Strengthening Health Systems for an AIDS-Free Generation 4th Annual IAS/IAC Pre-conference Meeting WASHINGTON, DC JULY 20-21, 2012

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1 Strengthening Health Systems for an AIDS-Free Generation 4th Annual IAS/IAC Pre-conference Meeting WASHINGTON, DC JULY 20-21, 2012 Challenges for Further Decentralization of HIV Treatment in Tanzania David Hoos ICAP

2 EXPANSION OF HIV CARE AND TREATMENT IN TANZANIA, ICAP is the assigned PEPFAR ART and PMTCT partner in Kagera, Kigoma, Pwani and Zanzibar. The expansion and decentralization of HIV care/art facilities has been dramatic (78-127) and are a mix of PHC andhospitals

3 595 FACILITIES OFFER PMTCT SERVICES, 118 OF WHICH HAVE ON - SITE ART SERVICES Most PHC offer PMTCT, and are geographically easily accessible to almost all pregnant women; ART is less accessible 4th Annual IAS/IAC Pre-conference Meeting: HIV and Health Systems: Strengthening Health Systems for an AIDS-free Generation July 20-21,

4 ACCESS AND UPTAKE OF CD4 TESTING FOR HIV+ PREGNANT WOMEN- 72% OF HIV+ PREGNANT WOMEN HAVE CD4 RESULTS 100% 37% of PMTCT clinics offer CD4, are high volume and serve 84% of HIV+ pregnant women. 82% of those women have CD4 test results 63% of PMTCT clinics do not offer CD4 tests - these clinics serve 18% of HIV+ pregnant women Of those HIV+ pregnant women without CD4 testing, 48% come from sites with access to CD4, 52% come from sites without CD4 80% 60% 40% 20% 0% April-June 2011 July-September 2011 October-December 2011 January-March 2012 PMTCT clinics offering CD4+ testing/who staging for HIV+ pregnant women HIV+ pregnant women with CD4/staging recorded at sites offering assessment HIV+ pregnant women with CD4/staging recorded: all sites

5 HIV INFECTED PREGNANT WOMEN EXPECTED TO START ART UNDER B AND B+ PMTCT uptake and provision is high, but 87% of newly identified HIV+ pregnant women in Tanzania did not initiate therapeutic ART Initiating these women on ART would increase ART enrollment by 40% 2,500 2,000 1,500 1, Apr-Jun 2011 Jul-Sep 2011 Oct-Dec 2011 Jan-Mar 2012 Pregnant women newly testing HIV+ through ANC New on ART, all patients (care and treatment clinics) New on ART (PMTCT) HIV+ pregnant women not starting ART

6 THERE IS A NEED FOR PROACTIVE COLLABORATION BETWEEN MODELLERS, POLICY MAKERS AND IMPLEMENTERS District, Sub-District Hospitals all offer PMTCT and ART Many large PHC offer PMTCT and ART Universal Access will rely on further expansion to PHC that currently offer PMTCT only Many do not have access to CD4 testing While nurses can initiate PMTCT regimens, currently nurses are not authorized to initiate or continue ART

7 CONCLUSIONS AND POLICY IMPLICATIONS The expansion of care and treatment facilities has been substantial, but the limited number of facilities offering ART inhibits true universal access PMTCT services are accessible to most women in Tanzania While CD4 testing may not be needed for initiation of Option B+, it remains a recommended component of continuity ART care Most but not all HIV+ pregnant women have access to CD4 the limited number of sites with CD4 access serve most HIV+ pregnant women programmatic improvement is needed to improve CD4 uptake PMTCT sites without CD4 access are large in number they serve a smaller proportion of HIV+ pregnant women but improving CD4 access will be challenging - systems issue

8 CONCLUSIONS AND POLICY IMPLICATIONS Initiation of B options will substantially raise ART enrollment Each choice for where these women will receive continuity ART raises challenges Existing Care and Treatment facilities Geographic access to Care and Treatment facilities is not universal Substantial increased enrollment may overwhelm these facilities PHC that currently are PMTCT only Training, staffing, access to CD4, supervision, mentoring each will require substantial investment