Implementation of Early retention monitoring of HIV positive pregnant and breastfeeding women; and data use in the EMTCT program MOH-UGANDA

Transcription

1 Implementatin f Early retentin mnitring f HIV psitive pregnant and breastfeeding wmen; and data use in the EMTCT prgram MOH-UGANDA

2 Presentatin utline Backgrund Methdlgy Issues addressed Challenges identified Dcumentatin and analysis Lessns Learned Recmmendatins

3 Uganda-Cuntry Cntext Ppulatin - 35 millin peple HIV prevalence 7.3% ; Wmen-8.3%, Men 6.1% ( AIS 2011) HIV prevalence amng pregnant wmen 5.5% PLHIV 1,600,000 HCT access in ANC- 98% HIV+ wmen accessing ART fr PMTCT- 85% 2014 First ANC attendance -97% 4 th ANC attendance -48% TFR-6.2 PNC attendance -33% Skilled attendance -59% Exclusive breast feeding(6 mnths) -62%

4 Definitin f terms Retentin: Cntinuus engagement frm diagnsis in a package f preventin, treatment, supprt and care services, fr thse n ART that is; ALIVE and n TREATMENT at specified time pints. In Uganda measured at 6,12,24 mnths etc up t 72 fr ART prgram, nw als measured at 1,2,3 mnths fr PMTCT LTFU/ drpped : Patients receiving ART and nt seen at >90days after their scheduled appintment and attempts have been made t cntact this client but cannt be fund Lst: Nt seen in the last quarter but was scheduled fr a visit. Appintment keeping: if the client either kept the appintment date, came any day befre the appintment date r within seven days after the scheduled appintment.

5 Backgrund: Cntext Uganda started Optin B+ rllut in The number f pregnant wmen initiating ART increased dramatically. An assessment dne in September 2013 demnstrated that 28% f mthers newly initiating ART never came back after the baseline visit. Mther-baby care pints were established t facilitate mtherinfant pair fllw-up, but n M&E system was in place t track results f this interventin. Can we please include a graph shwing the increasing trend in ART cverage? There is a nice picture pg 45 f the 2014 annual reprt but when I try t cpy it, I just get a purple square! Early retentin after initiating ART amng pregnant wmen Sept 2013

6 Early Retentin Mnitring and District Respnse Pilt With supprt frm PEPFAR thrugh EGPAF, MOH Uganda pilted early retentin mnitring and rapid district respnse in 30 facilities acrss 5 districts t address the fllwing issues: Mnitring early maternal ART retentin Imprving retentin thrugh the highest MTCT risk perid Enhancing fllw-up f mthers and babies t the end f PMTCT Appintment keeping fr mther baby pairs Data cllectin and reprting by health wrkers Data use t imprve perfrmance thrugh mnthly review meetings and use f quality imprvement initiatives at site level Oversight, mentrship and supprtive supervisin by the district and MOH at regular intervals

7 Methdlgy: 3 cmpnents 1. Real time mnitring: Develped a maternal ART retentin mnitring data cllectin/reprting tl and dashbard 2. Site-level quality imprvement: Strengthened facility quality imprvement teams with a fcus n mther-infant pair fllw-up 3. District versight: Established a system f District Respnse Teams using the existing district health team/qi structures t fcusing n identifying and priritizing critical issues frm the weekly reprts and facilitating crrective actin.

8 1. Real time mnitring Develped early retentin indicatrs fr pregnant and breastfeeding wmen initiating ART able t be cllected frm existing registers Percent retained at 1 mnth: Number f wmen returning fr their 1 mnth visit/ Number f wmen initiating ART 1 mnth ag Percent retained at 2 mnths: Number f wmen returning fr their 2 mnth visit/ Number f wmen initiating ART 2 mnths ag Percent retained at 3 mnths: Number f wmen returning fr their 3 mnth visit/ Number f wmen initiating ART 3 mnths ag Percent missed appintment Number f mther-baby pairs wh missed an appintment in the mnth Built upn existing natinal weekly reprting dashbard Incrprated a cmpnent fr tracking maternal ART retentin fr the 30 pilt sites by maternal ART chrt Data is submitted mnthly by SMS fr the retentin indicatrs

9 Uganda natinal dashbard t mnitr HIV testing f pregnant wmen and B+ initiatin

10 Retentin f HIV pregnant wmen and breastfeeding wmen n ptin B+ initiatin: by District

11 Retentin f HIV pregnant wmen and breastfeeding wmen n ptin B+, by facility in ne district

12 2. Site level quality imprvement Strengthened facility Quality Imprvement teams Mdified client flw Reinfrced dcumentatin Imprved use f appintment bk t identify missed appintments f HIV psitive pregnant wmen and mtherbaby pairs Incrprated methdlgies fr cntinuusly mnitring retentin & tracking lst-tfllw-up clients MOH and DRT cnducting site visit and reviewing QI prjects

