Improving Follow up of HIV Exposed Infants in Apapai Health Centre IV.

Transcription

1 M A K E R E R E U N I V E R S I T Y SCHOOL OF PUBLIC HEALTH (MakSPH-CDC FELLOWSHIP PROGRAM) Improving Follow up of HIV Exposed Infants in Apapai Health Centre IV. By Jennipher Akol & Ann Grace Among MAKSPH-CDC MEDIUM TERM FELLOWS (HEALTH SERVICE IMPROVEMENT) Supervisors: Dr. Solome Nampewo Dr. Violet Gwokyalya MARCH 2015

2 LIST OF ABBREVIATIONS ADHO ANC ART CME CQI DHO EID EMTCT EPI HIV HMIS HSD IPT MCH MOH PCR PNC TB YCC Assistant District Health Officer Ante Natal Care Anti Retroviral Therapy Continuous Medical Education Continuous Quality Improvement District Health Officer Early Infant Diagnosis Elimination of Mother to Child Transmission Expanded Program on Immunization Human Immuno deficiency Virus Health Management Information System Health Sub District Intermittent Presumptive Treatment Maternal Child Health Ministry Of Health Polymerase Chain Reaction Post Natal Care Tuberculosis Young Child Clinic ii

3 TABLE OF CONTENTS LIST OF ABBREVIATIONS... ii TABLE OF CONTENTS... iii DECLARATION... iv ACKNOWLEDGEMENTEXECUTIVE SUMMARY... v EXECUTIVE SUMMARY... vi INTRODUCTION... 1 Background to Apapai Health Centre IV... 2 PROBLEM IDENTIFICATION AND PRIORITIZATION... 3 BASELINE ANALYSIS OF THE PROBLEM... 3 ROOT CAUSE ANALYSIS OF POOR FOLLOW UP OF EXPOSED INFANTS... 5 PROBLEM STATEMENT... 5 OVERALL OBJECTIVE... 7 SPECIFIC OBJECTIVES... 7 INTERVENTIONS... 8 RESULTS LESSONS LEARNT AND CHALLENGES CONCLUSION AND RECOMMENDATION WORKPLAN BUDGET REFERENCES iii

4 DECLARATION I Jennipher Akol and Grace Among do hereby declare that the end of project report entitled Improving Follow up of HIV Exposed Infants has been prepared and submitted in fulfillment of the requirement of the Medium Term Fellowship Program at Makerere University School of Public Health and has not been submitted for any academic or non academic qualifications. Signed.Date.. Jennipher Akol, Medium Term Fellow. Signed Date Grace Among,Medium Term Fellow. Signed..Date. Dr. Odeke Francis, Institutional Supervisor. Signed..Date Dr. Nampewo Solome, Academic Supervisor. iv

5 ACKNOWLEDGEMENT We are very grateful to all the people who have supported us in the implementation of this project. Our sincere gratitude goes to the leadership of Serere District Local Government for selecting us to take part in the training. Special thanks go to the District Health Officer of Serere for all the guidance in implementation of the project, and the supervision he offered. We thank Makerere University School of Public Health-CDC Fellowship program for the skills given to us, the financial support in implementation of the project and all the supervision and mentorship offered. We specifically thank our mentors Dr Violet Gwokyalya, Dr Ikoona Eric, Dr Olico Okui, Dr Nampewo Solome and Mr Matovu Joseph. We also thank all the facilitators and mentors plus the staff of MakSPH-CDC Fellowship program. We thank the US Centres for Disease Control for funding this program. Lastly we thank our dear families and the staff of Apapai Health Centre IV for their contribution towards the success of this project. v

