Management of PMTCT Services Module 10 Management of PMTCT Services

Malawi PMTCT Training Package Module Objectives Explain the goals and objectives of PMTCT services. Describe the five steps of the programme cycle. Describe implementation of PMTCT services. Correctly define monitoring. List PMTCT service indicators. Utilize tools for monitoring PMTCT services. Malawi PMTCT Training Package

Module Objectives (continued) After completing the Practical Attachment, the participant will be able to: Provide core PMTCT services. Provide group education in PMTCT. Provide post-test counselling. Provide infant feeding counselling and support. Perform whole blood rapid test for HIV Provide counselling on ARV prophylaxis and therapy. Assess the clinical stage of a client with HIV. Provide referrals for HIV-related prevention, care, treatment and support services for HIV infected and affected women, their partners and their children. Record and report PMTCT information using standard MOH tools. Apply Universal Infection Prevention measures in the health care setting. Malawi PMTCT Training Package

Introduction to Management of PMTCT Services Unit 1: Introduction to Management of PMTCT Services Malawi PMTCT Training Package

Malawi PMTCT Training Package Unit 1 Objectives Explain the goals and objectives of PMTCT services. Describe the five steps of the programme cycle. Describe implementation of PMTCT services. Malawi PMTCT Training Package

PMTCT Services in Malawi Initiated in 2001, piloted in Embangweni Mission Hospital, Thyolo and Chiradzulu District Hospitals. Officially launched by MOH in 2003 Goals of the PMTCT programme are to: Prevent paediatric HIV infections Reduce HIV related morbidity and mortality among children, women and their families Malawi PMTCT Training Package

Objectives of the national PMTCT Programme To provide HIV pre-test counselling and HIV testing services to at least 5100% of the women attending ANC clinics. Increase the proportion of pregnant women undergoing antenatal HIV testing and receiving their status to at least 80% of those attending ANC. Increase the proportion of HIV positive pregnant women receiving a complete course of ARV prophylaxis to at least 80%, Increase the proportion of HIV-positive eligible women initiating antiretroviral treatment (including ART) or cotrimoxazole prophylaxis during pregnancy to at least 70% of the those HIV-positive women identified. Malawi PMTCT Training Package

Objectives of the national PMTCT Programme Increase by at least 20%, the proportion of mothers who practise exclusive breastfeeding for six months. Increase the proportion of HIV-positive mothers who practise early cessation at six months to at least 25% of those identified. Increase to at least 70% the proportion of HIV-exposed infants identified in PMTCT settings who begin cotrimoxazole prophylaxis at 6 weeks as per WHO guidelines. Support the enrolment and ART of at least 50% of eligible HIV infected children Malawi PMTCT Training Package

PMTCT Scale-Up Plans for 2006-2010 Based on a comprehensive approach Focuses on: Policy and strategy development Capacity building (human resources) Planning, monitoring and evaluation and research Procurement and Supply management Infrastructure development Partnership Malawi PMTCT Training Package

PMTCT as a Targeted Response Delivery of comprehensive PMTCT services, integrated into RH services, requires targeted response PMTCT Coordinator in HIV/AIDS Unit of MOH coordinates PMTCT service implementation National AIDS Commission (NAC) is responsible for overall coordination of HIV response in Malawi Malawi PMTCT Training Package

Malawi PMTCT Training Package Role of PMTCT Officer Coordinate the development of policy and guidelines Develop technical documents Coordinate planning, implementation and monitoring of PMTCT services Assist with IEC and social mobilization activities Mobilize resources for PMTCT Collaboration with development partners Malawi PMTCT Training Package

Malawi PMTCT Training Package Programme Cycle Process of assessing a situation, then designing, implementing, monitoring, and evaluating a public health programme in response to a need. Programme cycle can be compared to the process used when caring for a client. Assess client's health Design a client treatment plan Implement the treatment plan Monitor client's progress Evaluate success of the treatment plan Malawi PMTCT Training Package

Program Cycle (continued) Assessing First step is to analyse the problem by conducting a needs assessment Needs assessment identifies gaps in PMTCT implementation Malawi PMTCT Training Package

