Session 10: Implementation Solutions and
Approaches to Reach Epidemic Control among Adult Women
HIV Care and Treatment Cascade Adult Women
3
Strategic Approaches to Reduce HIV Morbidity and Mortality Among Women
All Adult Women
Accelerate early case identification of young women, prior to pregnancy
Improve adherence & retention to increase rates of VL suppression and women’s survival
Improve coverage of cervical CA screening & prevention
Focus on Pregnant Women
Focus on adherence, retention and suppressed viral load
--Mentor mother strategy
--Improved service delivery models
--High accountability partner management model
Multi pronged approach to drive down vertical transmission
4
Adult women exceeded targets in FY17 and continue to outpace adult men across the cascade
5
Nationally ART Coverage for Women Remains Low at 52%
PLHIV: IMASIDA 2015, Census 2017, Spectrum V5.6; TX_Curr: PEPFAR/MER (DATIM)
Highest unmet need for women found in Zambezia and Maputo Provinces
34%
67%
51%
63%
120%
38%
44%
33%
53%
71%
42%
0%
20%
40%
60%
80%
100%
120%
140%
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
Cabo Delgado Gaza Inhambane Manica MaputoCidade
MaputoProvíncia
Nampula Niassa Sofala Tete Zambézia
Co
vera
ge
# o
f P
LHIV
Number of Women on Treatment, Unmet Need, and Coverage by Province
TX_CURR Unmet Need Coverage
6
Problem Diagnosis Strategic Objective
Approach
Low case identification
among younger (20-25), never-pregnant women
Increase case identification of
HIV+ younger women, prior to
pregnancy
Problem Statement/Indicator
Providers not screening non-
pregnant women sufficiently for HIV
risk within high-yield sectors
Room to grow in
index case testing of partners of young woman
Monitoring and Partner Management
Decision Tree: Case Identification for Adult Women
7
Ongoing growth in case finding adult women in FY17
*Includes women from finer age categories above 10 to account for differences in unknown age POS by implementing partner. Source: DATIM
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
CHASS CCS ARIEL EGPAF FGH ICAP JHPIEGO
# o
f P
oS
fem
ales
Number of adult female positives identified, by quarter and by implementing partner, FY17 and FY18 Q1
Q1 FY17 Q2 FY17 Q3 FY17 Q4 FY17 Q1 FY18
8
Case identification among younger women has not kept pace with older women.
*Includes data from finer age category only; may exclude unknown age POS. Source: DATIM
9
Strategic shift to index case testing drives improved case finding among women
0
500
1,000
1,500
2,000
2,500
CHASS CCS ARIEL EGPAF FGH ICAP JHPIEGO WVI
# o
f In
dex
PO
S
Number of female* index case positives, by quarter and implementing partner, FY17 & FY18 Q1
Q1 FY17 Q2 FY17 Q3 FY17 Q4 FY17 Q1 FY18
10
Adult women case identification: Opportunity for geographic efficiencies
50% of All Adult Female unmet
need identified in these 25 Districts (16% of 161 total
districts)
Province District Adult Female POS
Maputo Matola 11,298
Sofala Beira 9,698
Manica Chimoio 7,182
Zambezia Quelimane 6,326
Cidade De Maputo Kamavota 5,841
Gaza Chokwe 4,845
Cidade De Maputo Nlhamankulu 4,505
Zambezia Mocuba 4,339
Sofala Dondo 4,218
Tete Tete 4,133
Maputo Marracuene 3,932
Cidade De Maputo Kampfumu 3,825
Cidade De Maputo Kamubukwana 3,788
Maputo Manhiça 3,551
Zambezia Namacurra 3,332
Zambezia Nicoadala 3,182
Cabo Delgado Pemba 2,982
Nampula Nacala 2,853
Cidade De Maputo Kamaxakeni 2,847
Inhambane Massinga 2,838
Gaza Chibuto 2,686
Manica Manica 2,638
Sofala Nhamatanda 2,574
Zambezia Maganja Da Costa 2,524
Zambezia Pebane 2,494
Manica Gondola 2,462
Gaza Bilene 2,404
11
Problem Diagnosis Strategic Objective
Approach
Low case identification
among younger (20-25), never-pregnant women
Increase case identification of
HIV+ younger women
Scale-up community-
based index case testing and PICT to capture young
women, geographic focus
for increased impact
Problem Statement/Indicator
Providers not screening non-
pregnant women sufficiently for HIV
risk within high-yield sectors
Providers not following-up
sufficiently with men for index case testing of female
partners
Index case testing coverage by
district; MER & new HTC registers
Monitoring and Partner Management
Decision Tree: Case Identification for Adult Women
Quarterly HTC review with
partners
Improving Retention & Adherence
Among Adult Women
13
Problem Diagnosis Strategic Objective
High rates of attrition and
non-adherence to
treatment among women
Improve adherence and
retention among women
Problem Statement/Indicator
Low patient
literacy/Lack of readiness for
treatment initiation
