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Planning for Transition from Opti on B to B+: Rwanda Experience

Planning for Transition from Opti on B to B+: Rwanda Experience. MUGWANEZA Placidie , Coordinator of HIV prevention Unit/RBC/MOH ART in pregnancy, breastfeeding and beyond, Johannesburg, June 18-20, 2012. OUTLINE. Rwanda context History of PMTCT guideline and regimen changes in Rwanda

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Planning for Transition from Opti on B to B+: Rwanda Experience

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  1. Planning for Transition from Option B to B+: Rwanda Experience MUGWANEZA Placidie, Coordinator of HIV prevention Unit/RBC/MOH ART in pregnancy, breastfeeding and beyond, Johannesburg, June 18-20, 2012

  2. OUTLINE • Rwanda context • History of PMTCT guideline and regimen changes in Rwanda • Roadmap and timelinefrom option B to option B+ • Current Program: areas for Improvement • Experience with Site supervision • Next steps

  3. RWANDA CONTEXT • East African country of 26,338 km2 • Population: ~10 m. inhabitants • Administrative framework • 4 provinces and Kigali City Council • 30 districts • 415 sectors/cells/villages • Generalized HIV epidemic • 3% prevalence in general population • 3,7% prevalence among women • Rapid scale up of HIV services • 456 PMTCT sites (82%) • 372 ART sites (70%) RWANDA

  4. PMTCT REGIMENS IN RWANDA

  5. TRANSITION FROM OPTION B TO B+ • Revision and approval of the guidelines 7- Tools revision (adherence register, indicators, Q&A and BCC) 1- Launch of the EMTCT National campaign September 2011 March- April 2012 May 2011 February March 2012 Ongoing 2. Recommendation from scientific workshop: shift from option B to B+ 5. Training of Health providers, launching of B+

  6. BUILDING ON EXISTING HEALTH SYSTEMS • Integrated service delivery model • High coverage of health facilities providing both PMTCT and ART • Integrated HIV training ( ART & PMTCT) • Coordinated procurement and distribution system & ARV quantification • Strong coordination and service provision structures already in place • National ↔ district ; facility ↔ community; ART ↔ PMTCT • Task shifting already in place • Strong political commitment

  7. HIGH COVERAGE OF INTEGRATED HIV SERVICES Source: RBC;

  8. Increasing Proportion of HIV-infected Pregnant Women Receiving HAART during Pregnancy Source: Trac Net database, RBC/IHDPC

  9. ARV REGIMENS FOR PMTCT • Option B (adopted November 2010): • Women with CD4 < 350: TDF/3TC/NVP • Women with CD4 > 350: TDF/3TC/EFV • Option B+ (Adopted April 2012) • All women : TDF/3TC/EFV • Infant: Daily NVP up 6 weeks

  10. ONGOING AREAS FOR IMPROVEMENT • ANC attendance • Only 38% attend ANC before the 4th month of pregnancy • Need for ongoing mentorship for nurses at PMTCT sites • Retention and ART Adherence for pregnant and lactatingwomen • ARV quantification and forecastingat district level • Rapidturnaround of EID results to sites for earlytreatment • Follow-up of ART patients at PMTCT standalone sites • Linkages to treatment for male partner and children • Follow-up of motherafter the breastfeedingperiod

  11. Supporting Program Implementation and Quality through Site Supervision: Example of Track 1.0 Transition • Planning • Identify and notify sites to be supervised • Establish a schedule • Define the resource needed (e.g HR, transport… • Provide tools and train supervisors • Implementation • Use standard tool • Identify strength and weakness • Provide feedback • Documentation

  12. TIMELINE FOR TRACK 1.0 SITE MONITORING Cohort 1 Transition 18 Sites Cohort 2 Transition 6 Sites Cohort 3 Transition 46 Sites 2010 2011 March Sept. Jan. Oct. Feb. June July Aug. July May Dec. Sept Aug. Nov. June April May C1 12-Month Follow-Up C1 Baseline C1 6- Month Follow-Up C2 Baseline C2 6-Month Follow-Up C3 Baseline C3 6-Month Follow-Up

  13. SITE VISITS & DATA COLLECTION • Teams visit all transitioned sites at baseline and every 6 months • November 2009-December 2010: CDC-led with MOH/partner participation • January 2011-Present: MOH led with CDC participation • Management Capacity • Interview health center director, accountant, data manager, ART and PMTCT nurses and lab technicians • Abstract data from quarterly PBF evaluations • Clinical Performance • Abstract clinical performance data from national HIV monitoring system (TRACNet) and Track 1.0 reports

  14. Mean HIV PMTCT Performance Results for Health Facilities at Baseline, 6 and 12 Months after Transition

  15. FEEDBACK: DISSEMINATION WORKSHOPS • Held at district hospitals for facilities in their catchment after each round • Facilitated by MOH • Agenda: • District-specific results • Site specific results, small group discussion • Action planning to address identified gaps

  16. LESSONS LEARNED • Accompanying MOH on routine site visits builds site- and central-level capacity • Decentralization of site visits could improve MOH efficiency, follow-up of recommendations • Involvement of all relevant MOH departments improves follow-up on recommendations

  17. NEXT STEPS • Finalize and disseminate revised tools • Accelerate accreditation process for PMTCT standalone sites to offer ART • Evaluate retention and adherence for mother-infant pair • Reinforce the PMTCT M&E (e.g: Revision of PMTCT indicators, program evaluation) • Establish ARV pharmacovigilance system • Reinforce capacity of health providers through training, supervision and mentorship

  18. Thank you Murakoze

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