Program Cycle (continued) Planning Plan specific PMTCT site that will respond to needs identified in the assessment Identifying staffing issues—who and how many should be trained Examining logistical issues—physical space, client flow, equipment, and supplies Establishing programme guidelines Developing a budget to cover costs Outlining a programme management plan Setting goals and objectives to be achieved within a specified period Malawi PMTCT Training Package

Program Cycle (continued) Implementing Third step is implementing PMTCT services according to plan Involves using standard procedures for service provision, training staff, and integrating programme into existing healthcare services Pilot phase that introduces new programme at healthcare facility helps identify problems before programme is fully implemented Malawi PMTCT Training Package

Program Cycle (continued) Monitoring Monitoring involves asking questions about services offered and service delivery process Includes gathering data on monthly basis to determine if services are meeting objectives HMIS ensures coordinated data gathering on pre-determined health indicators Malawi PMTCT Training Package

Program Cycle (continued) Evaluating Final step is to evaluate the PMTCT services Compare outcomes over time to goals and objectives Basis for evaluation is often data collected as part of monitoring PMTCT services. Determining why something did not work provides clues for resolving problems and improving PMTCT services. Malawi PMTCT Training Package

PMTCT Service Implementation PMTCT core team members: Doctors Clinical officers Medical assistants Nurses and nurse-midwives Nutritionists Pharmacists and Pharmacy technicians Laboratory personnel Health Surveillance Assistants Assistant statisticians (HMIS) Social workers Administrative and support staff Malawi PMTCT Training Package

PMTCT Service Implementation (continued) PMTCT-related service delivery takes place at: Central hospitals District hospitals and CHAM hospitals Rural and community hospitals Health centres (both government and CHAM) Private hospitals, clinics, nongovernmental organizations (NGOs) with maternity services Malawi PMTCT Training Package

PMTCT Service Implementation (continued) Logistical issues may pose challenges. Urban settings differ from rural settings Availability of transportation impacts uptake of services Development of PMTCT Implementation Work Plan facilitates provision of effective and quality services Malawi PMTCT Training Package

Monitoring and Evaluation of PMTCT services Unit 2 Monitoring and Evaluation of PMTCT services Malawi PMTCT Training Package

Malawi PMTCT Training Package Unit 2 Objectives Correctly define monitoring. List PMTCT service indicators. Utilize tools for monitoring PMTCT services. Malawi PMTCT Training Package

Small Group Discussion Exercise 10.1 Data Management: Small Group Discussion Malawi PMTCT Training Package

Malawi PMTCT Training Package Monitoring Definition Monitoring is routine tracking of key parts of a programme using recordkeeping and regular reporting. Malawi PMTCT Training Package

Malawi PMTCT Training Package Programme Monitoring Input: Resources that are expected to be used in the programme (financial, personnel, materials) Process: Ensure that programme activities are completed as planned and with the correct resources Output: Ensure targets are reached. Malawi PMTCT Training Package

Malawi PMTCT Training Package Purpose of Monitoring Monitoring of inputs provides information about: Staff availability and roles Utilization of resources Supply of resources Malawi PMTCT Training Package

Purpose of Monitoring (continued) Monitoring of processes provides information about: Training of staff Quantification, ordering, storage and distribution of drugs and supplies Clinic processes, e.g., HIV testing is routinely offered by nurse Collaboration and communication, e.g., referral mechanism established between ANC clinic and the L&D ward Malawi PMTCT Training Package

Purpose of Monitoring (continued) Monitoring of outputs provides information about: The PMTCT services received by women, children and their families Success in meeting training targets Success in meeting service targets (e.g. percentage of women tested for HIV, percentage of partners tested for HIV, percentage of women who took ARVs, etc) Malawi PMTCT Training Package

Malawi PMTCT Training Package Methods of Monitoring Monitoring requires systematic collection, analysis, and use of information. Observe provider client interaction and information recording Check supplies against inventories Examine records Discuss progress and problems with staff and community Collect data routinely Malawi PMTCT Training Package

