GETTING READY FOR DUAL EMTCT VALIDATION IN THE AMERICAS

1. GETTING READY FOR DUAL EMTCT VALIDATION IN THE AMERICAS Adele Schwartz Benzaken

2. OUTLINE • BACKGROUND OF EMTCT IN THE AMERICAS 2. DEVELOPMENT OF REGIONAL VALIDATION METHODOLOGY AND STRUCTURE 3. CONCLUSIONS

3. EMTCT HISTORY IN THE AMERICAS • 1994: The24th Pan American Sanitary Conference called for the elimination of congenital syphilis as a public health problem. • 1995: Development of the Plan of Action for elimination of congenital syphilis. • 2005: Regional HIV/STI Strategy for the Health Sector with ambitious HIV/STI PMTCT goals, including congenital syphilis elimination. • 2008: PAHO and UNICEF host Caribbean side event at IAC to explore elimination of MTCT of HIV • 2008- 2009: Sub-regional technical consultations & development of dual EMTCT implementation strategy • November 2009: official launch of Regional Dual EMTCT Initiative • September 2010: PAHO Member States adopt the regional EMTCT Strategy and Plan of Action by Resolution

4. REGIONAL DUAL EMTCT STRATEGY Pillars: • Strengthening and integration of HIV/STI, SRH, MCH, newborn care and family and community health services • Strengthening the capacity of MCH, newborn, child health and other services for early detection, care and treatment of HIV and syphilis in pregnant women, their children, and their partners • Intensify surveillance of HIV and syphilis in MCH services Regional implementation: • Development of tools, including a conceptual document, Regional Monitoring Strategy, Costing tool, Field Guide • Direct support to countries • Regional monitoring and reports

5. Pregnant women tested for syphilis at antenatal care in Latin America and the Caribbean (2012-2013)

6. Reported congenital syphilis rates in selected countries in the Americas, 2009-2013

7. New HIV infections in children in Latin America and the Caribbean 2001-2013 ARV coverage among pregnant women for prevention of mother to child transmission of HIV

8. Pregnant women tested for HIV in Latin America and the Caribbean, 2005-2013

9. DEVELOPMENT OF THE REGIONAL EMTCT VALIDATION STRUCTURE • Considering that several countries appeared to be close to achieving the EMTCT targets, PAHO, in collaboration with UNICEF and other partners, initiated development of a validation methodology in 2011: • Drafting of a methodology • Pilot implementation in two countries (St. Lucia & Chile) • Merging of efforts with WHO HQ in 2012 • Establishment of regional mechanisms in 2013-2014

10. VALIDATION METHODOLOGY 1. Verification of achievement of the elimination targets: • Verification of the quality of the reported data • Assessment of the underlying data collection and reporting systems 2. Verification of the existence of an adequate laboratory network that: • provides the services needed to achieve, maintain and measure the elimination targets • Generates reliable results 3. Verification of the existence of an adequate network of services that: • Provides all needed services, accessible to all in need • Provides quality services

11. Country pilots • Full assessments, which included interviews and site visits with: • All national programs (MCH, HIV, STI, etc) • Sample of first, second and tertiary level service delivery sites in the capital and districts with the highest burdens of disease (HIV or syphilis or both) • Feedback and discussion sessions with stakeholders (Minister of Health , managers and service delivery) • Final report produced by the external team with recommendations and final conclusions

12. PILOT IMPLEMENTATION • In two countries (St. Lucia & Chile) • External team of experts (6-10) in the areas of MCH, HIV, STI, laboratory, epidemiology, health systems. • One week of field work: 1) interviews with policy makers, program managers, service providers, civil society, clients;2) field visits to service delivery sites: 3) verification and recalculation of data on local and national level.

13. LESSONS LEARNED • Pilots indicated validity of the methodology to understand the national program, verify the data, and identify (potential) issues and challenges. • Estimated cost of country validation: $ 15,000-$ 20,000 (depending on size). • Considering the required investment and formal commitment for dual EMTCT, only country requests for validation of EMTCT of both HIV and syphilis will be considered.

14. Data gaps • PAHO emphasizes reporting on elimination impact and coverage targets based on “real” data. • Some countries might have gaps, in particular in coverage data due to various reasons, including significant private sector. • Acceptable modalities to assess these data gaps: • Special studies • Sufficient private sector representation in assessment samples? • Others

15. The Regional Validation Committee • Established as a high level Committee convened by the PAHO Director (May 2014). • Membership: 13-15 regional experts: independent experts, representatives from UN partners, representatives from regional technical organizations • Main role is to provide regional oversight of the validation process, coordinate country evaluation exercises, and determine whether a candidate country can be recommended for validation.

16. CURRENT STATUS • Ongoing refining of the methodology and tools, including development of approaches for small population sizes. • Ongoing application of the tools for program assessments upon request of countries in 2013 and 2014. • Preparations for first round of formal country validations (Cuba, Bahamas and others)

17. CONCLUSIONS • Region of the Americas has longstanding and formal commitments for elimination of congenital syphilis and vertical transmission of HIV. • Dual EMTCT is imminent for some countries in the region. • Validation requires establishment of formal and credible regional structures and processes aligned with global.

18. ACKNOWLEDGEMENTS • Dr. Massimo Ghidinelli (PAHO/WDC) • Dr. Sonja Caffe (PAHO/WDC) • HAYASHI, Chika (WHO/HIV Department) • Regional Committee for Validation of Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis (RVC)Members