6 EXECUTIVE SUMMARY Although mother-to-child transmission rates have been reduced to less than 5% in some low and middle-income countries 330,000 children were still newly infected in Early diagnosis of HIV infection is essential for ensuring timely initiation of ART and reducing the high morbidity and mortality that occurs among HIV-infected children who do not receive treatment. Apapai Health centre found in the Eastern region of Uganda, in Serere district was faced with very high rates of lost to follow up of exposed infants as high as 60% for over three years ( ) and yet even the few infants that were retained in care, a high proportion of them turned HIV positive. That high rate of drop out was primarily due to; inadequate counseling and education offered to the mothers, issuing wrong appointment dates to clients, poor filing of IED registers and appointment books, workload in the ANC clinics leading to reluctance in filling the appropriate registers, and low perception of mothers of the need to return for follow up care in addition to other causes. The Apapai health team aimed to implement a project to improve the follow up of exposed infants from the current 40% to at least 80% with 5 months. Strategies implemented included; training staff on complete and correct filling of the EID register, appointment book, and the child cards; conducting care givers meetings and formation of family support group to enhance adherence to appointment; on job training, mentorship and support supervision for staff to ensure quality client counseling, adherence to guidelines and proper documentation coupled with regular reviews to assess project progress; and review and intensifying tracking of exposed infants. With the above strategies, this project helped to get the outcomes of 44 of the 52 lost clients and discharged 30 of them. It also helped to establish a system at the facility to ensure that all the children identified to be HIV exposed are promptly handled and linked to the EID care point and adequately followed up. It will then eventually contribute to a reduction in the very high HIV positivity rates among exposed infants in care at Apapai Health Centre IV as well as the HIV related morbidity and mortality among those who turn out positive. vi

7 INTRODUCTION There have been significant developments in knowledge of interventions that can save lives of HIV-exposed infants. Current WHO guidelines recommend HIV testing of HIV-exposed infants at 4 6 weeks postnatal (early infant diagnosis, EID), and immediate antiretroviral therapy (ART) initiation for those testing positive. As early cessation of breastfeeding is associated with poor health outcomes for HIV-exposed babies, current guidelines support continued breastfeeding in conjunction with extended infant prophylaxis with nevirapine, and re-testing of the exposed baby at least 6 weeks after cessation of breastfeeding (2 nd PCR). Also, included within the guidelines are recommendations for infant feeding in the context of HIV, which stress that mothers need to be educated about the importance of exclusive breastfeeding in the first 6 months of life and the need to have the HIV positive mothers on ARVs for life (option B + ) to minimize as much as possible HIV transmission not only to that exposed infant but to subsequent pregnancies as well. All these guidelines aim at having a healthy HIV free baby but they necessitate continued follow-up of mothers and their exposed babies to ensure their full participation in the postnatal care cascade. Yet despite all these laid out interventions with potential to save lives of HIVexposed infants, many infants do not access the full package of services because of loss to follow-up (LTFU). As with the PMTCT cascade, infants are lost to follow-up at every step of the EID cascade with some studies showing that up to 85% of infants are lost by 1 year. Busy clinics, long wait times, stigma, excessive turn-around times, weak referral systems, lack of integration of services, infant death prior to receiving a PCR test or accessing HAART, and poor follow-up all contribute to the poor retention rates. Relatively recent implementation of national adaptations of the 2010 WHO Recommendations for PMTCT which include ARV prophylaxis to the mother or infant throughout breastfeeding (Options A,B) provides an ideal opportunity (although not yet fully utilized) to improve retention of the mother-infant pair within care, ensuring that all HIVexposed infants receive a final definitive diagnosis and HIV-infected infants initiate ART; initiation of lifelong ART to all pregnant and breastfeeding HIV positive women (Option B+) provides a similar and potentially even greater opportunity. 1

8 In Uganda since the rollout of option B + in 2012, many health facilities including Hospitals, Health Centre IVs, Health Centre IIIs and some high volume Health Centre IIs or those serving hard to reach areas have been supported to establish EID care points. At the EID care points, all exposed infants are enrolled in the exposed infant register, and then given regular appointments starting from 6 weeks for continued care and support. However the biggest challenge faced is loss of these exposed infants from the care cascade. An analysis done by Euphemia L. Sibanda et al, 2013 in several countries concluded that, there is unacceptable infant LTFU from PMTCT programs and recommended that countries should incorporate defaulter-tracking as standard to improve retention. Background to Apapai Health Centre IV Apapai Health centre is found in Eastern Uganda, Serere district, Kasilo County, Bugondo Sub County, Kongoto Parish and Apapai village. It s the only HC IV in Serere and it serves 4 Sub counties with a catchment population of 27,400. It was started in 1947 as a dispensary and promoted to health IV in It s a 21 bed capacity facility and it is run by 17 qualified health staff and 7 support staff. There are various departments in the facility such as Outpatient department, Dental, Anti Retro-viral Therapy, Expanded Programme on Immunization, Maternal and Child Health (MCH), Laboratory, Stores, Wards, a non functional operating theatre and Records Department. It offers both curative and preventive health services, outpatient and inpatient services. Other services include care of HIV exposed infants done in the MCH department specifically in the EID clinic. In Apapai Health centre IV, all pregnant women with their partners that come for ANC services are screened for HIV to promote EMTCT. Any pregnant mother newly diagnosed with HIV is initiated into care irrespective of the CD4count. Screening for mothers that bring their infants to the YCC is done and any mother that tests HIV positive is counseled and enrolled into care at the HIV clinic while their infant is enrolled in the EID clinic. The mothers are then given regular appointment as per the Ministry of Health guidelines to return for continued counseling care and support and refill of their ARV treatment. By March 2014, a total of 137 infants were enrolled in the EID clinic since 2011 when the clinic started and on average the clinic enrolls 42 infants a year. 2