Monitoring & Evaluation in Malawi Health Facility Level HCWs and other stakeholders routinely collect and analyse PMTCT information used for clinical and administrative management. This information helps to clarify: Whether the PMTCT service is meeting the targets Progress being made in implementing PMTCT services Linkages and referral Quality of programme implementation Malawi PMTCT Training Package

Monitoring & Evaluation in Malawi (continued) District Level Regular analysis and synthesis of the aggregate data from each health facility Collection and analysis of additional data, Supportive supervision Procurement and supply management and monitoring consumption Malawi PMTCT Training Package

Monitoring & Evaluation in Malawi (continued) National Level Reviewing quarterly aggregate data from districts providing PMTCT services Collection and analysis of additional data from special studies on service utilization and quality of PMTCT service provision Assessment of the programme’s impact on final outcomes (infant HIV transmission rates) Operational research as part of monitoring and evaluation Malawi PMTCT Training Package

Malawi PMTCT Training Package Data Collection HMIS tracks a number of national health indicators at all health facilities in Malawi. PMTCT sites are required to use the following tools for data management: Health Passports and Registers Standard Monthly Reporting Forms Malawi PMTCT Training Package

Tips for Good Data Collection Understand the data to be collected. Record the data every time. Record all the data. Record the data in the same way every time. Malawi PMTCT Training Package

PMTCT Data Collection & Reporting Procedure MOH, Health Management Information Unit, HMIU District Health Officer, DHO NAC and Partners Zonal Officer Health Facilities and NGOs Malawi PMTCT Training Package

PMTCT Service Indicators PMTCT indicators are measures that determine to what extent PMTCT interventions are achieving programme objectives. Indicators measure efforts (input), effectiveness (process) and change (output). Indicators measure the availability and quality of services and monitor progress towards PMTCT service goals. Malawi PMTCT Training Package

Malawi PMTCT Training Package Key PMTCT Indicators Definition Indicators Accessibility of services Number of sites providing PMTCT services Trained health personnel Number of health personnel trained in PMTCT Availability of HIV test kits % of health facilities providing PMTCT with no stock outs of HIV test kits for a period of one week HIV testing % and number of pregnant women tested for HIV Malawi PMTCT Training Package

Key PMTCT Indicators (continued) Definition Indicators Partners tested for HIV % and number of pregnant women whose partners were tested for HIV Infant feeding counselling % and number of pregnant women who choose exclusive breastfeeding for 6 months % and number of HIV exposed infants who are exclusively breastfed for 6 months HIV prevalence among pregnant women % and number of pregnant women who tested HIV+ Availability of ARV drugs in MCH clinic % and number of health facilities providing PMTCT services with no stock outs of ARV for PMTCT for a period of one week Malawi PMTCT Training Package

Key PMTCT Indicators (continued) Definition Indicators ARV prophylaxis % and number of HIV+ pregnant women receiving take home NVP Combined AZT-SD NVP % and number HIV+ pregnant women on AZT-SD NVP prophylaxis ARV prophylaxis for infants % and number of newly born infants whose mothers are HIV-infected who received ARV prophylaxis ARV prophylaxis during labour % and number of HIV-infected women receiving ARV prophylaxis during labour Malawi PMTCT Training Package

Key PMTCT Indicators (continued) Definition Indicators CPT for HIV+ pregnant women % and number of HIV-infected pregnant women on CPT CPT for exposed infants % and number of exposed infants on CPT FP Use % of HIV+ women using FP services Confirmed HIV status at 6 weeks (PCR) Malawi PMTCT Training Package

Key PMTCT Indicators (continued) Definition Indicators Confirmed HIV status at 18 months % and number of infants born to HIV-positive mothers who are HIV-infected at 18 months HIV status during labour and postnatal % and number of pregnant women with unknown HIV status who were tested during labour postnataly Referral to ART and support % and number of HIV+ women who were referred to ART and support services Pregnant women started on ART % and number of pregnant women started on ART Malawi PMTCT Training Package

Malawi PMTCT Training Package Exercise 10.2 Data Collection: Group Discussion Malawi PMTCT Training Package

