“Treatment for all pregnant women:

1. “Treatment for all pregnant women: Lessons learned and an overview of programmatic challenges” Presented by: Agnes Mahomva, MBChB, MPH Country Director , EGPAF Zimbabwe International AIDS Conference, Durban, South Africa July 18, 2016

2. Outline Introduction and Background Option B+ Successes Programmatic Challenges Lessons Learnt and Conclusion

3. PMTCT Drug Options Source: WHO, 2013

4. Background Option B+ is a model of treatment for allin a specific population All pregnant and breast feeding women living with HIV Rapid shift to initiate ART for all pregnant and breast feeding women living with HIV since 2013* Since end of Oct 2015 all 22 Global Plan priority countries (except Nigeria) officially endorsed Option B+ National Option B+ policy implemented at >90% of all sites in 14/22 *Source: IATT Update, October 2015

5. ART Sites in Zimbabwe, 2004-June 2015 Rapid increase of ART initiating sites in 2014/15 Source: Zimbabwe MOHCC national data

6. Option B+ Successes Vertical transmission benefit Increased coverage of ART among pregnant women Ease of implementation/rapid roll out Harmonized regimens High acceptability by pregnant women Adoption of differentiated care models Some HSS as part of roll out

7. Option B+ Successes:ART coverage as percent of all infected adults or children(Increased coverage of ART among pregnant women) Source: UNAIDSdata – AIDS info (Nov 2015)

8. Option B+ Successes Acceptability:Pregnant women’s responses to B+ Easy to accept lifelong therapy because it was similar to taking medication for diabetics or birth control Accepted lifelong therapy for the sake of their babies Seeing other people looking healthy on ART in their communities facilitated ART acceptance Low pill burden: one pill a day was much easier to manage Source: IAS 2016 Poster WEPEE514; Acceptability of Option B+ in Zimbabwe

9. Option B+ Successes Adoption of differentiated care models Decentralization of ART from OI/ART sites to all MNCH facilities OI/ART sites decongested Nurses capacitated to initiate ART – Task shifting Pregnant women able to access ART nearer home Introduction of same day ART initiation supported by strengthened adherence counselling at every ANC follow up visit

10. Option B+ Programmatic Challenges Limited investment in all HSS pillars Leadership to see through an efficient decentralization Financing for additional decentralized program needs Drugs and commodities – simplified regimen yes BUT procurement and supply chain management remained a challenge Implementation at site level not always well coordinated Delays in revision of M&E systems and limited program impact evaluations Loss to Follow up Poor retention in care

11. EGPAF Tanzania: Early retention (2+ visits) in HIV care among non-pregnant vs. pregnant women, by year of enrollment Source: EGPAF Tanzania data

12. Lessons Learnt • Health system strengthening for all six pillars with a focus on the following was key to a smooth roll out: • District and site leadership for efficient decentralization • Drug forecast and supply chain management • Life long ART was acceptable by those not yet ill • Retention in care remained a big challenge • Loss to Follow up

13. Lessons Learnt • Introduction of innovative care models important for rapid rollout of life long ART and for follow up : • Decentralization of ART to all MNCH sites • Same day ART initiation with strengthened adherence counselling at follow up visits • Support groups to strengthen follow up and adherence after deliver and during breast feeding (eg CATS* for adolescent mothers) *Community Adolescent Treatment Supporters (eMTCT Champions)

14. Thank you! Tatenda