retention and adherence in pmtct programs: namibia experience
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Retention and Adherence in PMTCT Programs: Namibia Experience
Karen Toivo Chief Health Program Administrator
Workshop on ART in Pregnancy, Breastfeeding, and Beyond Johannesburg, South Africa. June 18-20, 2012
Demographic Profiling of HIV burden in pregnancy
Background• Namibia launched the PMTCT programme in 2002 and
has scaled up to all regions• Access to services has remained good (95% ANC, 81%
facility deliveries; 93% DPT1 coverage and over 95% HIV testing: quality gaps still exist in reaching universal level coverage and targets
• High facility utilization but missed opportunities; While over 90% of exposed children receive ARV prophylaxis, less than 10% receive cotrimoxazole due to non reporting
• Namibia is a breastfeeding population, still exclusive breastfeeding for 6 months is less than 10%
• Current HIV prevalence among pregnant women is 18.8% and puts Namibia on 5 highest globally
Development process for the Follow Up Mechanism for HIV Exposed Infants 2008 - 2011
Development of Referral and follow up tools
Reviews and
discussions on
expansion or roll out
Improved access
Modeling in 4 high volume districts
Op Research concepts and design
Sampling and
identification of regions
Orientation and Training
Preparatory phase
Pre-testing and refining the tools and approaches
Improved Quality
2
Assets1. A local Consultant reviewed the available referral and follow up systems in the country and presented to MOHSS 2. The MOHSS with support from UNICEF adapted and pre-tested the recommended tool and applied in 3 high volume districts3. Implementation of the innovative approaches and leveraging of technical and funding support from other partners (GFATM,
USG/PEPFAR)4. Roll out discussions as a platform for elimination
Implementation, systems strengthening + partnership, joint monitoring, building HR capacity of the 4 districts
Increased linkages
4
1 3
Review of approaches and roll out discussions; platforms for elimination
Why children drop out of care
• High mobility of clients (within and between regions)
• Inefficient referral and tracking systems
• Inadequate access to health facilities (Long distance, Transport costs, Cultural acceptability, Attitude of facility staff
• Poor patient recording system • Long waiting times and queues at
health care institutions• Limited numbers of trained
community counselors• Children left with
grandparents/guardians
Pilot innovative tools and elements• A facility based child monitoring and
referral tool specific for children exposed to HIV appointment schedules, services required during each visit and outcomes at each stage
• Mobile phones and air time provided to the health facilities, to SMS and remind/notify clients
• Child Health Passport revised to capture relevant data from the mother’s passport
• Follow-up of defaulting clients by community health promoters
• Intensified support for supportive supervision of districts and community level interventions
Reducing drop outs from PMTCT Continuum, Oshana Region, Namibia
88%
Eliminating Paediatric transmissions, Oshana
1028
958
758
635
46 220
200
400
600
800
1000
1200
FY 2010 FY 2011
Total infants born exposed
Tested at 6 wk
Positive
Transmission risk 6%
Transmission risk 3.5%
74%
66%
Linking exposed/infected infants to treatment, Oshana region, Namibia
Use of Follow Up Channels
Phone calls and sms were critical channels for notification and reminder contacts. A follow-up ratio of 1:3 ANC attendees was observed from total 1672 contacts made during FY2010 for 5240 ANC1 attendees (1601 during FY 2011 for 5312 ANC 1 attendees).
Personal messages and home visits by community partner (TCE Volunteers) were crucial for follow up of defaulters not traceable via phone channels
Key Challenges• Defaulter clients
– due to migration from one site to another – Inaccurate telephone contacts of clients – Caretakers/grandmothers are not informed of the HIV exposed status of the
babies– mothers are not coming for follow-up especialy at 14 days
• Some children who defaulted are only captured at immunization clinic or growth monitoring programme
• Slow rolling out of the programme (post-natal infant follow-up) to other regions including DNA/PCR test.
• limited number of community partners for community support and tracking of defaulters for HIV-Exposed babies
• Data quality and management issues
Key Considerations for Replication
• Adequate technical and funding support • Capacity development of program managers and
care providers at facility level including community care providers
• Decentralized support for planning, monitoring and supervision
• Continued engagement with community partners and structures
• Engagement of the private sector
Thank you!Tangi Unene
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