National PMTCT and Pediatric HIV Care and Treatment Coordinator, MOHCC Towards EMTCT and Accelerating Access to Pediatric and Adolescent ART Focus on health system-community partnership coordination by local/ national government Dr Angela Mushavi National PMTCT and Pediatric HIV Care and Treatment Coordinator, MOHCC IAS 2016 18 July 2016 Durban

Outline of Presentation Background of Zimbabwe Community participation in the eMTCT strategy for Zimbabwe Village Health Care Workers in eMTCT Mbereko groups Mother support groups Padare’s male involvement strategy Case Care Workers Zvandiri Model

Zimbabwe Total population: 13mil (2012 Census) Adult HIV prevalence 14.7%* ANC HIV prevalence 16.1%) Total PLHIV 1.4 million Adults LHIV 1 300 000 Adult need for ART (2015): 1 136 730 Adults receiving ART: 817 397 Peds 0-14 years LHIV: 77 000 Peds on ART (2015): 61 064-80% ALHIV (10-19 years): 69 377 New HIV infections among children 4900 MTCT rate: 7% (Spectrum) Adult HIV prevalence has gone up-maybe due to the effect of ART on mortality-and increased survival of PLHIV New pediatric HIV infections are going down due to scale-up of PMTCT services Source: *Spectrum 2015 3

National Health Strategy (2016-2020) Reduce morbidity by at least 50% through the provision of accessible, affordable, acceptable and effective quality health services at community and health centre levels: Strengthen Community Systems Strengthen community participation Increase Community Based Workers Increase number of functional Health Centre Committees Establish health posts

The 7 Strategic Objectives of the eMTCT Plan Strengthen program leadership, management, coordination and supervision of sites Strengthen provision of quality PMTCT and Paediatric HIV treatment services integrated within the MNCH platform Strengthen human resource capacity Strengthen the supply chain management system for commodities

The 7 Strategic Objectives of the eMTCT Plan Strengthen laboratory capacity to support eMTCT Strengthen community involvement and participation Improve generation, dissemination and use of strategic information

Realigned Communication Strategy for EMTCT: 2015-2018

Maternal ART Coverages 2015

Among the GP countries, several have achieved or are close to achieving coverage that is close to elimination Rwanda is not shown, but ARV coverage is >95% and MTCT rate <2%

Plan to get to Elimination for HIV and syphilis “Pre-elimination” is an attempt to specifically recognize this progress in HIV PMTCT in high burden countries   ELIMINATION PRE-ELIMINATION HIV Syphilis IMPACT criteria MTCT < 2% OR < 5% in BF populations Case rate ≤ 50 per 100,000 live births Case rate ≤ 50 per 100,000 live births No case rate minimum PROCESS criteria ANC coverage ≥ 95% Testing coverage ≥ 95% ART coverage ≥95% Testing coverage ≥ 95% Treatment coverage >95% ANC ≥ 90% Testing in ANC ≥ 90% ART coverage ≥90% Plan to get to Elimination for HIV and syphilis

Tools applied in the assessment of validation Data verification and impact assessment Laboratory assessment Human rights, gender equality and community engagement Programs and services assessment Assessment of the scope, quality and sustainability of EMTCT-related programs and services Country report

The role of communities In Zimbabwe, 7% of women do not present for ANC 20% of women deliver at home and without skilled birth attendant Women come for with their babies for first immunization visits but go back without HIV exposed babies getting an HIV test Fewer children in school or OVC programs are not accessing testing Pregnant and lactating women on Option B+ are lost to follow up Male participation is low Disclosure 7% of women do not present for ANC-is it through lack of knowledge on importance of booking and delivering within health care settings? Culture and religion a barrier in some cases Poverty and disempowerment of women

Village Health Worker (VHW) program: an Opportunity in PMTCT implementation VHWs have become important in tackling HIV For PMTCT, VHWs encourage Early ANC booking and repeated ANC attendance HIV testing Facility deliveries Postnatal mother-baby pair follow-up Picture: Courtsey of Zvitambo

Mbereko groups Community peer to peer groups of pregnant and lactating mothers and caregivers Irrespective of HIV status 10- 15 members of the same village Led by the Village Health Worker (VHW) Meeting at least once a month on agreed days Income generation activities through ISAL scheme   Mbereko in Shona means a wrap that is used to hold a child on the mother’s back in the early years of life Mbereko Groups: A Model For Improving Access To Health Services For Mothers And Babies In The First 2 Years Of Life

Mother Support Groups What they do MSG in pictures HIV-positive mothers join groups soon after booking MSGs meet twice/month Groups are led by volunteer coordinators Health information is given by clinic nurses covering various topics

Community initiatives key to tackling low male participation in eMTCT An organization called Padare/Enkundleni/Men’s forum on gender, is leading an initiative to strengthen the capacity of traditional leaders (chiefs) to increase male participation in PMTCT Given an opportunity, men can be positively engaged to end vertical transmission In one such district where the chief is engaged, male participation in PMTCT has increased to 90% (with a national average of 23%)

Padare Works Through the Chiefs

Working with Case Care Workers and Department of Child Welfare DEMAND SIDE: Reaching the Community Community leadership engagement (chiefs, religious, political) Community structure engagement (Child Protection Committees, District AIDS Coordinator, Vulnerability Assessment Committees) Volunteers trained to mobilise and create awareness and educate (male mobilisers, mentor mothers) Volunteers trained to do referrals and case management for adherence & retention (Village Health Workers & CCWs)

Working with Case Care Workers and Department of Child Welfare Additional sources of support ISALs for caregiver ECD playgroups Parenting groups - ECD/PMTCT and parents of older children Adolescent support groups Home visits from CHWs for PSS, nutrition, and adherence advice

The Zvandiri Programme A model of differentiated care for children, adolescents and young people with HIV in Zimbabwe

Community Adolescent Treatment Supporters (CATS) HTS mobilisation Index case finding Linkage to HTS and follow up Identification and linkage to OI/ART services Community ART counselling, monitoring and support Support Groups Identification and referral for OIs, treatment failure, child protection, mental health, SRH Tracing loss to follow SMS Reminders Young mothers groups Vocational skills At the heart of Zvandiri are CATS – Community Adolescent Treatment Supporters - 18-24 yr old HIV positive young people who work in their own communities between the health facility and homes of children and young people with HIV. They support their peers and younger children with a package of services shown here (in the diagram) with the aim of improving linkage and retention in care as well as other outcomes including sexual and reproductive health and mental health. They work under the health facilities who have been trained by MoHCC and Africaid. They are being integrated as a critical component of the package of services provided by MoHCC for CAYPLHIV. They are promoting the active identification, referral, tracking and monitoring of CAYLPHIV through the HIV care cascade as they grow up in to adulthood. Monthly meetings with clinic staff, VHWs, social workers, CCWs and community nurses have been critical in ensuring a collaborative approach in managing CAYPLHIV between the facility and community. CATS, VHWs, CCWs and Community nurses are referring to one another and conducting joint visits. Linkage with Clinic, Village Health Workers, Social Workers, Case Care Workers, Community Nurses

Acknowledgements MOHCC HIV Program and Director Nursing Services UN Family Implementing Partners Civil Society Organisations EGPAF OPHID Padare World Education EPAZ-FACT Mutare Africaid Zvandiri

Thank you Tatenda! Siyabonga!