9 PROBLEM IDENTIFICATION AND PRIORITIZATION Upon return at the facility after the first module of Health Service improvement, the fellows met the DHO to brief him on the course and what was expected of them and requested for a joint meeting with him and the staff of the health facility. The facility meeting was attended by; 14 staff, Assistant DHO-MCH and the district HMIS focal person. The meeting begun with a CME on CQI, which was followed by a brainstorming session by the team on service delivery problems that the facility faced. Through this brain storming exercise, the team generated a list of performance problems as shown in the table. Problems like poor accommodation, little salaries, irregularity of salaries, lack of a clinician, and understaffing which were beyond the control of the team were left out. Voting by show of hands was then done to identify the most crucial problem. Table showing problem prioritization No Problem Number of Votes 1 Long patient waiting time 1 2 Poor CD4 follow-up 1 3 Low 4 th ANC attendance 2 4 Low IPT2 uptake by pregnant mothers 2 5 Poor follow-up and retention of HIV exposed infants 4 6 Incorrect filling of facility registers 3 7 Poor detection and follow up of TB cases 1 After analyzing the scores and discussing each problem in detail, members agreed that, poor follow up and retention of HIV exposed infants was a priority problem that warranted attention. BASELINE ANALYSIS OF THE PROBLEM Existing records at Apapai Health Centre revealed that the facility started EID services in July 2011 and has been enrolling an average of 42 exposed infants in EID care per year but majority of these exposed infants had been lost to follow up as shown in the table below. Indicator Year Total enrolled Remained active in care Remained HIV negative Turned HIV positive Lost Died HIV Seropositivity % Lost to follow up 3

10 (Follow up ongoing) Follow up - ongoing Total Graph showing outcomes of EID care for HIV exposed infants for the last three years (3) in Apapai Health Center IV From the data above the proportion of children lost to follow up was very high and had been increasing over the years. Out of the 137 infants enrolled since 2011, only 55 have been followed up to completion, this is only 40%. The 60% have been lost and their HIV outcome was unknown. However even those that had been followed up, the HIV positivity rate stood at 6.6%. The team analyzed the major causes of the high rate of loss of exposed infants and used the fisgn bone diagram below to document the key causes. 4

11 ROOT CAUSE ANALYSIS OF POOR FOLLOW UP OF EXPOSED INFANTS Poor documentation Work load Inadequate health education and counseling Lack of skills Un reconciled appointments Lack of knowledge Lack of knowledge Work load Work load Poor follow up of HIV exposed infants Ignorance Culture Understaffing Inadequate counseling Mothers poor attitude Work load Self referrals Long distance PROBLEM STATEMENT Apapai Health centre IV was faced with high loss to follow up of exposed infants. For the last there years, 60% of the infants enrolled in the EID clinic were lost to follow up. Some of the HIV positive mothers after giving birth didn t want to return to the facility any more for infant investigation. Others brought their babies for the 1st PCR and never returned especially if the result was negative and their thinking was that their babies would remain negative for the rest of life. Most women didn t abide by the given appointment hence the infant missed the PCR tests. Some mothers did not bring back their babies because they bought cotrimixazole for the babies in the clinics, and there were those that chose to refer themselves. This high loss posed a risk of increasing morbidity and mortality to these infants whose fate was not known. The likely cause of the problem could have been be due to; inadequate counseling and education offered to the mothers, issuing wrong appointment dates to clients, poor filing of IED registers and appointment books, unreconciled appointments (mother given a separate appointment for her HIV care and baby given a separate one in which case the mother decided to travel only once and 5