13 3. District versight thrugh District Respnse Teams Established a system f District Respnse Teams using the existing district health team/qi structures t fcusing n identifying and priritizing critical service gaps frm the weekly reprts, facilitate crrective actin, and track success f interventins Cnducted trainings fr District Quality Imprvement/District Health Teams n cllecting retentin data, and hw t understand, analyze, and use data Strengthen the capacity f health facilities and district health teams in data use fr planning thrugh mentrship and supprt supervisin activities. Develped a caching tl and district data tlkit t guide mentrship

14 District Data Tlkit Cntents 1 Pririty Setting Weekly B+: Use this tl t priritize issues identified in the analysis f the weekly B+ reprts and sites t visit 2 Pririty Setting Retentin: Use this tl t priritize issues identified in the analysis f the mnthly retentin reprts and sites t visit Calendar Schedule: Use this tl t set the site schedule accrding t pririties identified in the priritizatin matrices Facility Data Summary Feedback Frm: Use this frm t prepare site-specific feedback frm issues identified in the analysis and priritizatin matrices Actin Item Tracking Tl: Use this tracking tl t track the status f actin items identified during site visits

15 Results: Successes in Early Maternal Retentin Early maternal ART retentin indicatrs were feasible t cllect and reprt Three mnth retentin increased frm 74% t 90%. One mnth retentin appears t still be a majr challenge A 3 mnth learning and change perid was needed befre imprvement was seen Retentin Retentin fr Oct 2014 t Mar 2015 chrts 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Mnth-1 Mnth-3 14-Oct 79% 74% 14-Nv 75% 58% 14-Dec 77% 57% 15-Jan 76% 66% 15-Feb 79% 76% 15-Mar 93% 90%

16 Challenges identified thrugh mentring visits Dcumentatin health wrkers nt supervised t ensure cmpleteness f data entry cupled with many different registers kept at different service pints Health wrker shrtages resulting in few staff n duty & frequent transfer f trained health wrkers affects cntinuity f service delivery Pr client flw at facility level reduces efficiency f service delivery and data capture Nt all clients have mbile phnes and are difficult t fllw-up n missed appintments and funds fr hme visits nt adequate Pr accessibility in sme areas especially in the islands and mbile cmmunities Stigma and failure t disclse status still a big challenge especially fr pregnant mthers

17 Results: Lessns learned 1. Real time mnitring: Use f m-trac (based n m-health) t send reminder messages t health wrkers t submit weekly and mnthly reprts is critical Cntinuus supprt in dcumentatin thrugh mentrship and supprt supervisin as well as data quality checks are critical fr imprved perfrmance 2. Site-level quality imprvement: Pairing f clinical charts and writing identificatin serial numbers fr bth the mther and HIV Expsed Infants in the appintment bk facilitated crdinatin f appintments fr Mther-Baby pairs. This cupled with ensuring that mtherbaby appintments are synchrnized supprted imprvement in mther- baby adherence t visits Use f vlunteers (VHTs, peer educatrs, linkage facilitatrs) t track clients with missed appintments and lss t fllw up imprved retentin. Use f cntinuus quality imprvement dcumentatin jurnals t summarize weekly ptin B+ and mnthly retentin reprts and track perfrmance is critical fr prgram imprvement. 3. District versight thrugh District Respnse Teams DRTs benefit frm intensive caching and supprt t review and analyze weekly reprts and priritize facilities and issues fr interventin Weekly DHT meetings with site in-charges: data frm weekly and mnthly EMTCT reprts is discussed, perfrmance gaps identified and supervisin plans develped/reviewed

18 Recmmendatins Its Imprtant t maximize n existing effrts t mnitr bth early and late retentin fr HIV psitive pregnant mthers and mther-baby pairs Need fr clser retentin mnitring especially immediately after initiating ART fr bth pregnant and lactating mthers and during nging risk perid with cntinued breastfeeding due t the shrtened perid f adherence cunselling is critical There is a need t define interventins t target pints alng the cascade where greatest lsses are ccurring and supprt health wrkers t implement them Strengthening data use is critical fr imprved prgram implementatin thrugh Quality imprvement initiatives Wrking with the leadership at bth district and MOH level is critical fr wnership and sustainability Cntinue mentrship and supprtive supervisin is critical Effective engagement by implementing partners is critical fr the successful implementatin f new prgram initiatives Cmmunity structures including Family supprt grups, peer mthers, VHTs are critical in supprting service access as well as retentin

19 Cnclusin Uganda has been able t successfully begin real-time mnitring f early retentin n Optin B+ and has learnt lessns which we are nw ready t scale up Systems imprvements will cntinue t be made Natinal scale up f the early retentin mnitring will cntinue this year tgether with implementatin f ther areas f the B+ M&E Framewrk include birth chrt mnitring and ANC chrts thrugh use f lngitudinal ANC register.

20 Thank yu fr yur attentin!