Eliminating Mother to Child Transmission of HIV: The Partnership for HIV free Survival (PHFS)

Transcription

1 Eliminating Mother to Child Transmission of HIV: The Partnership for HIV free Survival (PHFS) Esther Karamagi (MBChB, MSc) Chief of Party, USAID ASSIST Project, Uganda University Research Co., LLC 1

2 The Partnership for HIV-Free Survival Nutrition in 1 st 1000 days (optimal infant feeding, nutrition and health practices) Option B+ (effective ARVs to reduce HIV transmission) QI HIV-free survival of HEI at 18 months 2

3 PMTCT outcomes at 22 demonstration sites 100% 90% 80% 70% 60% Percentage of HIV exposed babies discharged from PMTCT programs who test positive at 18 months (Feb Jan 2015) 50% 40% 30% 20% 10% 0% % Denominator: # of HIV exposed infants in PMTCT programs that have been discharged from EID care point 3% 2% 0 Feb-13 Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 3

4 emtct care spectrum Non-pregnant: Family planning (FP) counseling Preconception Care Partner HIV testing Antepartum: PITC in ANC CD4 (now VL) Testing ART treatment or prophylaxis Adherence support Infant feeding (IF) counseling Safe Motherhood Birth Preparedness PMTCT Intrapartum: Maternal Care Spectrum from Pregnancy to 18 months Post 1-8 Weeks Post 2-6 Months Post 6-9 Months Post Partum Partum: Partum: PITC in L&D CD4 testing (now VL) ARV treatment or prophylaxis Safe Delivery IF counseling FP counseling Adherence support Partum: Maternal postpartum followup Enrollment of HEI into care (EID care) ART treatment or prophylaxis during BF FP counseling IF counseling Adherence support Repeat CD4 (6 months pp). Now VL ART treatment or BF prophylaxis EID care for baby FP counseling IF counseling Adherence support ART treatment or BF prophylaxis EID care for baby FP counseling IF counseling Adherence support 9-12 Months Post Partum: ART treatment or BF prophylaxis EID care for baby FP counseling IF counseling Adherence support Months Post Partum: ART treatment EID care for baby FP counseling Adherence support Repeat CD4 (now VL) Effective PMTCT includes a series of biomedical and psychosocial interventions administered throughout the reproductive life of the woman living with HIV 4 The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development.

5 PMTCT & NACS Situation at Baseline Option B+ taken on as national strategy in 2012 System to monitor progress of option B+ set up National task team to review progress set up and functionalized Stakeholder meetings held at national level to share gaps in performance Data for mother and baby was delinked, missing critical data for HIV free survival, incomplete and inaccurate (2.9%) HEI were dropping out of care before 18 months (2.2%) Not every mother and baby were receiving recommended Option B+ and nutrition in first 1000 days package (2.9%) 5

6 The Approach: Improvement Collaborative HIV+ Mothers who are alive and in care Exposed Infants who are HIV-free, alive and in care Improve data system to identify areas for improvement Improve retention of mother-baby pairs Provide critical package of care at ROUTINE VISITS Provide critical package of care at SPECIAL VISITS (6w PCR and results visit, 6 and 12m visit, 18m visit)

7 Results: PHFS Dashboard at Baseline and After 11 Months. Baseline April 2013 PHFS February 2014 HCT in ANC ART initiat ion for preg nant wom en Retes ting of HIV negat ive wom en DBS at 6 week s for EID DBS Resul ts ART Prop h. Mater nal nutrit ion coun selin g IYCF coun selin g EBF withi n 1 hour of birth Repo rted Adhe rence to IYCF practi ces Nutrit ion asses smen t (infan ts) Nutrit ion asses smen t(mot hers) Reten tion of moth erbaby pairs in care Infant s testin g positi ve at final test Data Quali ty Health Unit ND ND ND ND 0 Kisoro Hosp NR ND ND ND ND 0 Rubuguri HCIV NPD NPD NDC ND ND ND ND ND 0 Kitwe HCIV * ND 100 ND ND 0 Itojo Hospital ND ND ND ND ND 0 Namutumba HCIII ND ND ND ND ND 0.1 Magada HCIII 100 NP NPD NPD RK 31 ND NR ND ND ND ND 0 Bugembe HCIV * 39.2 ND 34.9 RK RK ND NR 100 NR ND NR ND ND 0 Buwenge HCIV NR NR RK ND ND Mpumudde HCIV ND ND 100 ND ND 0 Tororo Hospital ND ND ND ND 17.4 ND ND 0 Nagongera HCIV ND ND ND ND ND ND 0 Mukujju HCIV ND 11.1 ND ND 0 Bubulo HCIV ND 0 ND ND 0 Bugobero HCIV NPD NPD ND ND 0 Rubaare HCIV nd ND 0 Ruhaama HCIII NEI NPD ND ND ND 0 Malaba HCIII NEI ND ND 0.2 Ivukula HCIII 93.2 NP NPD NPD ND ND ND ND 0 Muramba HCIII 0 NP NPD NPD NDC nd nd nd ND 0 Busanza HCIV 100 NP NDC ND ND 0 Magale HCIV nd 0.3 Bubuto HCIII NDC 81.8 HCT in ANC ART initiat ion for preg nant wom en Retes ting of HIV negat ive wom en DBS at 6 week s for EID DBS Resul ts ART Prop h. Mater nal nutrit ion coun selin g IYCF coun selin g EBF withi n 1 hour of birth Repo rted Adhe rence to IYCF practi ces Nutrit ion asses smen t (infan ts) Nutrit ion asses smen t(mot hers) Reten tion of moth erbaby pairs in care Infant s testin g positi ve at final test Data Quali ty Good Fair Poor Key Performing at 90% or more for that indicator or more Performance is between 60-89% Performance for that indicator is less than 60% ND NP+ NEI NPD NDC No Data No HIV positive women found No exposed infants reported No HIV positive deliveries No discharges 7