12 leave the baby at home); workload in the ANC clinics leading to reluctance in filling the appropriate registers, and low perception of mothers of the need to return for follow up care in addition to other causes as demonstrated in the fish bone diagram above. A few strategies had been employed to try and improve the performance and these included; (i) Allocation of one staff to be in charge of the EID clinic and do the necessary documentation and follow up, (ii) Establishment of a family clinic day on Thursdays to attend to mother baby and spouse, (iii) Emphasizing and adhering to screening of all pregnant mothers plus their partners and (iv) Screening for HIV of mothers that come for PNC and those coming to YCC. Much as those interventions were in place, they were weak and not being supervised, staff did not care about their success, and thus follow up and retention of exposed infants still remained a problem in Apapai HC IV. It is therefore in line with this that the Apapai Health team with the leadership of the fellows undertaking the course proposed to re-address this challenge and improve the follow up and retention of HIV exposed infants. 6

13 OVERALL OBJECTIVE To establish a system to improve follow up of HIV exposed infants from 40% to 80% by 31 st December 2014 SPECIFIC OBJECTIVES 1. To improve the filling in of EID tools 2. To improve the knowledge and skills of health care workers in counseling and communication 3. To increase community involvement and participation in the EID activities 7

14 INTERVENTIONS (1) Training staff on completion and use of data tools. Our objective was to increase on the completeness and accuracy of the EID register, appointment book, and exposed infant cards in Apapai Health Centre in five months. This was achieved through training staff on complete and accurate filling of the EID tools. The EID tools that staff were trained on included the; Referral book for HIV care, exposed infant clinical card, EID register, the exposed infant cards, the appointment book, ARV dispensing log book, and discharge form. We trained 24 staff out of the targeted 28. The training was practical on the infant clinical chart, how to give correct appointments that rhyme with the intended EID service like 2 nd PCR, immunization,nutrition assessment and all other necessary services. The staff was taught how to take the right directions /map of the care givers location so that they can easily be located during home visits as we follow up the HIV exposed infants. We also learnt how to fill the appointment book and how to reconcile mother and baby appointments. The training was reinforced with continued mentorship and support supervision especially by the EID focal person and the fellows. With improvements in filling these tools, all appointment dates were indicated making it easy for one to remind a mother when her appointment is due and to follow up those who miss their appointments. This also helped to track those who are due for 2 nd PCR so that they are reminded to receive this service. It also helped in scheduling mother-baby pairs for Family Support groups. The completion of tools was monitored at the end of each clinic day by the EID focal person and gaps identified and addressed. (2) Improve the appointment keeping through reconciling registers, sending sms reminders and phone calls to reduce missed appointment and increase the number of HIV exposed infants who return for 2 nd PCR. Staff were oriented on merging or reconciling appointments given to the mothers in their ART care cards with those given to the babies in the EID register. Before nay EID appointment is given out, the midwives cross-check the mothers blue cards. Continuous health education and counseling of care givers is being done in all entry points to early infant diagnosis. The entry points for EID are Antenatal care clinic, Routine counseling and testing, postnatal clinic, outreaches, outpatient department, maternity and the wards. The health workers conduct health education during which the mothers are 8

15 encouraged to bring their exposed infants to the facility for the given appointment. Health education addresses the following; Understand the importance of testing for HIV during pregnancy especial y (couple testing) What it means to be HIV positive. The implication of being HIV positive especially when pregnant or lactating. How HIV positive pregnant women can transmit HIV infection to their babies during pregnancy, breast feeding or delivery. What HIV pregnant and lactating women should do to prevent their infants from getting the virus by adhering to the medical guidance, keeping appointment and adherence to treatment regulations. The importance of attending ANC 4 times during pregnancy. The importance of keeping appointments 4. Establishment of family support groups. We formed 4 family support groups and they are being monitored. The formation of these groups involved the support of the VHTs, expert clients and local councilors. We conduct meetings with them and requested them to encourage HIV positive clients in their villages to attend the clinic. When they turned up at the clinic we sensitized them about family support groups and they attended. Initially the FSGs were at the facility but members proposed that we take them to the sub counties since members move for very long distances. They also proposed that the groups would not only be for clinic purposes but they should also help them with income generation as they support themselves and remind each other of the appointment dates. Mothers elected the executive members of the groups including Chairperson madan Akiteng Apale, she has a baby less than six month and is breastfeeding. Secretary madam Icimu Susan has a baby below two years but not breastfeeding. Treasurer madam Acen has a baby of six month is breastfeeding. Mobiliser mr. Elietu Abudala both partners are HIV positive and have a non breastfeeding infant of less than two years. The members agreed to contribute shillings 5000 each and to practice saving as a way of keeping their money and to be able to borrow money from the group at an interest of 1% 9

