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Integration of Antiretroviral Therapy (ART) in Maternal and Child Health (MCH) settings: the way forward for increasing access to ART for HIV-positive pregnant women in Zimbabwe

IAS – JULY 2011

A. Muchedzi1, T. Nyamundaya1, B. Makunike-Chikwinya1, A. Mushavi2, R. Mugwagwa2

1Elizabeth Glaser Paediatric AIDS Foundation, Harare, Zimbabwe, 2Ministry of Health and Child Welfare -PMTCT Unit, Harare, Zimbabwe

Abstract number:- WEAX0203

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Background – Zimbabwe HIV context

• Popn - 12 million• HIV prevalence:

– 24.6% to 13.7% ( 2009)

– ANC 16.1%• PMTCT since 1999• PMTCT in 95% of sites• National Goal-

Eliminate MTCT of HIV- WHO Option A

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Background:

• EGPAF supports the national PMTCT program

• By June 2010, over 818,000 pregnant women received PMTCT services at 724

• ARV prophylaxis for PMTCT-91% • However, only 7% of all HIV (+ve ) women

received ART due to:– Limited access to CD4 testing– Vertical service delivery with weak linkages– Centralised ART program – limited expansion

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Background: ART in MCH integration

• Provision of ART in ANC & PNC• In 2009, MOHCW instituted a sub committee• Learning sites selected -20• With support from EGPAF

– Learning visit to Swaziland– Development of SOPs– Stakeholder sensitisation meeting- Draft plans – Trainings on OI/ART management – Placement of nurses at centres of excellence – Resources mobilisation for POC CD4 machines

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Method:- Progress Review

• Six months after the planning process a progress review was conducted at the learning sites to:– Assess site readiness & progress – Identify challenges and lessons learnt– Make recommendations for future integration

of ART in MCH • A checklist used to collect data (SOPs)• Progress assessed using adapted

implementation model –T.S Stevens

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Results:- Readiness towards integration

A total of 19/20 learning sites visited– Coordinator appointed- 12/19– Supply chain management ARVs- 18/19– OI/ART trained staff (N=245)

• Adult (43%), Pediatric 21%

– Nurses initiating ART- 8/19– Availability of CD4 machines-16/19 – All sites PMTCT M& E tools in place– Only 2 sites using ART M&E tool (SOPs)

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Results:- Phase of ART in MCH implementation

• Pre planning (4/19)– Facilities referring to

co-located/offsite– Integration not started– Management still

needed to buy in

• Planning (5/19)– Local consultations,

planning, logistics and client flow system discussions

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Phased approach implementation model adapted from Thomas P. Stevens

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• Implementation phase (8/19)– Women being initiated on ART

• Maintenance phase (2/19)– Implementation on going, M&E and sharing experiences

• Of these 10 sites providing ART for pregnant women within the MCH (ANC& PNC)– Five sites had started < 3 months prior review– Rest >3 months prior

Results:- Stage of ART in MCH implementation

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Challenges

• Lack of policy allowing nurses to prescribe ART• Frequent breakdown and unavailability of CD4

reagents• Inadequate number of OI/ART trained nurses• Increased workload• Shortage of space for the integration• Unavailability secure storage for ARVs• Lack of job aides to facilitate implementation• Lack of local level support at some facilities

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RESULTS: Lessons Learnt

• Integrating ART in MCH is feasible in Zimbabwe

• Nurses can initiate women on ART• Cornerstones for successful integration of ART

into MCH– Sensitizations of stakeholders, clear SOPs – Access to CD4 testing

• On-the-job training, mentorship, support and supervision is important

• Lack of management support affect progress

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Recommendations

• Advocacy for a task shifting policy• Mobilize resources for POC CD4 machines• Advocacy at local level buy in• Intensified site support & mentorship required• All ART in MCH sites to use ART program M/E

tools• Develop national plans to roll out nurse led ART in

MCH integration– Track the changes in proportions of women initiated on

ART – Assess quality of service of the nurse led program

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Acknowledgements

• Zimbabwe MOHCW• ART in MCH Subcommittee

– Family AIDS initiative partners- OPHID Trust, KAPNECK Trust, ZAPP-UZ

– Zvitambo,, CHAI,UNICEF• Elizabeth Glaser Pediatric AIDS Foundation• USAID & DFID• Healthcare workers and women at the 19

learning sites

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Thank you