Equity focused bottleneck analysis anddevelopment of costed evidence informednational plan for MTCT elimination:United Republic of Tanzania
Dr. Deborah M. Kajoka
December 7th, 2011
OWN, SCALE-UP & SUSTAIN
The 16th International Conference on AIDS & STIs in Africa
4 to 8 December 2011, Addis Ababa
www.icasa2011addis.org
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CONTENT OUTLINE
•Overview of the PMTCT Program
•PMTCT service uptake
•Equity Bottleneck analysis
•Lessons learnt
•Future plans
Overview of Mother-child transmissionof HIV
•Population:44,502,629 (NBS 2010)
•1,8m deliveries per year
•50% health facility deliveries
•HIV prevalence rate of 6.9%(pregnant women)
•Contraceptive prevalence rate: 27%
•Fertility rate of 5.4 births per woman 25% areun-intended
•Unmet contraceptive need:25%
PMTCT Performance Overview
•Started in 2000 as pilotproject
•2004 started scale up.
•4,301 sites byDecember 2010 (93% ofRCH sites)1
•PMTCT integrated intoRCH services,
1: PMTCT report Dec 2010, 2: 2010 DHS
PMTCT service uptake
•Pregnant women attendingANC 92%
•Testing uptake amongestimated pregnant women85%
•70% HIV+ pregnant womenutilize any form of ARVprophylaxis.
•57% of HIV exposed babiesreceived prophylaxis
Equity Focused Bottleneck analysis
•MoHSW with the support from UNICEF, engagedconsultants to conduct bottleneck analysis (October– December 2011)
•Bottleneck analysis tool developed globally used toconduct the analysis and 7 tracer interventions wereselected for the four prongs
•Tracer Interventions – Primary prevention of HIV, FP,Quality ANC, PMTCT, Exclusive BF, EID, C&T for HIVpregnant Mothers
Equity Focused Bottleneck analysis
•Broad areas for analysis included Supplydeterminants - Commodities, Human Resource,Geographical Access and Geographical facilityCoverage
•Demand determinants- include Service Utilization,Continuity and Quality of Services
Equity Focused Bottleneck analysis
•Preliminary results were shared with key stakeholders.
•Some key Findings included
–Regional disparities for absolute unmet needs (ANC, HIVtesting, CD4, ARVs, and EID) and the 7 tracer interventions
–Late ANC booking and continuity visit 4
–Low FP utilization, continuity and quality, Weak follow upsystem for HIV infected women within facility and incommunity
–Lack of system for identification HIV exposed babies inImmunization and under-five clinics
–Inadequate CD4 testing capacity at all levels
–Inadequate skilled staff
–Shortage of commodities
Unmet needs for HIV testing
Unmet needs for CD4
Unmet needs for ARVs
Tracer :Provision of Quality ANC
Prevention of unintended Pregnancies amongwomen of Reproductive Age
Development of eMTCT Plan
•Based on Bottle Neck analysis information
–Review of PMTCT scale up plan is in progress
–Revised eMTCT targets (Spectrum)
–eMTCT plan being developed
–Costing going on concurrently
–Plan to be finalised by end 2011 and to beLaunched early 2012
Strategic Interventions
•Implement new initiatives – Use of mobile phones for thefollow ups of clients
•Integrate with EPI programme (outreach)
•Institute point of care machines to lower levels for CD4
•Scale up Integrated Logistic Management System (ILMS)
•Expand pre service training of health workers to respondto HR shortage
•Expansion of psychosocial support services to pregnantwomen, their partners and families through NGOs
•Deploy CHWs for MNCH including PMTCT services
What is needed to reach the targets 2015? – model based
Key Model Inputs & Outputs
2010
2011
2012
2013
2014
2015
Tanzania NationalData, 2010
Tanzania NationalData, 2011
Tanzania NationalProjection, 2012
Tanzania NationalProjection, 2013
Tanzania NationalProjection, 2014
Tanzania NationalProjection, 2015
Perinatal Data Inputs
ANC uptake
96%
97%
98%
98%
98%
98%
HIV Testinguptake/known HIV+ status
86%
90%
94%
95%
98%
99%
HAART
11.0%
15%
20%
35%
40%
40%
WHO 2006regimens
39%
55%
30%
0%
0%
0%
Option A/Option B1
0%
0%
40%
50%
53%
58%
Sd-NVP
20%
10%
0%
0%
0%
0%
Women on noARVs
30%
20%
10%
15%
7%
2%
PerinatalMTCTOutputs
6 week MTCT(among all HIV+women inTanzania)
10.62%
7.88%
4.30%
4.48%
2.80%
1.80%
Post-partum
Data Inputs
% of infantsbreastfeeding2
93%
Average durationbreastfeeding(months)
12
MTCT Outputs
BreastfeedingMTCT rates
15.10%
14.50%
7.95%
4.25%
3.07%
2.34%
CummulativeMTCT rates(among all HIV+women inTanzania)
25.71%
22.37%
12.25%
8.73%
5.87%
4.14%
Lessons learnt
•Country Leadership, ownership andinvolvement of all players on the ground iskey to elimination agenda
•New opportunity to re-look at theprogramme to further accelerate theimplementation of the eMTCT – what dowe do differently
Lessons learnt
•Understanding key bottlenecks helps inprogramme focusing. Good Bottle Neckanalysis relies on availability of adequate dataat all levels
•Strong linkages with other RCHs/HIV andcommunity interventions is key
•Clear guidance and TA from IATT has enabledthe country to systematically develop theeMTCT costed plan
Future plans
•Finalize, launch and accelerate implementationof costed National eMTCT plan – PEPFAR Fundsan opportunity
•Support regional and district eMTCT plans basedon National plan
•Formation of accountability structures for eMTCTat National, Regional and district levels (Politicalcommitment)
•Conduct an Impact Assessment
Acknowledgement
•MoHSW
•UNICEF – Country and Regional Office
•USG – PEPFAR, GF, UNITAID, CHAI
•National Task Team and Sub teams for eMTCT
•Inter Agency Task Team (IATT)
•PMTCT secretariat
The 16th International Conference on AIDS & STIs in Africa, Addis Ababa
OWN, SCALE-UP & SUSTAIN
ASANTE SANA!
Thank You!