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