RWANDA: A Case Study

1. RWANDA: A Case Study Introduction of an Integrated Package on MIYCN & PMTCT - Training, Counselling and Other Tools Cornelia Van Zyl, EGPAF Rwanda Country Director Peggy Koniz-Booher, Senior Technical Officer, PATH July 20, 2011 IAS, Rome, Italy

2. Rwanda PMTCT Program • PMTCT program started in 1999 with few sites • In 2009, 373 sites implementing PMTCT services • 82% of sites in Rwanda • In 2010, 70% of all pregnant women accessed for HIV testing during pregnancy • 81% of women testing with partners • HIV prevalence among pregnant women = 4.3% • 78% of all HIV positive women received ARVs for PMTCT in 2010 • 74% of all infants received ARVs for PMTCT in 2010 GOR priority to eliminate MTCT by 2015!

3. EGPAF - Brief Rwanda Program Overview • In Rwanda since 2000 • Since 2007, implementing USAID HIV clinical services program • EGPAF’s work is aligned with the MOH strategies and priorities • Comprehensive, family centered HIV prevention, care and treatment services as well as MCH, FP, nutrition services • Since 2007, providing central level TA to the MOH in the HIV exposed IYCF/PMTCT program, with support from PATH

4. Maternal, Infant & Young Child Nutrition Counselling Package • Counsellingcards for both community and facility health workers • Take home brochures for mothers and caregivers • Posters on breastfeeding and ante-natal care • Corresponding training materials

5. PMTCT/IYCF guidelines package A specific package to support the dissemination and uptake of new PMTCT and IYCF guidelines: • A Question and Answer Guide • Take home brochures, and • Poster

6. Overview of the Development Process - 2010 • Advocacy to MOH, using draft UNICEF generic package and mockups (Sept) • MOH buy-in and leadership (ongoing) • 4 day workshop to review harmonize materials following global release of UNICEF package (Nov) • Adaptations to package /development of new materials (Nov - Dec) • Q&A drafted, created the brochure and poster on new PMTCT/IYCF guideline (Nov - Dec) • Review/approval by Nutrition and PMTCT TGWs (Dec)

7. Overview of the Development Process - 2011 • Translation of MIYCN/PMTCT package into Kinyarwanda(Feb) • Field Testing with MOH and 18 partners (March) • Review of findings, consensus building and adjustment of materials (April – May) • Development of budget and phased scale up plan • Field testing of entire package/25 community health workers (June) • Adjustment of package and submission to MOH for final approval (July)

8. The Counselling Cards & Key Messages • 2 integrated sets of counselling cards for both community health workers and facility-based health workers • High quality & colorful graphics encourage specific behaviors- translated into Kinyarwanda • Health worker training focuses on counselling skills & the effective use of the cards

9. Individual cards reflect specific key messages

10. 5 additional cards on IYCF in the context of HIV

11. Three take-home brochures for mothers and caregivers

12. Two complementary posters focus on exclusive breastfeeding & ANC

13. Three unique materials to support the dissemination of the guidelines on PMTCT

14. The Rwandan MIYCN Community Training Package • The training materials are based on the generic UNICEF Community IYCF Counselling Package with unique participatory approach: • Adult learning principles • Interactive • Building on personal experience • Participants and trainers sitting on mats at same level • National scale up plan: • 24 master trainers, who will train • 1200 facility based trainer/supervisors in • 300 clinics in the 30 districts, • who will train 45,000 CHWs covering 1500 villages

15. Operations and/or Implementation Possible Research Questions Questions about the training: • What changes in infant feeding knowledge are documented over the course of a 5 day training for health care workers on the new MIYCN and PMTCT/ IYCF training and counselling packages? • What is the optimal training method to introduce the new MIYCN and PMTCT/IYCF training and counselling packages to health care workers in rural Rwanda? • 5 day training methodology vs. a 2 day orientation vs. no additional training (distributing the tools in a regular 2 hour monthly meeting)

16. Operations and/or Implementation Possible Research Questions Questions about the mother’s knowledge: • What proportion of HIV-infected mothers receiving infant feeding counselling in rural Rwanda understand the message that they should exclusively breastfeeding for 6 months and then introduce other foods while continuing to breastfeed, and also take ARVs? • What proportion of HIV-infected mothers have this understanding, before and after the CHWs in the selected areas for the research are trained?

17. More information on one research question . . . • Look at one research question on mother’s knowledge • Is this OR or IR? • This is implementation research since it is research on a strategy related to a specific product

18. Possible study design • Proposed series of cross sectional surveys with HIV-positive mothers who have received counselling in health facilities in selected areas of rural Rwanda before and after the local CHWs are trained using the new materials Introduction of training on new tools to CHWs Study Population Cross sectional survey with another group of HIV-positive mothers Cross sectional survey with HIV-positive mothers Compare Time

19. More information on one research question . . . • How will the results inform practice? • We will use the results to improve how the counselling materials are utilized and to improve the knowledge of HIV-infected women in rural Rwanda.

20. Thank you for listening!