Family Centered Approach in PMTCT Program , Rwanda, 2005-2011.

Ange Anitha IRAKOZE, MD

Washington July 20th, 2012

Co:Authors : S.NSANZIMANA1, M. Jennifer, E. REMERA 1, KARANGWA .C , L. Tsague3, E.

NYANKESHA3, P. MUGWANEZA1

Rwanda

Division (HIV,AIDS,STIs and OBBI)

Outline • Context

• Background

• Objectives of the Program

• Methodology

• Results

• Conclusion and recommendations

Rwanda Context

East African country of 26,338 km2

Population: ~10 million inhabitants

4 provinces and Kigali City Council

30 districts

415 sectors

Generalized HIV epidemic(RDHS 2010)

3% prevalence in general population

3.7% prevalence among women

RWANDA

Background Scale up of PMTCT program started in

2001

Since 2003, Rwanda HIV Program recommended partner testing in PMTCT

HIV testing is routinely offered to all pregnant women and their partners at the first ANC visit

The test results are given the same day

They are asked to bring their children for testing and the one who test HIV positive are enrolled for follow up

Benefits of Family Involvement

• Reduction of mother-to-child HIV transmission by improving the follow-up: Better adherence & Higher retention

• Enhancements use of condoms and other prevention methods and among sero-discordant couples

• Facilitate couple communication related to sexual risks & Family Planning

• Enrollment and early treatment of other HIV positive family members: partner and children

• Reduction of mortality among children

Family-Centered Approach in PMTCT in Rwanda

• Program starts during ANC, where almost all pregnant women are offered HIV testing.

• They are encouraged to be accompanied by their male partners for HIV counseling and testing at the 1st ANC

• Pregnant women who test positive are encouraged to bring all their children so they may be tested and started in the care & treatment program if positive

• Family planning : Male participation is highly encouraged

• Follow up of the HIV exposed children in the PMTCT Program

Support for mother and family

The HIV-positive pregnant mother is followed up from the time she gets her HIV positive results, is started on ARV prophylaxis from 14 weeks.

Male involvement in PMTCT has enabled family support to be successful

Specific programs such as M2M, Family Package, Male Championship have been instrumental in supporting the family approach in PMTCT.

Support for the Mother and the Family

Partner and family testing is registered the chart, PwP interventions enhance family focused follow-up and care

Family testing is systematic in patient’s chart

(No partner) (Not tested) (HIV - )

(Partner)

(Children)

Rwanda Key strategies: Political commitment

• Couple counseling and testing (CHCT) Campaign was launched by President Kagame in 2003

• First Lady of Rwanda promotes the Family Package approach to PMTCT

• Mayors’ Performance Contracts with the President

• Sensitization through monthly community work (Umuganda)

Rwanda Key strategies to strengthen Family approach (cont’d)

• Invitation letter from Health Facility to

male partners

• Performance Based Financing for

clinic staff based on family approach

• Weekend CHCT services

• Sensitization by Community Health

Workers

• Community forum

www.pepfar.gov/press/81257.htm

Objectives

• Describe the expansion of PMTCT services in Rwanda

• Describe uptake of male partners testing through

PMTCT

• Describe institutional deliveries among HIV positive

women

• Describe the prophylaxis of HIV exposed infants

Methods

• Data was collected from reports submitted to a national electronic database (TRAC NET) by health providers based on patients files and health facility registers

• PMTCT variables collected include: Number of PMTCT sites, HIV testing among pregnant women and male partners, deliveries at health facilities among HIV positive women, prophylaxis and testing for exposed infants

• Descriptive analysis done on PMTCT variables in the electronic database using Microsoft EXCEL

• Period: January 2005 to December 2011

Scale-up of PMTCT Sites, Rwanda, 2005-2011

209 234

285

341

377 404

450

0

50

100

150

200

250

300

350

400

450

500

2005 2006 2007 2008 2009 2010 2011

Nu

mb

er o

f P

MTC

T Si

tes

Period

HIV Prevalence Among Pregnant Women in ANC

178,417 238,284

245,490

296,286 296,331

302,174

322,842 4.8

4.4

3.8

3.0 2.7

2.4

1.7

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

0.0

1.0

2.0

3.0

4.0

5.0

6.0

2005 2006 2007 2008 2009 2010 2011

Pre

gnan

t w

om

en in

AN

C

HIV

Pre

vale

nce

Am

on

g P

regn

ant

Wo

men

in %

Period

Pregnant women tested HIV prevalence

Uptake of HIV Testing of Male Partners in ANC

32,5%

53,1%

65,9%

77,8% 84% 84%

84,3%

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

2005 2006 2007 2008 2009 2010 2011

Nu

mb

er o

f P

regn

ant

Wo

me

n

Period

Pregnant women tested for HIV Male Partner tested for HIV

HIV Testing and HIV Prevalence Among Male Partners

58,067

126,580

161,896

230,491 248,806

253,904 272,221

5.4

4.5

3.6

3.1 2.7

2.4

1.7

0

50,000

100,000

150,000

200,000

250,000

300,000

0.0

1.0

2.0

3.0

4.0

5.0

6.0

2005 2006 2007 2008 2009 2010 2011

Mal

e P

artn

ers

Test

ed f

or

HIV

HIV

Pre

vale

nce

Period

Total male partner tested fir HIV HIV Prevalence among male partners

Proportion of HIV Positive Women Who Delivered in a Health Facility

994

1,427

1,765 1,791 1,810

3,860

4,577

70.0

81.4 86.1 88.9

90.5 94.1

95.0

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

0

10

20

30

40

50

60

70

80

90

100

2005 2006 2007 2008 2009 2010 2011

Del

iver

ies

Am

on

g P

osi

tive

Wo

men

Pro

po

rtio

n o

f D

eliv

erie

s in

HF

Am

on

g

HIV

Po

siti

ve w

om

en

Period

Total deliveries among HIV positive women

Delivered in HF among HIV positive women

Evolution of ART Prophylaxis for HIV Exposed Infants

1872 2013 2196

4101

5216

47.2

75.5

86.4 89.5

96.2

0

10

20

30

40

50

60

70

80

90

100

0

1000

2000

3000

4000

5000

6000

2007 2008 2009 2010 2011

Exp

ose

d in

fan

ts

Pro

po

rtio

n o

f ex

po

sed

infa

nt

wh

o

rece

ived

AR

T P

rop

hyl

axis

Period

Total HIV exposed infants ART prophylaxis among exposed infants

Conclusion • PMTCT program was scaled up over the years

and the coverage doubled between 2005 and 2011

• Our country achieved a lot in terms of involvement of male partners in ANC and their HIV testing by commitment from our leaders and innovative strategies.

• Hospital deliveries among HIV positive women increase from 70% in 2005 to 95% in 2011

• The results show a great improvement in follow

up of HIV exposed infants regarding the

proportion receiving prophylaxis

Recommendations

• Devise strategies to attain 100% coverage for both PMTCT services and male partner testing

• PMTCT program should ensure that any of HIV positive mothers, male partners and infants miss in to care and treatment follow up program for the well being of every family member and for ending vertical transmission.

Thank You!