Inadequate counseling/psyco-
social support
Systems barriers that decrease access
to treatment
Stigma/ Discrimination
Decision Tree: Adherence and retention for adult women
14
Retention of adult women sub-populations by province
0%
20%
40%
60%
80%
100%
_MilitaryMozambique
Niassa Cabo Delgado Nampula Zambezia Tete Manica Sofala Inhambane Gaza Maputo Cidade DeMaputo
TX_RET_AGYW (15 to 24 Years)
TX_RET_Pregnant Women
TX_RET | Adult Non Pregnantwomen
15
VL Suppression Rates by Age and Gender, FY17 (DATIM)
Total estimated VL suppression of 67% among women at FY17 (using EPTS data)
Low suppression rates, especially in younger population
16
5 Retention Pillars for Adult Women
Core Pillar Activities
Differentiated Service Delivery
• Expand Community Adherence and Support Groups (CASGs) • Expand 3-month drug dispensing • Expand family health approach • Expand one-stop-shop models • Begin distribution of ART in the community (through mobile brigades) • Adherence clubs
Quality Improvement • Expansion of National QI Strategy to
• Strengthen mentorship model
• Integrated site supervision visits
• Rapid improvement cycle pilot in MCH in Nampula
Psycho-social Services • Ensure availability of HF cadre dedicated to providing pycho-social support • Improve mentoring/technical assistance for psychosocial services and support for women • Partner disclosure for discordant couples • Mental health screening and referral • Mentor mothers (focused on pregnant and BF women)
Stigma and Discrimination • Community dialogues
• Community awareness raising
• Patient rights focus and patient empowerment via community health committees and patient advocates
Community Support to Improve Linkages and
Retention
• Preventive home visits for high risk defaulters including PBFW • Support groups for adult women including savings groups • Improve literacy focusing on patient and community education (including practitioners of traditional medicine,
community leaders) • Community mentor mothers strategy
17
Stigma & discrimination package to improve retention & adherence among women
Strengthen service quality through women’s
empowerment
Improve the knowledge of HIV and ART among
women
Improved linkage between
community and health
services, through
meaningful community
engagement/health
advocates
Increased use of HIV
services and adherence and
retention to HIV
18
Community package to improve retention & adherence among women
Increased the use of HIV services and
adherence and retention to HIV
Improve treatment literacy by leveraging
key community stakeholders and
structures
Community-level support through GAAC’s, mentor mother strategy, PLHIV
and savings groups
Improved monitoring of community interventions
supporting retention
Improve PLHIV economic conditions and social integration
19
Problem Diagnosis Strategic Objective
Approach Problem Statement/Indicator
Monitoring and Partner Management
Decision Tree: Adherence and retention for adult women
Enhanced retention
monitoring; DSD M&E
Retention indicators
disaggregated by gender and age
Evaluation of root causes of poor retention and sample-based
LTFU assessment
High rates of attrition and non-adherence to treatment among women
Systems barriers that decrease access to treatment Challenges with availability and quality of services Inadequate counseling/ psycho-social support Stigma/ discrimination Low patient literacy
Improve adherence and retention among women
Community outreach to
reduce stigma, improve quality of
care via health advocate platform
Improve psychosocial
services
Differentiated service delivery
Improving quality of services
Community support to
improve linkages and
retention
20
Problem Diagnosis Strategic Objective
Approach
High unmet need for
cervical CA screening in
HIV+ AW
Prevent cervical cancer and identify/treat pre-clinical
lesions
Problem Statement/Indicator
Low program coverage
Limited equipment
Low training
coverage
Site level infrastructure
challenges
Limited M&E framework
Monitoring and Partner Management
Decision Tree: Unmet meet for cervical CA prevention/screening
21
Filling the gap in cervical cancer screening & prevention in Mozambique
*MOH Report 2017/**IMASIDA
VIA + in HIV+ wome in 2017 (Mo report, 2017)
Cervical cancer in Mozambique affects 65 per 100,000 women
Mortality incidence from cervical cancer is 40.2 per 100,000 women
HIV+ women’s risk of progression of preclinical lesion is 3-4 times more frequent than HIV-
Low % of HIV+ women have access to reproductive health services (RHS) consultations - 23.8% of HIV+ women access RHS.