Exercise 10.2 Case Study, Part 1 Nankhoma is a 26-year-old woman who comes into ANC for her first visit. She is 16 weeks pregnant with her first child and tests HIV-positive. She tells the nurse that her partner has moved away and she has no contact with him. The nurse provides her with information about HIV, HIV testing and the PMTCT service; Nankhoma decides to be tested for HIV. She tests HIV-positive and during the post-test counselling session agrees to take nevirapine as ARV prophylaxis. Malawi PMTCT Training Package

Exercise 10.2 Case Study, Part 2 Nankhoma comes for all the ANC visits and receives prophylaxis to take at the onset of labour. At 38 weeks, she presents to the labour and delivery ward in active labour with the baby crowning. She tells the nurse she forgot to take the NVP tablet. Within two hours, she delivers a 3-kg male infant. Nankhoma has chosen to exclusively breastfeed and the baby is placed to the breast. The baby receives the recommended NVP prophylaxis prior to discharge. Malawi PMTCT Training Package

Reviewing the PMTCT Indicator Report: Group Discussion Exercise 10.3 Reviewing the PMTCT Indicator Report: Group Discussion Malawi PMTCT Training Package

Malawi PMTCT Training Package Module 10: Key Points The goals of the national PMTCT programme are to: prevent paediatric HIV infections; and reduce HIV related morbidity and mortality among children, women and their families. The National AIDS Commission (NAC) is responsible for the overall coordination of the HIV response in Malawi. The HIV/AIDS Unit of the Ministry of Health is responsible for coordinating the implementation of PMTCT services nationally in collaboration with districts and implementing partners Malawi PMTCT Training Package

Module 10: Key Points (continued) Programme cycle involves assessing, planning, implementing, monitoring, and evaluating PMTCT services. Monitoring is routine tracking of key parts of a programme using record keeping and regular reporting. Monitoring requires the routine collection and recording of data to track progress on indicators. PMTCT service indicators measure to what extent PMTCT interventions are achieving programme objectives. Malawi PMTCT Training Package

Management of PMTCT Services UNIT 3 Practical Attachment Module 10 Management of PMTCT Services UNIT 3 Practical Attachment

Practical Attachment Objectives Provide core PMTCT services. Provide group education in PMTCT. Provide post-test counselling. Provide infant feeding counselling and support. Perform whole blood rapid test for HIV Provide counselling on ARV prophylaxis and therapy. Malawi PMTCT Training Package

Practical Attachment Objectives Assess the clinical stage of a client with HIV. Provide referrals for HIV-related prevention, care, treatment and support services for HIV infected and affected women, their partners and their children. Record and report PMTCT information using standard MOH tools. Apply Universal Infection Prevention measures in the health care setting. Malawi PMTCT Training Package

Practical Attachment Goal To reinforce classroom learning by providing participants with practical experience in an ANC setting or another clinical setting that provides PMTCT services. Malawi PMTCT Training Package

Practical Attachment Schedule Prepare participants: 1/2 hour each morning (or the previous evening) Conduct Practical Attachment: 4-6 hours each day Debrief on Practical Attachment: 2 ½ hours each afternoon (typically 1:30-4:00) Lunch and breaks: 1½ hours each day Return-trip transport: 1 hour each day, more or less depending on location of clinical Malawi PMTCT Training Package

Maintaining the relationship with host facility Stay on time Respect the confidentiality and privacy of the clients Express thanks when you leave No surprises: Try not to make any last-minute requests Malawi PMTCT Training Package

Practical Attachment Competencies Areas of Assessment 1. Group education counselling  2. Data recording  3. Testing using WBRT Clinical staging HIV-positive pregnant women 4. Individual post-test counselling Malawi PMTCT Training Package

Practical Attachment Competencies Areas of Assessment 5. Clinical staging 6. Refer for CD4 cell count 7. Initiate ARV prophylaxis or refer to ART 8. Initiation of CPT prophylaxis 9. Referral of pregnant women and mothers to appropriate services Malawi PMTCT Training Package

Practical Attachment Interview Guide Was developed as a resource to support participant learning during the PMTCT Practical Attachment. Review the question in advance and modified as appropriate. Feel free to ask additional questions or to drop questions that no longer see appropriate. Listen closely to all the questions and answers to prevent repetitive questioning. Malawi PMTCT Training Package