Best Practices in Rwanda PMTCT Program

Dr Brenda Asiimwe-Kateera

Rwanda

Outline of Presentation

• Background

• PMTCT program review and bottlenecks

• Strategies and Structure

• Successes and Challenges

• Sustainability and Replication

• Lessons Learned

• National HIV prevalence has been stable at 3% since 2005• HIV prevalence among pregnant women is 3.3%• 10,000 HIV positive pregnant women are expected to access PMTCT services

annually

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15-19 20-24 25-29 30-34 35-39 40-44 45-49Percent HIV positive

Women

Men

HIV Prevalence by Sex HIV Prevalence by Age

Source: RDHS 2005 & RDHS 2010 Source: RDHS 2010

Rwanda HIV Epidemiological situation Rwanda HIV Epidemiological situation

National PMTCT Program Milestones1999-2015

PMTCT pilot

• National PMTCT program (sd-NVP)• Initial sites expansion

• More Efficacious ARV introduced• ART program decentralized• EID pilot

• Transition to More Efficacious Regimens

• Decentralization of CD4 count

1999 - 2000

2001-2004 2005-2006 2007-2008 2009- 2010

• Task-shifting policy• Option B PMTCT regimen

in Nov 15th 2010• eMTCT goal in NSP

2011- 2015

• Launching of eMTCT by First Lady

• eMTCT strategy and action plan

• Option B+ in 2011• PMTCT program 6-week

Impact study

Emergency Response to HIVIn 2001, HIV programs coordinated by two bodies

– Necessary for the emergency response to the epidemic

– PNLS , CNLS (NACC) for policy, resource mobilization and HIV awareness

– TRAC for guideline development and implementation of biomedical HIV interventions.

In 2010/2011 HIV and AIDS response was reviewed:– CNLS and TRAC coordination functions– Implementation of PMTCT program

Finding of the review and solutions

CNLS and TRAC Functions

• Great response to HIV emergency & high scale-up of HIV services including PMTCT

• Coordination bottlenecks– Duplication of efforts in

coordination and inefficiency– limited ownership at sub-national

levels

Solution to the bottlenecks

1. Having one coordinating board

2. Decentralized planning and implementation

These solutions called for

‘Effective Leadership in Planning and Implementation of PMTCT programs’

HIV Overview in Rwanda

Findings of the review and solutions

PMTCT Programme Implementation

• Good coverage but gaps in:– HIV testing among pregnant

women and their male partners of at least 31%

– ARV for PMTCT among HIV positive pregnant women of 24%

– ARV prophylaxis among exposed infants of 22%

• Implementation bottlenecks– Inadequate integration of PMTCT

services in the MNCH services – Unavailability of routine offer of

PMTCT services in the private sector

Solution to the bottlenecks

Integration of PMTCT service at different levels:•National planning process including private sector•MNCH platform•Community

These solutions enabled ‘Achieving Universal Access to Integrated PMTCT services’

HIV Overview in Rwanda

BP 1: Effective Leadership in Planning and Implementation of PMTCT programs

Strategy 1:•Creation of Rwanda Biomedical Center (RBC) under the Ministry of Health. •Parliament endorsement of RBC•Inclusion of RBC as coordination body into national policy and strategic documents• HIV division within RBC mandated to:– coordinates policy and strategy development,

implementation of HIV programs – oversees multi-sectoral response

BP 1: Effective Leadership in Planning and Implementation of PMTCT programs

Strategy 2:•Engagement of districts teams on their eMTCT data. – Led to development of district specific eMTCT

operational plans including district capacity building plan– National level support for quality data analysis and use

for improvement of services delivery.•Creation of District coordination structures – District health management unit under the leadership of

the vice mayor of social affairs coordinates HIV activities– The district hospital health team was mandated to

provide PMTCT technical support to the health centers.

BP 1: Effective Leadership in Planning and Implementation of PMTCT programs

Strategy 3:•Task shifting was introduced and nurses were trained on ART initiation•Collaboration between health centers and community health workers strengthened.•Introduction of performance based financing (PBF) mechanisms linked to PMTCT was a motivation for the staff to achieve targets

Successes• Creation of RBC has resulted in better coordination,

resource mobilization and technical support from the different programmes

• Decentralization and better coordination of eMTCT services has led to development of district specific eMTCT plans

• Managers have been empowered to collaborate with development partners at district level and to leverage resources in support of action plans.