(MoH 2017 annual report)
3,119,423# of 1st RHS consults*
467,913Est # HIV+ women**
111,502# HIV positive women receiving RHS*
62,517# HIV+ women VIA + in
2017*
(24% of all pos)
356,411 Est gap in HIV+
women receiving VIA
22
What is needed to expand access and improve quality in CC prevention and screening?
1. Demand creation for RHS and cervical CA prevention/screening
2.Develop national strategic plan/operationalization framework
3. Strengthen referral and counter referral for treatment of preclinical and clinical lesions and follow up after treatment
3. Increase offer of cryotherapy and LEEP services for HIV+ patients
2.Increase access and screening for HIV + patients
6. Guarantee acquisition of cryotherapy and LEEP and colposcopy and maintenance parts and supply chain
7. Quality assurance (E-HUB)
8. Develop M &E framework
23
Strategic Approaches to Reduce HIV Morbidity and Mortality Among Women
All Adult Women
Accelerate early case identification of young women, prior to pregnancy
Improve adherence & retention to increase rates of VL suppression and women’s survival
Improve coverage of cervical CA screening & prevention
Focus on Pregnant Women
Focus on adherence, retention and suppressed viral load
--Mentor mother strategy
--Improved service delivery models
--High accountability partner management model
Multi pronged approach to drive down vertical transmission
PMTCT
25
*DHS 2011
Problem Diagnosis Strategic Objective
Approach
Poor retention of PBFW;
Ongoing high VT
Improve retention/adherence in
care BEFORE VT
Problem Statement/Indicator
Improving yet not satisfactory retention in
pregnancy (67%)
Too few women on treatment before
becoming pregnant
Late initiation of ART (1st ANC average ~20
weeks*)
Low viral suppression rates
Monitoring and Partner Management
Decision Tree: Retention and adherence for PBFW
26
Policy Updates PMTCT
Policy Status Timeframe
DSD guidelines (components for PBFW, adolescents) For stable breastfeeding women in HEI clinic after first negative PCR test when infant is 9 months of age : Tri-monthly drug distribution
One stop shop for PMTCT Teen clubs DSD for children and teens including spaced visits and
multi-month scripting
Pending finalization in March, 2018
Mentor mother strategy for PBFW and children <5 Peer support, psychosocial support services, preventive home visits, defaulters’ and LTFU tracing
Final approval February 2018
Enhance implementation of psychosocial support policy: revise instruments for high fidelity implementation (PMTCT, peds, adolescents and general population) Support and enhanced counseling home visits for new initiations and at risk patients after screening
New instruments under revision PPS Policy approved 2015 Workshop for provincial input 27-28 Feb/ Pilot of new instruments slated for April 2018
ARV distribution in mobile brigades for PBFW and children within primary care context for communities with poor access to facilities
Pilot in COP17 in CDG and scale COP18 MISAU decisions Feb 2018
Continued high achievement in PMTCT _STAT and PMTCT_ART in Q1
333,327 325,873
26,253 25,239 12,649 12,590
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
ANC Clients Know Status HIV+ PW On ART Newly initiated ART Already on ART at ANC Initiation
FY17.Q4 HIV+PW 25,799 FY17.Q3 HIV+PW 26,838 FY17.Q2 HIV+ PW 28,373 FY17.Q1 HIV+ PW 25,253
98%
8%
96% 50%
50% HIV+ PW on ART
at ANC initiation
28
PMTCT_ART: Site level achievement analysis*
Province District Facility PMTCT_STAT
_POS PMTCT_ART
ART Coverage %
Interventions driving high ART coverage in PBFW
1 Cidade De Maputo
Nlhamankulu Jose Macamo CS 441 465 105% Dedicated MCH counselor team. Integrated multi-disciplinary referral system for HIV+ women declining treatment. Early adoption mentor mother strategy, September FY17.
