Adherence & Retention
Integration of Prenatal Care with the Testing and Treatment of HIV and Syphilis in Peru
Introduction
This situation report was written for the first phase in Peru of the Latin American and Caribbean Initiative for the Integration of Prenatal Care with the Testing and Treatment of HIV and Syphilis, a partnership between the National AIDS program of Brazil, Colombia, Cuba, Nicaragua, Paraguay, Peru, the Dominican Republic, and Uruguay, the Regional Office of UNICEF for Latin America and the Caribbean, the Regional Support Team of UNAIDS for Latin America, the International Center for Technical Cooperation on HIV/AIDS (CICT) and Harvard Medical School. In Peru, the Initiative is a collaboration among the National Health Strategy for the Prevention and Control of Sexually Transmitted Diseases and HIV/AIDS (Estrategia Sanitaria Nacional de Prevención y Control de Infecciones de Transmisión Sexual y VIH/SIDA, or ESNITSS) of the Ministry of Health of Peru (MINSA), UNAIDS, UNICEF, the non-governmental organization Socios En Salud (SES or Partners In Health-Peru), and Harvard Medical School, with financial support provided by UNAIDS.
From August to November of 2008, we conducted interviews with key representatives of the Peruvian health system, including high-level health care officials at MINSA, administrators of Health Directorates, clinical staff, members of advocacy groups, and representatives of people with HIV in the regions of Ancash, Amazonas, Apurimac, Arequipa, Callao, Cajamarca, Cuzco, Ica, Junín, La Libertad, Lambayeque, Lima, Lima Provinces, Loreto, Moquegua, Piura, Puno, San Martín, Tacna, Tumbes, and Ucayali. The interviews covered the following areas: the organization of the national programs for AIDS, sexually transmitted infections (STIs), and prenatal care; the monitoring system for health services; treatment and prevention protocols (including those for prevention of mother-to-child transmission (PMTCT) of HIV and syphilis); the structure of the national laboratory network; the training of health care personnel in the administration of HIV tests, confidentiality agreements, and counseling for alternative treatments; the training of physicians in HIV treatment; the funding of HIV and syphilis prevention; and systems of insurance and user fees. In addition, we collected reports about HIV and syphilis screening during pregnancy and local, regional, and national epidemiological data. This report was supplemented with comments from a November 2007 meeting in Lima, where the authors presented a preliminary version of this report; participants included representatives of the Ministry of Health, the Comprehensive Health Insurance program, the National Multisectorial Coordination for Health (CONAMUSA), UNAIDS, UNICEF, and Socios En Salud (see Annex 2 for the list of participants).
Based on the compiled data, we generated this situation analysis report, whose principal aims are to identify strengths and weaknesses in the diagnosis and management of HIV and syphilis during pregnancy and to propose intervention areas for improving prenatal care as an entry point for testing and treatment of HIV and syphilis for women in Peru. This analysis, framed from the perspective of the offer of maternal health services in Peru, will be complemented with the perspectives of users (pregnant women), which will be gathered during 2009.
First, this report presents a summary of the health care system in Peru, a review of the technical guidelines for prenatal care, HIV, and syphilis, and a description of the relevant epidemiological data by region. Second, the report outlines weaknesses in the health system, focusing on the following themes: planning problems due to incomplete data, problems in the procurement and financing of diagnostic tests, problems in the classification and procurement of antiretroviral drugs (ARVs), late presentation for prenatal care, disarticulation of care during prenatal care, problems in laboratory turnaround time, delays in initiation of prophylaxis and treatment during pregnancy, problems in postpartum follow-up of women diagnosed with HIV or syphilis and of their newborns , and attitudes of health care providers towards women diagnosed with HIV. The report presents the barriers that prevent women from seeking prenatal care, from being screened during her prenatal visits, and— when she does receive test results—from receiving them in a timely manner with the appropriate clinical intervention. The main problems that emerged from our interviews and review of documents are: the economic and geographic difficulties of pregnant women in accessing the health care facility, the lack of articulation between and among the National Health Strategies and their regional offices, the lack of coordination between health care facilities at different levels of complexity, the uncertain and incomplete implementation of current technical guidelines in health care facilities, the lack of human resources and medications and supplies for prenatal care in health care facilities, disparities in the reimbursement of the costs of HIV and syphilis tests in health care facilities at different levels of complexity, and difficulties in monitoring and evaluating the services provided during prenatal care. These factors create a lack of continuity in the services offered, as well as a loss of opportunity for the early diagnosis of HIV and syphilis in pregnant women—which contributes to a preventable increase in the morbidity and mortality associated with HIV and syphilis among women of childbearing age and in the transmission of these infections to their children and sexual partners. Third, this report reviews some interventions successfully developed in Peru to integrate prenatal care with the testing and treatment of HIV and syphilis. Finally, the report presents the areas identified for strengthening the integration of prenatal care with the testing and treatment of HIV and syphilis in Peru.
Index
Organization of the health system in Peru 8
Technical guidelines for the diagnosis of HIV and syphilis and financing system 12
Epidemiological indicators on prenatal care and on HIV and syphilis during pregnancy 18
Weaknesses in the health care system 33
> Problems in planning due to lack of complete data 33
> Problems in the procurement and financing of diagnostic tests 34
> Problems in the classification and procurement of antiretroviral drugs 34
> Late presentation for prenatal care 35
> Disarticulation of patient care during pregnancy 36
> Problems in laboratory turnaround time 37
> Delays in initiation of prophylaxis and treatment during pregnancy 38
> Problems in postpartum follow-up of women diagnosed with HIV or syphilis and of their newborns 39
> Attitudes of health care providers towards women diagnosed with HIV 40
Interventions developed to integrate prenatal care with the testing and treatment of HIV and syphilis 41
Areas identified for strengthening the integration of prenatal care with the testing and treatment of HIV and syphilis 44
I would like to thank Drs. Jaime Bayona and Arachu Castro for their ok to publish this resource in GHDonline.
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