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1. ART access for pregnant women living with HIV and follow-up care for HIV exposed infants: A four country assessment of key PMTCT interventions Priscilla Idele, PhDCo-authors: Jessica Rodrigues, Chewe Luo, Ade Fakoya, Chinyere Omeogu, Rene Ekpini SESSION: WEAD04 Surviving and Thriving: Children, Adolescents and HIVDate: 23/07/2014 (14:30-16:00 PM) Room: Plenary 2 #PMTCT #AIDSfreegeneration. #4change #AIDS2014

2. Background • 2010 WHO PMTCT guidelines included the following options: • Lifelong ART foreligible HIV infected pregnant women • Two ARV prophylaxis options • Option A – AZT backbone during pregnancy and prolonged ARV prophylaxis to baby • Option B – ART to the mother during pregnancy through breastfeeding for HIV infected women not eligible for treatment • Implementation of recommendations could significantly reduce the risk of MTCT and ensure increased maternal and child survival. • The Global Fund supported countries to reprogramme existing grants towards accelerating PMTCT scale-up with more efficacious regimens

3. Objectives • Assess status of adoption of 2010 WHO PMTCT guidelines at the time of the assessment • Understand how nationally adapted guidelines had been translated into action at the service delivery level • Identify successes and current operational challenges, and highlight operational feasibility • Assess uptake of selected PMTCT and paediatric HIV care services

4. Data and Methods • Assessment in Tanzania, Malawi, Zambia, Lesotho between November 2011 - February 2012 • Document review - national PMTCT guidelines, scale up plans and progress reports • Key informant interviews - national PMTCT managers and partners; district health officers and health facility staff • 10 health facilities purposively selected in each country with Ministry of Health • Implementing 2010 guidelines; • At least 2 regions and 2 districts within the region; • urban/rural; • level of facility; and • supported by IP or not

5. Data and Methods • Structured health facility questionnaires • Availability of guidelines & provider job aids • Staffing and training • Essential laboratory diagnostics • Availability of essential medicines • Service linkages & referral mechanisms • Record keeping and monitoring tools • Dataabstractionfrom health facility registers and clinical records at 10 health facilities in each country and for the last quarter

6. Data abstraction on selectedindicators Pregnant women • Uptake of maternal HIV testing during antenatal care • CD4 testing for HIV+ pregnant women • Uptake of ARVs/ART for HIV+ mothers (both ARV prophylaxis, ART for mothers) Infants • ARV prophylaxis for HIV exposed infants • Cotrimoxazole prophylaxis within 2 months of birth for HIV exposed infants • Infant HIV diagnosis (EID) within 2 months of birth

7. Results

8. Adoption of 2010 WHO PMTCT guidelines

9. STAFF TRAINING ON NEW GUIDELINES • Percentage of ANC staff trained in PMTCT and paediatric HIV care at 10 selected health facilities in each country, November 2011-February 2012 Source: UNICEF and Global Fund. Rapid Assessment of Implementation of 2010 WHO PMTCT Guidelines in Lesotho, Malawi, Tanzania, Zambia, November 2011- February 2012. November 2012

10. AVAILABILITY OF ON SITE HIV, CD4 & EID TESTING Availability of essential laboratory tests at 10 selected health facilities in each country, November 2011-February 2012 *One urban filter clinic refers patients to another facility for HIV testing Source: UNICEF and Global Fund. Rapid Assessment of Implementation of 2010 WHO PMTCT Guidelines in Lesotho, Malawi, Tanzania, Zambia, November 2011- February 2012. November 2012

11. AVAILABILITY OF ESSENTIAL PMTCT MEDICINES Number of facilities with no stock outs of essential medicines in the past 3 months at 10 selected health facilities in each country, November 2011-February 2012 *Available as a one-pill fixed dose combination; -- Those medicines were not assessed given the PMTCT Option Source: UNICEF and Global Fund. Rapid Assessment of Implementation of 2010 WHO PMTCT Guidelines in Lesotho, Malawi, Tanzania, Zambia, November 2011- February 2012. November 2012

12. Coverage of selected PMTCT services Percentage coverage of selected PMTCT services among pregnant and HIV+ women in 10 health facilities in each country, November 2011-February 2012