2 Gaza Xai-Xai Chicumbane HR 342 360 105% MCH program officer supporting the HF. Dedicated MCH counselor team. . Mentor mother program implementation since late 2016. Early adoption mentor mother strategy in late 2016.
3 Sofala Marromeu Marromeu HR 521 531 102% On the job training and mentoring of MCH nurses on implementation of option B+. Mentor mother strategy implementation. Enhanced training of MCH nurses in the psycho-social package to promote adherence/retention to ARV treatment
4 Manica Cidade De Chimoio
Nhamaonha CS II
595 606 102% Ongoing support through TA, focusing on records review to ensure that all HIV+ pregnant women receive ART in ANC and ensure that they are registered. Focus on male engagement: through PDSA (QI) and mentoring.
5 Cidade De Maputo
Kamavota 1º de Junho PS 530 530 100%
Re-structuration of CCS district MCH team, with assignment to the facility of a new MCH nurse, highly motivated and committed. District with a committed MCH nurse chief; during each supportive supervision visit, she monitors ART provision and discusses results with the MCH team, which is required to justify any low performance and action taken. Counselors assigned to ANC. ANC and EPTS data triangulation and ANC monthly data discussion; weekly monitoring plan developed for poorly performing indicators. Mentor mother implementation since September FY17.
6 Cidade De Maputo
Kamavota Albasine PS 486 486 100%
Re-structuration of CCS district MCH team, with assignment to the facility of a new MCH nurse, highly motivated and committed. District with a committed MCH nurse chief; during each supportive supervision visit, she monitors ART provision and discusses results with the MCH team, which is required to justify any low performance and action taken. Counselors assigned to ANC. ANC and EPTS data triangulation and ANC monthly data discussion; weekly monitoring plan developed for poorly performing indicators. Mentor mother implementation since September FY17.
7 Cidade De Maputo
Kamavota Mavalane CS 548 548 100% Similar as above (same district). Two new commited MCH nurses with good leadership and suuport from the district MCH chief. Mentor mother implementation since September FY17.
8 Gaza Cidad De Xai-
Xai Xai-Xai CS 499 499 100%
MCH program officer supporting the HF. Mentor mother program implementation. Dedicated MCH counselor team. Mentor mother implementation since September FY17.
9 Cidade De Maputo
Nlhamankulu Xipamanine
CSURB 598 597 100%
ANC MCH nurse s/p exchange visit trip to Inhambane. Dedicated MCH counselor team. ANC and EPTS data triangulation and ANC monthly data discussion and action plans for indicators with poor performance. Mentor mother implementation since September FY17.
10 Maputo Manhiça Manhiça
CS I 598 596 100%
Pre-test education session before ANC with mix of women with known HIV+ and unknown HIV status; HIV+ women give a testimony about their life with HIV and the session works as a kind of support group. If a woman is diagnosed as HIV+ during ANC, she receives additional post-test counseling provided by a counselor who is also HIV+ and shares her experience with her.
