Planning for Transition from Option B to B+: Rwanda Experience

MUGWANEZA Placidie, Coordinator of HIV prevention Unit/RBC/MOH

ART in pregnancy, breastfeeding and beyond, Johannesburg, June 18-20, 2012

OUTLINE Rwanda context

History of PMTCT guideline and regimen changes

in Rwanda

Roadmap and timelinefrom option B to option B+

Current Program: areas for Improvement

Experience with Site supervision

Next steps

RWANDA CONTEXTEast African country of 26,338 km2 Population: ~10 m. inhabitantsAdministrative framework

–4 provinces and Kigali City Council–30 districts–415 sectors/cells/villages

Generalized HIV epidemic–3% prevalence in general population–3,7% prevalence among women

Rapid scale up of HIV services –456 PMTCT sites (82%)–372 ART sites (70%)

RWANDA

PMTCT REGIMENS IN RWANDA

Period PMTCT Regimen Eligibility criteria for ART for life

2002 - 2005 NVP ≤ 200 CD4

2005-2010 AZT+NVP ≤ 350 CD4

2010 Option B for pregnant women with CD4>500(HAART until 18 months postpartum)

≤ 500 CD4 (while nonpregnant adults eligible at CD4<350)

April 2012 Option B+ All HIV + pregnant women

2. Recommendation from scientific workshop: shift from option B to B+

TRANSITION FROM OPTION B TO B+

May 2011

September 2011

March- April 2012

7- Tools revision (adherence register, indicators, Q&A and BCC)

3. Revision and approval of the

guidelines

February March 2012

5. Training of Health providers, launching of B+

Ongoing

1- Launch of the EMTCT National campaign

BUILDING ON EXISTING HEALTH SYSTEMS

Integrated service delivery model

− High coverage of health facilities providing both PMTCT and ART

− Integrated HIV training ( ART & PMTCT)

− Coordinated procurement and distribution system & ARV quantification

Strong coordination and service provision structures already in place − National ↔ district ; facility ↔ community; ART ↔ PMTCT

Task shifting already in place Strong political commitment

HIGH COVERAGE OF INTEGRATED HIV SERVICES

Source: RBC;

Increasing Proportion of HIV-infected Pregnant Women Receiving HAART during

Pregnancy

Source: Trac Net database, RBC/IHDPC

ARV REGIMENS FOR PMTCT

Option B (adopted November

2010):

‒ Women with CD4 < 350: TDF/3TC/NVP

‒ Women with CD4 > 350: TDF/3TC/EFV

Option B+ (Adopted April 2012)

‒ All women : TDF/3TC/EFV

Infant: Daily NVP up 6 weeks

ONGOING AREAS FOR IMPROVEMENT

ANC attendance

‒ Only 38% attend ANC before the 4th month of pregnancy

Need for ongoing mentorship for nurses at PMTCT sites

Retention and ART Adherence for pregnant and lactating women

ARV quantification and forecasting at district level

Rapid turnaround of EID results to sites for early treatment

Follow-up of ART patients at PMTCT standalone sites

– Linkages to treatment for male partner and children

– Follow-up of mother after the breastfeeding period

Supporting Program Implementation and Quality through Site Supervision:

Example of Track 1.0 Transition Planning

‒ Identify and notify sites to be supervised‒ Establish a schedule ‒ Define the resource needed (e.g HR,

transport… ‒ Provide tools and train supervisors

Implementation ‒ Use standard tool‒ Identify strength and weakness‒ Provide feedback

Documentation

May Jun

eJuly

Aug.Sept

Oct

.Nov.

Dec.Jan.

Feb. March

April MayJune July Aug.

Sept.

2010 2011

Cohort 1 Transition18 Sites

Cohort 2 Transition6 Sites

Cohort 3 Transition46 Sites

C1 Baseline C1 6- Month Follow-Up C1 12-Month Follow-Up

C2 Baseline C2 6-Month Follow-Up

C3 Baseline C3 6-Month Follow-Up

TIMELINE FOR TRACK 1.0 SITE MONITORING

SITE VISITS & DATA COLLECTION

Teams visit all transitioned sites at baseline and every 6 months‒ November 2009-December 2010: CDC-led with

MOH/partner participation‒ January 2011-Present: MOH led with CDC participation

Management Capacity‒ Interview health center director, accountant, data

manager, ART and PMTCT nurses and lab technicians‒ Abstract data from quarterly PBF evaluations

Clinical Performance‒ Abstract clinical performance data from national HIV

monitoring system (TRACNet) and Track 1.0 reports

Mean HIV PMTCT Performance Results for Health Facilities at Baseline, 6 and 12 Months after

Transition

FEEDBACK: DISSEMINATION WORKSHOPS

Held at district hospitals for facilities

in their catchment after each round

Facilitated by MOH

Agenda:

– District-specific results

– Site specific results, small group discussion

– Action planning to address identified gaps

LESSONS LEARNED

Accompanying MOH on routine site visits

builds site- and central-level capacity

Decentralization of site visits could improve

MOH efficiency, follow-up of recommendations

Involvement of all relevant MOH departments

improves follow-up on recommendations

NEXT STEPS

Finalize and disseminate revised tools

Accelerate accreditation process for PMTCT standalone sites to offer ART

Evaluate retention and adherence for mother-infant pair

Reinforce the PMTCT M&E (e.g: Revision of PMTCT indicators, program evaluation)

Establish ARV pharmacovigilance system

Reinforce capacity of health providers through training, supervision and mentorship