8 Jan-00 Mar-00 May-00 Jul-00 Sep-00 Nov-00 Jan-01 Mar-01 May-01 Jul-01 Sep-01 Nov % 90% 80% 70% 60% 50% 40% 30% 20% 10% Percentage of HIV positive pregnant women newly initiated on ART (Option B+) in 22 PHFS sites Feb Dec % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of HIV exposed babies reported to be adhering to IYCF guidelines in 22 sites (Feb Dec 2014) 0% 8

9 Increasing retention of mother- baby pairs in care monthly Proportion of mother-baby pairs retained in care each month in 22 PHFS sites in Uganda June 2013: Peer mothers involved in counselling mothers on May 2013: Merged EID and ART services at one services point and gave same appointment date Apr 2013: Pairing of mothers and babies All 22 PHFS sites One high-volume site (~150 pairs/month) One low-volume site (~85 pairs/month) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Dec 2013: Set specific / separate day to see M-B pairs Sept 2013: Assigned EID focal person to pair cards and make phone calls to June 2013: Peers escort MB pairs to the clinic Mar 2014: Phone calls to mothers Nov 2013: ART and EID merged so M-B July 2013: Family support group meetings used to identify MB pairs and see them 0% May 2013: Pairing of mother s and babies Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Number of mother-baby pairs who should be accessing care that month Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15

10 Increasing the MBP receiving a standard package of care at routine visits 100% Percentage of mother-baby pairs who receive a standard package of care at routine visits in 22 PHFS sites and one example facility with annotated changes 90% 80% 70% 60% 50% 40% 30% Sept 2013: Expert clients trained to do MUAC and assigned responsibility of assessing and nutrition counselling Aug 2013: Merging of ART and EID services Nov 2013: Mothers told about what services to expect so they can remind HW if they forget a service 20% 10% 0% June 2013: Learning session 2; new client flow chart developed Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Total number of mother-baby pairs seen in the clinic in the month Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15

11 Improving the quality of emtct data KEY LESSON 1 11

12 Taking to scale: Change packages A collection of tested changes to improve an aim / area (e.g. data quality, retention of mother-baby pairs) developed through a consultative process with quality improvement teams. Useful to improve indicator performance beyond the demonstration/pilot sites Teams may adapt changes to suit their context Insightful when developing guidelines, policies, etc. 12

13 Sustaining: the case of PHFS Introduction and roll out of the mother-baby care points Coordination of the National PMTCT M&E TWG National Level Support National evaluation of the motherbaby care points Update data system, logistics and supplies at MBCP, PMTCT training material QI Support to 7 implementing partners to improve PMTCT partners PMTCT dashboard for IPs to use Implementing partner support Spread of the PHFS change packages 13

14 Results of spread waves: PHFS results 14

15 Improving retention of Mother-Baby pairs in 22 initial sites in Uganda 15

16 2017 National Evaluation: Services at the MBCP 43.2% of MBCP provided an integrated package of emtct and nutrition services, including; ARVs for mother (TDF 3TC EFV), Nevirapine for infants under six weeks of age, Cotrimoxazole for infants over six weeks of age, Nutrition assessment for the mother (MUAC), Nutrition assessment for the baby IYCF counselling, DBS services (1 st and 2 nd DNA PCR test), Viral load or CD4 for the mother 82% of the MBCP maintained a minimum stock of all the three basic drugs: TDF/3TC/EFV combination, NVP syrup, Cotrimoxazole (120 mg) 63% of MBCP provide the basic laboratory services 1 st and 2 nd DNA PCR test, CD4 count or viral load

17 2017 National Evaluation: Patient Satisfaction Would return to MBCP for services Would encourage a friend or relative to seek services at MBCP No, 1.5 No, 1.7 Yes, 98.5 Yes, 98.3

18 Emerging gaps: New Mother-Baby Cascade Mother Baby cascade July June , ,593 99, , ,000 60,000 40,000 71, , , Identified positive women Started on ART for emtct 1st PCR ARV Baby 2nd PCR Rapid test at 18months 0 Number served Percentage served Picture : Mother-Infant cascade Source DHIS2

19 Results of EID EPI improvement collaborative: 3 districts only ( Jan Jun 2017) No. Eligibl e for testing Total Newly tested Retest ed Newly tested positiv e Known positiv es Due for DBS TEST ED 1st DBS Rapid tests done Positive on rapid test Mbps linked to care Mbps return ed to care Amuru Apac Mayug e Totals 11,688 3,813 5,

20 Acknowledgements District and facility staff in Ntungamo, Kisoro, Manafwa, Tororo, Jinja, Namutumba Mayuge, Luweero, Bushenyi, Apac and Amuru Ministry of Health of Uganda and UNEPI PEPFAR implementing partners SPRING, STAR- SW, STAR-EC, and TASO USAID ASSIST Project PHFS partners U.S. President s Emergency Plan for AIDS Relief The American people through USAID and CDC 20

21 For more information Esther Karamagi To access the phfs change packages, visit: 21