*>43 sites nationally reporting >95% PMTCT_ART
Ongoing high rates of “new on ART” reflect retention challenge and late entry to care
18% 23%
32% 35%
52%
43% 48%
26%
64%
62% 61%
42% 53%
48% 54%
12%
7% 4% 5% 4% 4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
APR13 APR14 APR15 SAPR16 APR16 APR17 FY18 Q1
PMTCT Regimens: 2013-2018
Option A or refusals
Newly on ART
ART at entry
30
Uneven regional gains in proportion of PW on ART at 1st ANC, mapped to VT in FY18 Q1
39% 40%
46% 46% 48%
33%
38% 40%
33%
37%
23%
79%
52%
70%
43%
48%
31%
17%
44% 45%
57%
23%
1% 1%
2%
3% 3%
3%
4%
5%
7%
6% 6%
0%
1%
2%
3%
4%
5%
6%
7%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Cidade de Maputo Tete Maputo Cabo Delgado Gaza Inhambane Niassa Manica Sofala Zambezia Nampula
Axi
s Ti
tle
Ver
tica
l Tra
nsm
issi
on
, FY
18
Q1
Already on at entry at ANC APR 16 Already on at entry in ANC APR17 Vertical transmission rate<2 ms (MER Q1)
31
Retention of PW below target but improving
12 month retention by province APR16 APR17
PROVINCE TX_RET PMTCT (12mo.)
TX_RET PMTCT (12mo.)
Inhambane 64% 85%
Cidade De Maputo 42% 84%
Maputo province 63% 84%
Tete 79% 75%
Gaza 65% 73%
Niassa 71% 71%
Cabo Delgado 58% 71%
Manica 48% 63%
Nampula 74% 63%
Zambezia 61% 61%
Sofala 61% 60%
Grand Total 62% 67%
APR16 APR17
Partner TX_RET PMTCT (12mo.)
TX_RET PMTCT (12mo.)
CCS 52% 85%
ARIEL 61% 76%
EGPAF 65% 73%
CHASS 62% 65%
ICAP 65% 65%
FGH 65% 59%
Grand Total 62% 67%
12 month retention by partner
32
Ongoing vertical transmission demands urgent attention
Data source:
National INS
Database
33
FY 18 Q1 Vertical Transmission Rates by Partner and Province- Mozambique MER Data
7.5%
5.9%
6.8% 6.5%
5.3% 5.2%
4.2%
3.0% 2.6%
1.9%
2.5%
1.2% 1.1%
10.2%
9.6% 9.4%
9.0%
8.5%
8.0% 7.7%
5.6%
3.4%
3.0% 2.9%
2.0% 2.0%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
Zambezia CHASS Nampula ICAP Zambezia ICAP Sofala CHASS Zambezia FGH Manica CHASS Niassa CHASS Cabo DelgadoARIEL
Gaza EGPAF Maputo ARIEL Inhambane CCS Cidade DeMaputo CCS
Tete CHASS
FY 18 Q1 Vertical Transmission Rates by Partner and Province- Mozambique MER Data
VerticAL TRANSMISSION < 2 Mo Vertical transmission 0-12 mo
34
Estimates of true VT in Mozambique vary; data drives accountability
10.0%
3.9% 4.5%
6.0% 5.6%
3.6%
16.1%
6.7%
9.2%
3.1%
9.5%
13.8%
6.3%
8.3%
10.1% 9.8%
5.3%
18.1%
10.8%
9.6%
5.3%
13.4%
14.6%
1.9%
7.3%
5.7%
8.2%
4.5%
13.3%
4.6%
8.7%
0.8%
12.4%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
Cabo Delgado (Ariel) Cidade De Maputo(CCS)
Gaza (EGPAF) Inhambane (CCS) Manica (CHASS) Maputo (Ariel) Nampula (ICAP) Niassa (CHASS) Sofala (CHASS) Tete (CHASS) Zambezia (FGH, ICAP,CHASS)
2017 Comparison of HIV Positivity by Cohort Data, INS Data, and MER Data Mozambique
Moz Cohort Data 1/18-10/18 <12mo INS Data (<9mo) MER Data (<12mo)
35
Vertical transmission decreasing over past 5 years in most but not all provinces
EID Transmission Data, INS database, diagnosis <9 months
11.82%
12.95%
12.12%
17.65%
15.36%
13.33%
8.54%
13.33%
12.47%
10.55%
8.64%
7.54%
10.34%
13.80%
10.97%