16 after one month to develop themselves. Members begun contributing and by the third meeting there was shillings 115,000 contributed by the members then the project also gave in the budgeted 100,000 for aiding formation of FSGs. So far there are four active FSGs i.e. two in Bugondo Sub County and two in Kadungulu sub county. The family support groups are made up of HIV positive women that have infants less than two years, these infants could be breastfeeding or not. The other category of HIV positive women are those that are pregnant and should be getting ART services from Apapai health center IV. The family support groups are held monthly, the team ensures that on such days, a package of services including taking off a Dry Blood Spot sample from the infants, ARV refills, counseling, refill for Niverpine syrups, Septrin refill etc are all offered so that mothers do not have to return for the same services in which case they find it a bother. (3) Home visits to lost clients. We also conducted targeted home visits to all the 52 exposed infants who had got lost. We successfully traced 44 (84.6%) of them; the remaining 8 had migrated with their parents and could not be found. Of those traced, 1 exposed infant had died but no report was brought to the facility, 2 were HIV positive and we eventually enrolled them in care, 30 were confirmed HIV negative and fit for discharge so we discharged them and 11were already in care at the facility but there was no documentation. During the home visits we counseled the care givers on the need to keep appointments and provided DPS and rapid testing services. We have also established a system to follow up clients who will be missing appointments. Now that we record their clear directions and phone contacts for those who have, we send them sms to remind them of their appointments and if they miss, we call them. If they still fail to turn up for a new appointment, we conduct a home visit. (4) Establishment of a mother baby care point. This had been established before but it was not very function so during this project we revived it allocated a staff to be in charge of it and manage all the client appointments. She is then joined by the different staff depending on the activities at hand and duty allocation. She also coordinated the family support groups 10

17 RESULTS The project has led to the recovery of 44 lost infants (84%) and their follow up revealed so many factors contributing to this loss which we can now avoid in our subsequent care. The graph below shows the outcomes of the exposed infants who had been lost to follow up. Although 2 of our infants turned out positive most probably because of lack of care and support, they were linked to the HIV clinic and we continue to follow them up to ensure they stay alive. Also the ones that were found negative, their care givers were adequately which gave them an opportunity to live a better life. Those that are still negative will continue receiving care, they have already been enrolled in family support groups and we shall support them until they are discharged from care. Outcomes Number and outcomes of exposed infants traced through home visits Appointment keeping of clients has improved. According to our EID register, the enrollment for HIV exposed infants from August to October is 14; out of these 10 have always kept their appointments. The other 4 are not yet regular but we continue supporting and following them up to ensure they remain in care. 11

18 We have registered an improvement in the completion of EID care tools and in appointment keeping of our clients as a result of better counseling and health education. Implementation of this project has also led to improved team work especially as the staff work together during home visits, forming family support groups and the monitoring exercise. One staff has been given the responsibility of the mother baby care point in order to improve on the documentation. Mother baby care point has been established at the immunization room which is connected to the maternity and post natal room so that if the exposed infant is due for immunization, it is given within the same place to avoid unnecessary movement and time wastage. We now have established family support groups in which we continue to support our babies and care givers. On average we have 23 care givers in these support groups but with more counseling and sensitization, we hope to get more clients in them. 12

19 LESSONS LEARNT AND CHALLENGES LESSONS LEARNT We learnt the importance of proper documentation. Some HIV exposed infants were declared lost to follow due to poor documentation. We also learnt the very vital contribution of VHTs to the success of facility programs. The VHTs can reach client homes and help a lot in giving feedback to facilities which could be very hard and costly to obtain without them. When clients are involved in decision making, service provision becomes acceptable to them. They made decisions on how family support groups could be conducted and we are confident this time that these groups will not collapse as was the case when they were first established. For effective follow up care givers need to be given correct and consistent information on the importance of keeping given appointments so that their HIV exposed infants receive a full package of EID services. CHALLENGES Follow up of clients is quite often complicated by lack of telephone contacts and clients giving wrong addresses. Some of them still have stigma, while other stay very far from the facility. Reaching them is a problem. Some clients also migrate or self transfer without informing the health team. We have continued to counsel clients, work with the VHTs to help in locating directions and stressing to staff that they try to explain to the clients and care givers to give correct phone contacts and home addresses. We have also continued to educate clients of the importance of keeping in care and that if they need to change location they should obtain a formal referral so that they don t interrupt their care. 13

