Overview of the Current National PMTCT program in Ethiopia Dr Tadesse Ketema January 2014 Addis Abeba
Outline I. Current status of PMTCT II. III. IV. Initiatives underway B+ recommendation roll out EMTCT strategic plan EID efficiency improvement Challenges of the program Way forward
CURRENT STATUS OF PMTCT ANC coverage= 89.1% Institutional delivery =20.4 % & clean and safe del=13.2%,no. of facilities providing PMTCT more than 2,100 ARV prophylaxis coverage 43 % in EFY 2005 increased which from 9.3% 2003 (9, 775 received ARV out of 14,134 positives in 2005 Post natal care coverage 60.1 Discrepancy between ANC and PMTCT coverage, although decreasing, is still large HIV prevalence in 15-45=1.5% Among 1,186,167 ANCs counseled tested,positives identified were 14,134 in 2011/12
CURRENT STATUS OF PMTCT Full integration of PMTCT into MNCH services Number of HFs providing PMTCT services 2,142 Expansion of rapid testing to PMTCT and PITC sites Engaging PLHIV (e.g. MSGs, CCs) Increase demand and utilization for MNCH/PMTCT services Capacity building activities and availing the necessary supplies
Roll Out of PMTCT B+ Recommendation In light of the country commitments to elimination of new pediatric infections and new evidences, Ethiopia has examined its PMTCT guidelines and recommendations Has prepared an operational plan for rolling out of the option and lots of activities has been done Has prepared update and generic training materials and have provided update trainings to providers in all regions Logistics including ARVs procured and distributed to ART collocated sites New M & E tool that emphasizes longitudinal follow up of mother infant pair is on preparation
Operationalization of B+ Roll Out How: How can roll-out be accomplished What: What will B+ care consist of Who: Who s responsible for B+ roll out and service provision Where: Where will services be provided When: What is timeline for implementation Cost: Cost of roll out M & E:Changes in M & E required to follow program
How: Build on existing strengths and address existing challenges/gaps-1 Existing Strengths: Large number of health care providers with recent PMTCT training in Option A; PFSA currently distributes HIV drugs and test kits to all ART sites and almost all PMTCT-only sites; Can take advantage of long shelf life of ARVs to minimize risk of both stock-outs and wastage; Mentoring teams actively support HFs across country and can serve as site level facilitators of B+ implementation; MSGs can assist in promoting adherence and retention
What will Option B+ look like? Care of mother & infant localized to the MNCH unit mother/child pair monitored together throughout the at-risk period; At time of diagnosis, treatment will be immediately available though in most instances mother will be advised to return a few days later for adherence prep One ART regimen--tdf/3tc/efv; ANC provider prescribes ART until birth; PNC provider prescribes ART from birth to weaning and thenafter in PMTCT only facilities or transferred to ART clinic in ART facilities. CD4 checked every 6 months for follow up Obtaining DBS sample from infant at 6 wks and post-weaning will be performed by or ordered by the PNC provider at time mother comes for her ART Mother and infant will be referred for ongoing care at ART clinic if infant tests positive, if CD4 pattern suggests treatment failure, or for complications beyond capacity of PMTCT provider
Who is responsible for service provision and roll out of Option B+? Health facility MNCH and ART service providers are responsible for service provision RHBs are responsible for the roll-out in their region: Identify the sites meeting minimum requirements; Identify mentors from higher level facilities for lower level sites for mentoring support; Work with existing mentoring teams supported by development partners to plan regional roll-out and transition of mentorship ; Lead supportive supervision visits; Report PMTCT indicators to FMOH
WHERE will B+ be implemented Minimum Required Standards: Human resources: Public & private/ngo hospitals-4 trained staff HCs & MNCH specialty clinics-2 trained staff Availability of mentorship / supervision-higher facility to lower facility-hospital to HC /ART HC to Non ART HC Infrastructure: confidentiality / privacy should be assured Drugs/supplies: uninterrupted source of needed drugs & commodities assured.
Status of Roll Out of B+ Currently more than 1,400 facilities are providing B+ Rolling out in PMTCT only facilities is underway Guideline adoption is under progress
EMTCT Strategic plan Rationale Given the burden of HIV in pregnancy in the country The experience gained by the accelerated plan & commitment demonstrated Align nation goals with the national and global initiative and plan to achieve virtual elimination (emtct) by 2015 FMOH has made high priority to PMTCT and is committed to eliminate HIV by 2015 and make the necessary improvements in coverage and quality of PMTCT service delivery.
Goal Eliminate new paediatric HIV infection and improve maternal, newborn and child health and survival
Strategic Objectives Improve community ownership through strengthening of Health Extension Program and Health Development Army to create demand and increase utilization of MNCH and e-mtct of HIV services Improve equitable delivery of quality integrated MNCH/PMTCT services at all levels Provide integrated family planning services to HIV positive women and protect unwanted pregnancy Strengthen continuous availability of good quality medicines, diagnostics and other essential supplies and commodities PMTCT/MNCH
Strategic Objectives Strengthen leadership, management and partnership for e-mtct of HIV programme at national, regional, zones and woreda levels to deliver effective and efficient services Strengthen Monitoring and Evaluation systems for e- MTCT of HIV and promote the generation and use of information for evidence based decision making
The PMTCT Bottleneck Analysis Plan developed through the process of identifying bottlenecks The process involved review of national strategies, guidelines and reports, consultative meetings with key informants, experts, target audiences and other stakeholders This plan builds on and improves the current accelerated plan for scaling up PMTCT in Ethiopia (2012) by focusing on addressing the identified bottlenecks The Plan is harmonized and build on existing initiatives at community and health facility levels alongside HSDP-IV.