18.17%
13.30%
9.56%
5.34%
9.87% 10.05%
8.33%
5.30%
6.26%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
20.00%
national Cabo Delgado Niassa Nampula Zambezia Sofala Tete Manica Inhambane Gaza MaputoProvince
Maputo City
2012 2013 2014 2015 2016 2017
36
VT taking place largely for mother-baby dyads reported as “On-ART”
0%
5%
10%
15%
20%
25%
30%
35%
40%
NAMPULA CABODELGADO
ZAMBEZIA SOFALA NIASSA INHAMBANE MANICA GAZA MAPUTOCIDADE
MAPUTOPROVINCIA
TETE
Ver
tica
l tra
nsm
issi
on
, IN
S d
atab
ase,
FY1
7
No ART Option B+
N=519
N=14308
N=643
N=3006
N=58
N=4732
N=154 N=185
N=3905
N=95 N=153
N=7855 N=8382
N=120
N=97
N=6685
37
Problem
Diagnosis
Strategic
Objective
Approach
Poor retention
of PBFW
Ongoing high
VT
Improve
retention in care
BEFORE VT
Problem
Statement/Indicator
Improving yet not
satisfactory
retention rates in
pregnancy (67%)
Low % of PBFW
HIV+ already on
treatment at ANC
entry
Late initiation of ART
(1st ANC average 20
weeks)
Low viral
suppression rates
Monitoring and
Partner
Management
Decision Tree: Retention for PBFW
Fully scale mentor
mother strategy
Closely track
achievement of
benchmarks and
fidelity of
implementation
M2M DIRECTLY
implementing high
fidelity model in
provinces of
concern
38
Mentor mother scale-up underway
0
200
400
600
800
1000
1200
1400
1600
CaboDelgado
Niassa Nampula Zambezia Tete Manica Sofala Inhambane Gaza Maputo City MaputoProvince
Num
ber
of tr
ain
ed a
nd r
ecru
ite
d m
en
tor
moth
ers
Q1 Q2 Q3 Q4
Q1 and Q2: Number of
available mentor
mothers in each period
Q3 and Q4: Number of
projected mentor
mothers for each
period
39
Evidence of impact; mentor mother implementation and VT decline in Gaza Province
6.8
3.7
0
1
2
3
4
5
6
7
8
Transmission at first PCR, Gaza
January
February
March
April
May
June
July
August
September
October
Mentor mother strategy at scale, Gaza Province cohort data
40
National scale up of mentor mother strategy, with focus on high VT localities
High fidelity scale up of mentor mother strategy by M2M in high coverage demonstration sites/intensive district and site level TA for provincial leadership and clinical IP in Nampula, Zambezia, Sofala and Manica
National scale up of mentor mother strategy by IP’s with M2M TA; COP19 mandate for mentor mother cadre support for 90% of HIV+ PBFW in PEPFAR supported sites
41
Problem Diagnosis Strategic Objective
Approach
Poor retention of PBFW
Ongoing high VT
Improve retention in care BEFORE VT
Problem Statement/Indicator
Improving yet not satisfactory retention
rates in pregnancy (67%)
Low % of PBFW HIV+ already on treatment
at ANC entry
Late initiation of ART (1st ANC average 20
weeks)
Low viral suppression rates
Monitoring and Partner Management
Decision Tree: Retention for PBFWMentor mother strategy
High quality, high fidelity psychosocial
support
Closely track fidelity of
implementation—mandate district
level teams
Improved service delivery models for PBFW: One stop shop Mobile brigades
DTG roll-out for PBFW once approved by
WHO
42
What are psychosocial support strategies for PBFW?