20 CONCLUSION AND RECOMMENDATION CONCLUSION Reduction of the high rate of loss to follow up of HIV exposed infants in Apapai Health centre IV has been as a result of three key interventions; staff training, establishing a follow up system and establishment of family support groups. The success of these required team work, involvement of the community and the care givers themselves. We intend to sustain the improvements we have achieved so far through; (i) Regular meeting to review the performance eof the family support groups; (ii) Continuous CMEs and support supervision to make sure staff continue doing the right things; (iii) Continuous health education and counseling to mothers and regular tracking of clients who miss their appointments; and (iv) Integrating home visits in other activities like outreaches. RECOMMENDATION We recommend that the district supports the facility with funds to conduct home visits to clients who may consistently miss their appointments. We also recommend that more staff be given an opportunity to train in quality improvement as the orientation that was given by the fellows was not enough they need more grounded training in quality improvement. There is need for more support supervision form the district so that more staff at the facility can be encourage to participate I such improvement projects even when there is no financial support. 14

21 WORKPLAN FOR IMPROVING FOLLOW UP OF HIV EXPOSED INFANTS IN APAPAI HC IV Activity Time Frame Responsible May Jun Jul Aug Sept person Cost Training staff on complete and accurate filling of the EID tools as well as on proper counseling Enhancing message delivery on the importance of EID retention in ANC visits Formation of family support groups through conducting care givers meeting Monitoring of the family support groups SMS reminders for mothers on appointments Phone calls to mothers who missed appointments Targeted home visits Conducting monthly performance review meetings Mentorship and support supervision for facility staff Mentorship and support supervision for lower unit staff Report writing Grace and Jennipher All midwives and staff in ANC Grace and Jennipher Grace and Jennipher EID focal person EID focal person Grace, Jennipher, EID focal person Jennipher, CQI chairperson Grace Grace Mentor, incharge, Grace, and Jennipher ,440, ,000 15

22 BUDGET FOR IMPROVING FOLLOW UP OF HIV EXPOSED INFANTS IN APAPAI HEALTH CENTRE IV FROM MAY TO SEPTEMBER Activity Unit measure No of Unit Freq Total units cost uency Training staff on correct Flip charts ,000 and accurate filling of EID register,appointment book Markers 2 pkts ,000 and infant card Writing pads ,000 Pens 1 box 15, ,000 Facilitators allowance 02 50, ,000 Transport refund 02 20, ,000 Enhancing messages through health education during ANC visits Mentorship and support supervision to facility staff Meeting facilitation 32 I5, ,000 Subtotal Mentorship and support supervision to lower unit level staff Forming family support groups Monitoring of family support groups Targeted Home visits Coordination of project implementation Transport 02 40, Air time 02 20, ,000 Community mobilization Aiding the individual , groups with a top-up to establish I.G.As Sub-total Transport Airtime 02 10, Subtotal Transport Subtotal SDA 02 12, Transport 02 20, ,000 Refund (to and fro serere town to access internet) Air time 02 10, Bank charges (to

23 Accountability and report writing withdraw the money from the district account) Subtotal Ream of paper Box files Typing, Printing and - 30, photocopying Transport to print and photocopy ing the reports 01 5, ,000 Sub total 305,000 Grand total 4,944,000 17

24 REFERENCES Euphemia L. Sibanda et al, (2013). The magnitude of loss to follow-up of HIV-exposed infants along the prevention of mother-to-child HIV transmission continuum of care: a systematic review and meta-analysis. Interagency Task Team on the Prevention and Treatment of HIV infection in Pregnant women mothers and Children (2012). GSG Mid Term Review Meeting report, December 6-7, Option B+Training Curriculum For EMTCT In Uganda(STD/AIDS Control Programme (ACP0,MoH Feb 2013 Uganda Clinical Guidelines, MoH,(2012I) Integrated management of Childhood illness (MoH and World Health organization) 18