% 1.6%

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Table 2 shows the answers given by health workers and TBAs when asked to name measures to reduce HIV transmission from the mother to the child. While safe delivery procedures were mentioned by 65% of the health workers in Uganda, non - breastfeeding was the most frequently mentioned measure in Tanzania (49%). When directly asked whether e.g. drugs may reduce MTCT, 72% and 55% of the health workers but only 24% and 17% of the TBAs in Uganda and Tanzania, respectively, confirmed that transmission may be reduced through this measure.

Table 2 : Knowledge of health personnel and TBAs on preventive measures of mother-to-child transmission of HIV

Health workers and TBAs

Uganda Health workers TBAs

Tanzania Health workers TBAs

Name ways to reduce MTCT Safe delivery procedures Drugs Cesarean section No breastfeeding May MTCT be reduced by? Drugs Cesarean section No breastfeeding 72% 44% 81% 24% 24% 17% 55% 39% 74% 17% 1% 22% 65% 16% 2% 26% 24% 0% 7% 3% 22% 31% 0% 49% 5% 0% 0% 5%

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Infant feeding practices In a further approach, the local feeding patterns in the intervention areas of Tanzania and Uganda were assessed. Data show that exclusive breastfeeding, as recommended for HIV-positive women, is rarely practised in the two country-settings. Furthermore, the timing and type of solid food and liquids added during breastfeeding in Tanzania and Uganda differed considerably. Figure 5: Time of introduction of solid food and liquids in Tanzania and Uganda Tanzania

Uganda

The findings will be used to identify risk factors for postnatal transmission and for recommendations on infant feeding to HIV - infected mothers in the intervention areas.

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Impact of intervention A prospective mother - child cohort study aims to assess the impact of the intervention on child mortality. The cohorts differ by nevirapine intake and by HIV infection status. Additionally, in two of these cohorts, the influence of different factors on the vertical HIV transmission are determined at specific intervals such as timing of nevirapine administration, drug levels in different compartments and viral load. The development and possible transmission of nevirapine resistance are further research focuses. Feasibility of antiretroviral treatment Data on feasibility and treatment success in resource-limited settings are still scarce. Within a comprehensive monitoring protocol, clinical, immunological and virological data are collected with the aim to evaluate different approaches for monitoring of treatment indication and treatment success. Factors influencing treatment success and treatment failure such as adherence, drug toxicity and resistance development are determined. Methods for monitoring of CD4 cell counts Standard methods for the analysis of CD4 cell counts such as flow cytometry are complicated and expensive, thus of limited use for resource - poor settings. In this context, a simple and cheaper method for immunological monitoring of ART was evaluated. As shown in figure 6, CD4 cell counts obtained by a manual method (Cytosphere method) were comparable to those obtained by standard flow cytometry (correlation coefficient r = 0.9). Figure 6:
C D 4 c o u n t s m a n u a l m e t h o d ( C y t o s p h e re )

Correlation of manual CD4+ cell counting method with standard flow cytometry

CD4 counts Flow Cytometry

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Organisational Design
The responsibility on the German side lies with the Ministry for Economic Cooperation and Development (Bundesministerium fr wirtschaftliche Zusammenarbeit und Entwicklung / BMZ), which has commissioned GTZ s Department of Health, Education and Social Protection at GTZ HQ in Eschborn, Germany, with the execution of the Project. The Project is coordinated by the Humboldt University of Berlin (International Coordination Office GTZ PMTCT - Project) and in each country by a local coordinator. The international and national coordinators ensure the information exchange with the national and international partners.

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Bibliography and Relevant Documents

1. Use, infrastructure and organisation of ANC and maternity services in four health facilities in Western Uganda. Report, International coordination office GTZ PMTCT - Project Berlin, 2002. 2. Awareness and knowledge of mother to child transmission of HIV and preventive measures in western Uganda. Report, International coordination office GTZ PMTCT - Project Berlin, 2002. 3. Awareness and knowledge of mother to child transmission of HIV and preventive measures in Mbeya Region, Tanzania. Report, International coordination office GTZ PMTCT - Project Berlin, 2003. 4. Evaluation of impact of a PMTCT - Programme on child survival and mother-to-child transmission of HIV Proposal for accompanying research of a PMTCT - Programme using nevirapine in Uganda. International coordination office GTZ PMTCT - Project Berlin, 2002. 5. Evaluation of impact of a PMTCT - Programme on child survival and mother-to-child transmission of HIV Proposal for accompanying research of a PMTCT - Programme using nevirapine in Tanzania. International coordination office GTZ PMTCT Project Berlin, 2002. 6. Implementation and Monitoring of an Antiretroviral Treatment Programme following a HIV PMTCT - Programme in Western Uganda. International coordination office GTZ PMTCT - Project Berlin, 2002. 7. Prevention of mother to child transmission (PMTCT) and antiretroviral treatment (PMTCT Plus) of HIV in Kenya, Tanzania and Uganda. Abstract, Sommerseminar GTZ September, 2003 8. Awareness and knowledge of mother to child transmission of HIV and preventive measures in Western Uganda and Tanzania. Abstract, Sommerseminar GTZ September 1-3, 2003. 9. Comparison of a manual CD4+ T cell counting method with a standard dualplatform protocol in a Ugandan rural HIV treatment cohort. Abstract, IAS Paris, July 13-16, 2003. 10. WHO. Scaling up antiretroviral therapy in resource limited settings. Guidelines for a public health approach. Geneva, June 2002. 11. National Guidelines for the Prevention of Mother-To-Child HIV/AIDS Transmission (PMTCT). MOH, Kenya, 2002. 12. National Guidelines for Clinical Management of HIV/AIDS. MOH Tanzania, April 2002 13. National Antiretroviral Treatment and Care Guidelines for Adults and Children. MOH, Uganda, June 2003. 14. Policy For The Reduction Of Mother-To-Child HIV Transmission in Uganda. MOH, Uganda, December 1999. 15. DHHS-Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents. Department of Health and Human Services (DHHS), June 14, 2003. 16. Perinatal HIV Guidelines Working Group. Perinatal Health Service Task Force Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women to Reduce Perinatal HIV-1 Transmission in the United States. June 2003. (www.hivatis.org) 17. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. The Working Group on Antiretroviral Therapy and Medical Management of HIVInfected Children, National Pediatric and Family HIV Resource Centre (NPHRC), The Health Resources and Services Administration (HRSA), and The National Institutes of Health (NIH). June 25, 2003. (http://AIDSinfo.nih.gov)

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Project Addresses
Kenya MoH/GTZ PMTCT - Project Migori and Kuria Districts P.O. Box 202 Migori, Kenya Coordinator: John Odera Tel/Fax: +254-387-20753 e-mail: pmtct@africaonline.co.ke

Tanzania MOH/GTZ PMTCT Project Mbeya Region P.O. Box 2328 Mbeya, Tanzania Coordinator: Dr. Paulina Mbezi Tel/Fax: +255-25-2504206 e-mail: pmtct.gtz@atma.co.tz

Uganda MOH/GTZ PMTCT Project Western Uganda P.O. Box 27 Fort Portal, Uganda Coordinator: Dr. Fred Kagwire Tel: Fax: e-mail: +256-77-780045 +256-483-23043 gtz.art@afsat.com

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Dag-Hammarskjld-Weg 1- 5 Postfach 51 80 65726 Eschborn Telefon: 0 61 96 79-0 Telefax: 0 61 96 79-11 15 Internet: http://www.gtz.de

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