Targeted enhanced adherence support
1. Patients with identified adherence problems 2. Viral load > 1000 Copies and/or CD4<200 3. Patients with suspected treatment failure 4. All children with positive EID PCR results
1. All patients initiating ART with high adherence risk (using stratification tool)
2. All PBFW (intensity stratified by risk) 3. All children 0-14 years (Risk stratified for wrap
around services) 4. TB-HIV patients 5. Patients with other chronic severe clinical
conditions and malnutrition
Preventive/Supportive Home Visits for PBFW, weekly defaulter tracing
Focus on PBFW:
Community/ Facility-based
Support
Vaccination
Vitamin A
Child Growth
Monitoring
Family Planning
Pre-Natal + Post-
Partum Care
Maternal Health
Testing & counseling
Community
Mobile
Brigade
ART/PMTCT Psychosocial
support
44
Scale up high fidelity PSS and patient centered service delivery models, with focus on high VT localities, focus on Nampula
Focus on Nampula
M2M roll out in COP17/COP18 to support high burden sites and intensive TA to provincial leadership
IM portfolio shift to facilitate dedicated focus on improving MCH performance in Nampula
Rapid quality of care improvement cycles Mandate district and site level team support Enhanced support from ICAP HQ ICAP multi-pronged acceleration plan in place ICAP Moz leadership transition in August 2017
45
Scale up high fidelity PSS and patient centered service delivery models, with focus on high VT localities
Regional initiatives for high VT localities Mobile brigades to provide high quality primary care and PTV
in remote-access communities (CDG, Nam, Zam, Tete)
National implementation of improved models of care for PBFW Improve quality of counseling and adherence support before
default All PBFW to receive supportive home visits from mentor mother
cadre (intensity stratified by risk) PSS Tools/M&E to track weekly identification of PBFW default
and follow-up PSS tools to ensure EAC for PBFW with poor adherence/high VL Systematic screening for mental health disorders and link to
treatment Continued full implementation one stop model DTG for pregnant women when recommended by WHO Timely identification of treatment failure and prompt switch to
2nd line
Additional Regional initiatives for high VT localities CDG: Model PTV districts Zam: Expansion village health committee/right to health programming
46
Problem Diagnosis Strategic Objective
Approach
Poor retention of PBFW
Ongoing high VT
Improve retention in care BEFORE VT
Problem Statement/Indicator
Improving yet not satisfactory retention
rates in pregnancy (67%)
Low % of PBFW HIV+ already on treatment
at ANC entry
Late initiation of ART (1st ANC average 20
weeks)
Low viral suppression rates
Monitoring and Partner Management
Decision Tree: Driving accountability
Monthly review of VT by partner, province,
district and site
Routine, high accountability meetings, with
enhanced monitoring visits to problem sites
Monthly review early retention performance by partner, province, district
and site
Driving Decreases in VT
Monthly cohort monitoring in
EID, integration with national QI process, routine
partner meetings
Accounting for disposition of
every HIV positive infant
via cohort monitoring
Focus on adherence and retention via
monitoring and strategic field
visits
VT high/low performers; Routine site level accountability and learning
*Monthly EID Cohort Data, Jan-Oct 2017
Province Health Facility IM # HIV PW, 1st
ANC* VT rates Successful interventions/ Site level improvement plans
Maputo Cidade CS Alto Maé CCS 417 0% Early adoption mentor mother strategy, Sept 2017; Enhanced counseling
program. High ART coverage prior to pregnancy. Maputo Cidade CS Malhangalene CCS 319 2%
Maputo Cidade CS Mavalane CCS 544 2%
Maputo Provincia CS Ndlavela ARIEL 408 2% Early adoption family approach (2015); High ratio peer educators filling mentor
mother role; High ART coverage prior to pregnancy.
Gaza HR Chicumbane EGPAF 304 3% Early adoption mentor mother strategy (April 2016); Reinforced counselling;
Robust communication activities (radio and theater)
Nampula Nacala-Porto CS I ICAP 326 20%
Implementation mentor mother strategy (Nov 2017); IP clinical focal point allocated
at site level from Feb 2018; M2M site level support from FY18Q4; Routine HF ART
Cmte. QI cycles focused on PMTCT cascades
Sofala Marromeu HR CHASS 443 18% Mentorship to MCH nurses for reinforced counselling; In-service training on key
messages; Mentor mother strategy and home visit implementation( Q1-Q4 FY 18)
Zambezia Nicoadala CS II ICAP 664 15%
M2M implementing mentor mother strategy from FY18Q2. IP clinical focal point
allocated at site level from Feb 2018; Proposed transition IP support to FGH in
Q1FY19.