The PMTCT Bottleneck Analysis Inform the development of e-mtct of HIV Strategic plan Identify populations with highest unmet need, Prioritize key programme strategies and interventions that will accelerate progress towards MTCT elimination Target and ensure more efficient allocation of available resources and Facilitate designing a real-time performance monitoring of programmes focusing on bottlenecks and tracking of results
Results of Bottle neck analysis Supply side challenges Some basic infrastructure including 24/7 electricity and water supplies, communication and referral means in some health facilities Reports of irregular stock outs of FP, MNH and ARV commodities at times Skill of available human resources on FP, MNH, PMTCT, EID Attrition of human resources trained on PMTCT and other related subjects Access to CD4 and EID testing sites
Results of Bottle neck analysis Supply side challenges Not all facilities providing PMTCT services (36%) Iintegration of services (PMTCT / ART / FP ) High turnaround time for EID and result communication to facilities Male and youth friendly services IEC/BCC materials and job aids M & E
Results of Bottle neck analysis Demand Side Uptake of HIV testing at ANC (37 %) Uptake of PMTCT (25%)(Now 43%) Low health facility delivery (20%), Poor infant feeding practices (exclusive breastfeeding) (32%), Low male involvement Stigma and discrimination Lost to follow-up in health care cascade (from community (HP) to HC and ART clinics High unmet need of FP (25%) Low utilization of EID services and Paediatric care
Strategies to Overcome Bottlenecks Expand provision of MNCH, PMTCT services including Paediatric HIV, Care and treatment services Roll out the CQI implementation Strengthen integrated training of FP, EID and MNCH/PMTCT Strengthen pre-service and in-service training on FP,PMTCT, MNCH and EID
Strategies to Overcome Improve national capacity for maintaining CD4/EID and related machines Roll out of national EID implementation manual Establishing efficient system for communicating results Pilot POC technologies for CD4 testing and strengthen DBS for PCR EID Roll out of national EID implementation manual Strengthen referral systems and tracking mechanisms at health facilities and communities
Strategies to Overcome Scaling up of best practices and models for integration of services Establish a functional intra facility referral mechanism Strengthen Integration of PMTCT/EID within maternal, newborn and child health platform
Key Strategic Focuses Empowering Zonal and Woreda health teams to ensure local ownership and improve accountability Prioritizing rapid results and impact through a phasedapproach based on the performance of the MNCH platform Integrate ART into MNCH services through rolling out simplified regimen of Option B+ for pregnant women in the context of PMTCT Capitalizing on the Health Extension Program and Health Development Army to effectively engage communities and improve maternal and child health outcomes
Targets Reduce the incidence of HIV in reproductive age group by 50% Reduce the unmet need for FP among all women Provide ARV prophylaxis to 90 % women living with HIV and their exposed infants during pregnancy and breast feeding Reduce the overall MTCT rate of HIV to less than 5% at population level Provide ART for all HIV positive pregnant women through Option B+
Impact targets Impact target 1: Reduce the number of new HIV infections among children by 90% by 2015 through implementation of the 4-Prong strategy for PMTCT Impact target 2: Reduce by 50% HIV related maternal deaths by 2015 Impact target 3: Reduce by 50% Under-5 HIVrelated deaths by 2015 Impact target 4: Reduce population-level mother-tochild transmission rate (MTCT) to <5% by 2015
Strategy for emtct of HIV Childbearing Women (15-49) HIV prevention. Women Prevent new HIV infections Avoid unintended pregnancies LWHIV Family Planning HIV Pregnant women ARVs, Feeding PMTCT Pediatric care & Tx HIV-infected Children
Create Demand and Increase Utilization Individuals and Community Involvement HEP, HDA, Women Coalition, Clan leaders, religious leaders Community linkage with HF, retention and FU MSGs, HEWs
Improve Quality of Care Build HCWs capacity Reduce missed Opportunities and drop outs (Implement CQI model ) Roll out Option B+ Expand Primary Prevention and FP HEWs and HCW providing FP and Youth friendly services
Monitoring and Evaluation Strengthen M&E Use of data for discition making at all levels Conduct supportive supervision in an integrated and effective way
Leadership, Management and Partnership Resource Mobilization Enhance partnership with stalkholders Quality Assurance
Logistics Management and Commodities security PFSA to coordinate, lead and ensure Procure, forecast, store and distribute Increase capacity- IPLS at all levels build capacity of HCWs at HFs in public and private facilities to mange supplies and link them to nearest hub
Implementation The emtct of HIV Plan will be implemented for three years (2013 2015) Builds on the acceleration plan for scaling up PMTCT in Ethiopia (2012) and HSPD-IV initiatives. To ensure effective coordination, quarterly steering committee and stakeholders meetings to harmonize, coordinate and evaluate the Plan at regional and national levels will be conducted Achievements and challenges for the implementation will be assessed and reported every year
EID service efficiency Challenges of retaining exposed infants in care and do early infant diagnosis In addition challenge of getting test results of testing on time to decide client management Implementation manual prepared to create consensus of stakeholders involved (Postal ofice, EHNRI,FMOH) Dissemination and orientation will be done
The major challenges to PMTCT to be addressed Limited expansion of PMTCT services; Inadequate use of PMTCT service where it is available No ART facility in 175 weredas (700 HC) Limited access to and utilization of early infant diagnosis Low percentage of deliveries attended at health institutions, weak HIE follow up Weak community-health facility referral linkages Poor male partner involvement
Way Forward The Government targets for 2015 HSDP 4 Provide ANC services to 90 % of pregnant women Ensure all women are attended at delivery (62% by skilled attendant and 38% by HEWs) Provide ARV prophylaxis to 90% of HIV positive pregnant women Reduce national incidence of HIV infection by 50%