Successes and ChallengesSuccesses:• Capacity building of health care workers and PBF has

resulted into a more motivated and efficient health care workers at the health facility and community level

Challenges:• Effective multi-sectoral response to HIV– There is a need for greater participation of

representatives from other sectors in the HIV response

• Ensuring available of technical support at decentralized levels.

BP 2: Achieving Universal Access to Integrated PMTCT services

Strategy 1: Integration at

National level–Improvement of infrastructure of MNCH, equipment and human resources– Creation of Public-Private partnerships

Service delivery level, –Integration of PMTCT into MNCH platform–Empowerment of managers to re-organize service delivery at their level and to make decisions on how best to integrate PMTCT services in MNCH

• Creation of a one-stop model for PMTCT and MNCH services

BP 2: Achieving Universal Access to Integrated PMTCT services

• Community level, – High level advocacy

for male involvement to increase couple testing, adherence and retention into PMTCT services

RBC, IHDPC Report, 2011

510 ART sites (96%)

544 VCT sites (99%)

494 PMTCT sites (96%)

Universal access to PMTCT is within reach

Male involvement in PMTCT

DECLINING TRENDS IN MTCT RATES AT 6 WEEKS AND 18 MONTHS ,RWANDA 2006-2014

1.81.6

Challenges and Solutions• Despite the gains made in the Rwanda PMTCT program, challenges

such as – Reaching out to women not accessing services are some of the

barriers that need to be addressed for the country to go an extra mile towards eMTCT targets

– loss to follow-up of mother-infant pairs within the continuum of care

• Implementation of innovative and effective strategies are needed

– use of technology such as mobile phones for tracking and tracing of clients. Rwanda is currently facilitating timely transfer of EID results from laboratory to the health facilities using text messages

– establishing effective linkages between health facility and community based services are being considered.

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Lessons learnt• Successful integration of PMTCT program within MNCH

platform is dependent of a health system that has demonstrated the capacity to deliver high coverage (over 90%) of child survival interventions such as antenatal care and immunization.

• The management at the facility level have a critical role in determine how to re-organisation service delivery to foster integration– Integration of services differs according to the level of

health facility and availability of resources.

• Community engagement is critical in ensuring PMTCT is integrated within the community health care system

Lessons learnt• Public-private partnerships is critical to achieving universal access

to PMTCT service

• The comparative advantage of a sector to deliver services without losing the multi-sectorial aspect of the response is critical in deciding which sector should lead on HIV/AIDS response.

• Decentralized planning and implementation is key to program ownership and in addressing challenges of equitable access and quality of services.

• Male involvement is an entry point for increased couple testing and disclosure of HIV results.

• Performance based financing could be a more cost-effective strategy to address human resource challenges.

Replicability• Countries should decide which sector to take the lead

in coordination of the HIV response without losing the aspect of multi-sectorial approach to responding to HIV and AIDS

• Decentralized planning and coordination is easily replicable by leveraging the existing administrative structures

• Task shifting and PBF linked to PMTCT indicators would be a proposed solution to human resource constraints as opposed to voluntarism.

Conclusion• Delivery of high impact comprehensive eMTCT interventions

through a well-coordinated decentralized system has enabled Rwanda to achieve high coverage of eMTCT services and low MTCT rates.

• Task shifting and mentorship are key in ensuring access to quality comprehensive eMTCT services.

• PBF linked to set results has been instrumental in keeping health providers motivated to work hard toward achieving desired results and improve the quality of health services.

• In order to achieve universal access, involvement of private sector in PMTCT service delivery is critical.

• Performance of MNCH platform as indicated by other CSD indicators is critical for successful integration of PMTCT services.

Acknowledgements

• Beneficiaries- pregnant women and partners interviewed

• Service Providers• Managers at the district level• eMTCT BP documentation review committee• UNICEF for financial and logistical support

Thank you all