planning for transition from opti on b to b+: rwanda experience
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Planning for Transition from Opti on B to B+: Rwanda Experience. MUGWANEZA Placidie , Coordinator of HIV prevention Unit/RBC/MOH ART in pregnancy, breastfeeding and beyond, Johannesburg, June 18-20, 2012. OUTLINE. Rwanda context History of PMTCT guideline and regimen changes in Rwanda - PowerPoint PPT PresentationTRANSCRIPT
Planning for Transition from Option B to B+: Rwanda Experience
MUGWANEZA Placidie, Coordinator of HIV prevention Unit/RBC/MOH
ART in pregnancy, breastfeeding and beyond, Johannesburg, June 18-20, 2012
OUTLINE Rwanda context
History of PMTCT guideline and regimen changes
in Rwanda
Roadmap and timelinefrom option B to option B+
Current Program: areas for Improvement
Experience with Site supervision
Next steps
RWANDA CONTEXTEast African country of 26,338 km2 Population: ~10 m. inhabitantsAdministrative framework
–4 provinces and Kigali City Council–30 districts–415 sectors/cells/villages
Generalized HIV epidemic–3% prevalence in general population–3,7% prevalence among women
Rapid scale up of HIV services –456 PMTCT sites (82%)–372 ART sites (70%)
RWANDA
PMTCT REGIMENS IN RWANDA
Period PMTCT Regimen Eligibility criteria for ART for life
2002 - 2005 NVP ≤ 200 CD4
2005-2010 AZT+NVP ≤ 350 CD4
2010 Option B for pregnant women with CD4>500(HAART until 18 months postpartum)
≤ 500 CD4 (while nonpregnant adults eligible at CD4<350)
April 2012 Option B+ All HIV + pregnant women
2. Recommendation from scientific workshop: shift from option B to B+
TRANSITION FROM OPTION B TO B+
May 2011
September 2011
March- April 2012
7- Tools revision (adherence register, indicators, Q&A and BCC)
3. Revision and approval of the
guidelines
February March 2012
5. Training of Health providers, launching of B+
Ongoing
1- Launch of the EMTCT National campaign
BUILDING ON EXISTING HEALTH SYSTEMS
Integrated service delivery model
− High coverage of health facilities providing both PMTCT and ART
− Integrated HIV training ( ART & PMTCT)
− Coordinated procurement and distribution system & ARV quantification
Strong coordination and service provision structures already in place − National ↔ district ; facility ↔ community; ART ↔ PMTCT
Task shifting already in place Strong political commitment
HIGH COVERAGE OF INTEGRATED HIV SERVICES
Source: RBC;
Increasing Proportion of HIV-infected Pregnant Women Receiving HAART during
Pregnancy
Source: Trac Net database, RBC/IHDPC
ARV REGIMENS FOR PMTCT
Option B (adopted November
2010):
‒ Women with CD4 < 350: TDF/3TC/NVP
‒ Women with CD4 > 350: TDF/3TC/EFV
Option B+ (Adopted April 2012)
‒ All women : TDF/3TC/EFV
Infant: Daily NVP up 6 weeks
ONGOING AREAS FOR IMPROVEMENT
ANC attendance
‒ Only 38% attend ANC before the 4th month of pregnancy
Need for ongoing mentorship for nurses at PMTCT sites
Retention and ART Adherence for pregnant and lactating women
ARV quantification and forecasting at district level
Rapid turnaround of EID results to sites for early treatment
Follow-up of ART patients at PMTCT standalone sites
– Linkages to treatment for male partner and children
– Follow-up of mother after the breastfeeding period
Supporting Program Implementation and Quality through Site Supervision:
Example of Track 1.0 Transition Planning
‒ Identify and notify sites to be supervised‒ Establish a schedule ‒ Define the resource needed (e.g HR,
transport… ‒ Provide tools and train supervisors
Implementation ‒ Use standard tool‒ Identify strength and weakness‒ Provide feedback
Documentation
May Jun
eJuly
Aug.Sept
Oct
.Nov.
Dec.Jan.
Feb. March
April MayJune July Aug.
Sept.
2010 2011
Cohort 1 Transition18 Sites
Cohort 2 Transition6 Sites
Cohort 3 Transition46 Sites
C1 Baseline C1 6- Month Follow-Up C1 12-Month Follow-Up
C2 Baseline C2 6-Month Follow-Up
C3 Baseline C3 6-Month Follow-Up
TIMELINE FOR TRACK 1.0 SITE MONITORING
SITE VISITS & DATA COLLECTION
Teams visit all transitioned sites at baseline and every 6 months‒ November 2009-December 2010: CDC-led with
MOH/partner participation‒ January 2011-Present: MOH led with CDC participation
Management Capacity‒ Interview health center director, accountant, data
manager, ART and PMTCT nurses and lab technicians‒ Abstract data from quarterly PBF evaluations
Clinical Performance‒ Abstract clinical performance data from national HIV
monitoring system (TRACNet) and Track 1.0 reports
Mean HIV PMTCT Performance Results for Health Facilities at Baseline, 6 and 12 Months after
Transition
FEEDBACK: DISSEMINATION WORKSHOPS
Held at district hospitals for facilities
in their catchment after each round
Facilitated by MOH
Agenda:
– District-specific results
– Site specific results, small group discussion
– Action planning to address identified gaps
LESSONS LEARNED
Accompanying MOH on routine site visits
builds site- and central-level capacity
Decentralization of site visits could improve
MOH efficiency, follow-up of recommendations
Involvement of all relevant MOH departments
improves follow-up on recommendations
NEXT STEPS
Finalize and disseminate revised tools
Accelerate accreditation process for PMTCT standalone sites to offer ART
Evaluate retention and adherence for mother-infant pair
Reinforce the PMTCT M&E (e.g: Revision of PMTCT indicators, program evaluation)
Establish ARV pharmacovigilance system
Reinforce capacity of health providers through training, supervision and mentorship