Session 10: Implementation Solutions and Approaches …€¢ Preventive home visits for high risk defaulters including PBFW • Support groups for adult women including savings groups

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


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


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


Decision Tree: Case Identification for Adult Women

Quarterly HTC review with

partners

Improving Retention & Adherence

Among Adult Women

13


High rates of attrition and

non-adherence to

treatment among women

Improve adherence and

retention among women


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


Approach Problem Statement/Indicator


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


Approach

High unmet need for

cervical CA screening in

HIV+ AW

Prevent cervical cancer and identify/treat pre-clinical

lesions


Low program coverage

Limited equipment

Low training

coverage

Site level infrastructure

challenges

Limited M&E framework


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


Approach

Poor retention of PBFW;

Ongoing high VT

Improve retention/adherence in

care BEFORE VT


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


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


Approach

Poor retention of PBFW

Ongoing high VT

Improve retention in care BEFORE VT


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)



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


Approach

Poor retention of PBFW

Ongoing high VT

Improve retention in care BEFORE VT


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)



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)

49

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

50

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)

52

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

Documents

Session 10: Implementation Solutions and Approaches …€¢ Preventive home visits for high risk defaulters including PBFW • Support groups for adult women including savings groups