Nampula Namicopo PS ICAP 330 15%
Implementation mentor mother strategy from Nov 2017; IP clinical focal point
allocated at site level from Feb 2018; M2M site level implementation from FY18Q4;
Routine HF ART Cmte. QI cycles focused on PMTCT cascades
Sofala Dondo Sede CS I CHASS 327 14%
Allocation of additional MCH nurses; Appointment books for consultations; Mentor
mother strategy and home visit implementation; Partners invitation and QI cycles
( Q1-Q4 FY 18)
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High accountability monthly meetings, with site level review of high VT facilities and detailed program planning
PEPFAR APR17 data, Sites in red do not appear in cohort data
Province District Health facility HIV infected infants Vertical transmission rates # of HIV+ PW
Nampula Mogovolas Nametil CS I 48 38% 184
Gaza Chibuto Chibuto HR 158 34% 453
Zambezia Chinde Chinde CS I 58 32% 148
Nampula Moma Moma CS I 31 28% 202
Nampula Angoche Angoche HR 40 27% 200
Cabo Delgado Cidade De Pemba Natite PS 65 27% 380
Cabo Delgado Palma Palma CS II 16 26% 124
Zambezia Mopeia Mopeia CS I 49 25% 189
Zambezia Cidade De Quelimane Madal CS 52 24% 210
Cabo Delgado Macomia Macomia CS I 20 24% 185
Cabo Delgado Cidade De Pemba B. Eduardo Mondlane PS 29 23% 303
Zambezia Ile Ile CS I 40 23% 115
Zambezia Cidade De Quelimane Maquival Sede CS III 71 20% 290
Zambezia Gile Gilé CS II 27 19% 184
Zambezia Cidade De Quelimane Centro de Saude de Icidua 43 18% 322
Cabo Delgado Mocimboa Da Praia Mocímboa Praia HR 25 18% 353
Cabo Delgado Montepuez Montepuez HR 38 18% 359
Zambezia Nicoadala Licuare CS III 72 17% 324
Sofala Caia Caia CS I 39 17% 290
Cabo Delgado Muidumbe Muambula CS III 16 16% 214
Zambezia Inhassunge Inhassunge CS I 29 16% 215
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Accountability via cohort monitoring in FY17 driving down VT in most provinces
0.0 %
5.0 %
10.0 %
15.0 %
20.0 %
25.0 %
Ariel EGPAF CCS CHASS CCS Ariel ICAP CHASS CHASS CHASS FGH ICAP
CaboDelgado
Gaza Inhambane Manica MaputoCidade
MaputoProvíncia
Nampula Niassa Sofala Tete Zambézia
a. January
b. February
c. March
d. April
e. May
f. June
g. July
h. August
i. September
j. October
Enhanced monitoring shows improving trend over last 12 months in PMTCT short term retention (Jan 17-Dec 17 bi-monthly analysis)
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COP18 Mozambique, Aggressive PMTCT & EID Targets
Year PMTCT_STAT PMTCT_STAT_POS PMTCT_ART PMTCT_EID TX_NEW <1
FY17 Achievement 1,344,231 98,614 103,201 51,297 4,837
FY18 (target) 1,087,215 101,402 95,784 92,039 700
FY19 (target) 1,342,201 95,692 90,497 84,198 10,275
Targeting for COP18 continues to demand high program quality; 95% of women at ANC must know their status and 95% of the positives must be linked to ART. For EID, 95% of exposed infants (denominator is PMTCT_STAT_POS) must be tested by 12m and 95% of the HIV positive infants linked to care. 80% of exposed infants must be tested by 2m. TX_new is calculated from FY17 EID yield (at district %) multiplied by # of tests targeted—PMTCT_EID-- with a 95% linkage assumption.
Obrigada