13. Coverage of selected paediatric HIV care services Percentage coverage of selected paediatricHIV care services among HIV-exposed infants in 10 selected health facilities in each country, November 2011-February 2012 Source: UNICEF and Global Fund. Rapid Assessment of Implementation of 2010 WHO PMTCT Guidelines in Lesotho, Malawi, Tanzania, Zambia, November 2011- February 2012. November 2012

14. Community linkages and referral mechanisms • Community outreach common practice in all countries via community health workers, volunteers, lay counsellors, mentor mothers or expert patients • Some involvement of community leaders, traditional healers, use of radio, health campaigns, and use of cell phones for appointment reminders and conveying test results • Referrals community <-> health facilities often informal, verbal • Some good examples of formal two-way referrals using forms and accompaniment of clients to health facilities in Malawi and Zambia

15. Recording keeping and data availability and completeness • Countries were in the process or had not yet adapted registers and monitoring forms to accommodate all of the 2010 WHO PMTCT recommendations • Data on maternal HIV testing and maternal ARVs during pregnancy were easily available and with well completed registers in both ANC and maternity • Data on post-natal follow up of HIV+ mothers and exposed infants were often incomplete or unavailable: • CD4 testing, infant HIV testing, cotrimoxazole, infant feeding, postnatal ARVs for PMTCT, and follow-up care for HIV-exposed infants often lacking or incomplete • Referral forms exist, but no formal mechanisms of documenting referrals and whether the service was received • A few facilities improvise registers to capture information considered useful but not in the old registers • Some partners have separate registers at specific sites they support to collect agency-specific data

16. Summary and Conclusions • Feasibility, ease of roll out, cost and health benefits were important considerations for adoption of guidelines in all countries • Implementation of new guidelines requires considerations in: • Strategic planning, adapting and disseminating of new guidelines, along with job aids to assist health care workers in following new PMTCT protocols. • Capacity development, i.e. training to update and provide new skills and knowledge to health workers and managers • Ensuring essential logistics and supplies of medicines, laboratory tests and equipment for all facilities delivering PMTCT interventions. • Strategic shifts e.g. task shifting, decentralization, and supervision and mentoring, and community engagement (Malawi, Lesotho) • Revision of registers and monitoring tools to incorporate new recommendations • Safe transport of laboratory samples and results between facilities, district hubs and national testing centres

17. Summary and Conclusions • In Malawi, implementation of Option B+ accelerated ART access for HIV+ pregnant women, but not similar effects on paediatric HIV services – e.g. low HIV testing among infants • Need for family-centred approach as mother’s and children get services from the same place • Integration of paediatric HIV care into routine MCH services – immunization, community outreach, etc. to optimize access • Improving longitudinal care for mother-infant pairs until confirmed HIV diagnosis at 18 months is critical regardless of PMTCT option • Point of care diagnostics is important to minimise loss to follow up, long turnaround time and late initiation of care and treatment

18. Limitations • Rapid assessment of initial experiences in the roll out of the 2010 WHO PMTCT guidelines and did not cover all areas of importance • Timing: national roll-out incomplete, countries in transition from previous guidelines • Incomplete or lack of data: registers or clinical forms were not updated & referrals for CD4 & EID HIV testing led to long turnaround time for test results causing delays in updating records • Data abstraction from only 10 facilities per country and hence not comprehensive and representative of the national status; though indicative of coverage

19. Acknowledgements International consultants Paula Munderi Carolyn Green Country consultants GivansAteka – Lesotho BellingtonVwalika – Zambia Rose Mpembeni – Tanzania JephterMwanza – Malawi National PMTCT Program Managers Max Bweupe – Zambia MalisepoMphale – Lesotho Deborah Kajoka – Tanzania DalitsoMidiani - Malawi 91 Key informants – in 4 countries #PMTCT #AIDSfreegeneration. #4change #AIDS2014 UNICEF HQ / ESA Regional Office Ken Legins Edward Addai Dorothy Mbori-Ngacha Global Fund Ade Fakoya UNICEF Country Offices Joyce Mphaya - Tanzania BlandinahMotaung - Lesotho KondwaniNgoma - Malawi SitaliMwasenyeho - Zambia