GETTING READY FOR DUAL EMTCT VALIDATION IN THE AMERICAS Adele Schwartz Benzaken

OUTLINE 1.BACKGROUND OF EMTCT IN THE AMERICAS 2. DEVELOPMENT OF REGIONAL VALIDATION METHODOLOGY AND STRUCTURE 3. CONCLUSIONS

EMTCT HISTORY IN THE AMERICAS 1994: The 24th Pan American Sanitary Conference called for the elimination of congenital syphilis as a public health problem. 1995: Development of the Plan of Action for elimination of congenital syphilis. 2005: Regional HIV/STI Strategy for the Health Sector with ambitious HIV/STI PMTCT goals, including congenital syphilis elimination. 2008: PAHO and UNICEF host Caribbean side event at IAC to explore elimination of MTCT of HIV : Sub-regional technical consultations & development of dual EMTCT implementation strategy November 2009: official launch of Regional Dual EMTCT Initiative September 2010: PAHO Member States adopt the regional EMTCT Strategy and Plan of Action by Resolution

REGIONAL DUAL EMTCT STRATEGY Pillars: Strengthening and integration of HIV/STI, SRH, MCH, newborn care and family and community health services Strengthening the capacity of MCH, newborn, child health and other services for early detection, care and treatment of HIV and syphilis in pregnant women, their children, and their partners Intensify surveillance of HIV and syphilis in MCH services Regional implementation: Development of tools, including a conceptual document, Regional Monitoring Strategy, Costing tool, Field Guide Direct support to countries Regional monitoring and reports

Pregnant women tested for syphilis at antenatal care in Latin America and the Caribbean ( )

Reported congenital syphilis rates in selected countries in the Americas,

ARV coverage among pregnant women for prevention of mother to child transmission of HIV New HIV infections in children in Latin America and the Caribbean

Pregnant women tested for HIV in Latin America and the Caribbean,

DEVELOPMENT OF THE REGIONAL EMTCT VALIDATION STRUCTURE Considering that several countries appeared to be close to achieving the EMTCT targets, PAHO, in collaboration with UNICEF and other partners, initiated development of a validation methodology in 2011: – Drafting of a methodology – Pilot implementation in two countries (St. Lucia & Chile) – Merging of efforts with WHO HQ in 2012 – Establishment of regional mechanisms in

VALIDATION METHODOLOGY 1. Verification of achievement of the elimination targets: – Verification of the quality of the reported data – Assessment of the underlying data collection and reporting systems 2. Verification of the existence of an adequate laboratory network that: – provides the services needed to achieve, maintain and measure the elimination targets – Generates reliable results 3. Verification of the existence of an adequate network of services that: – Provides all needed services, accessible to all in need – Provides quality services

Full assessments, which included interviews and site visits with: – All national programs (MCH, HIV, STI, etc) – Sample of first, second and tertiary level service delivery sites in the capital and districts with the highest burdens of disease (HIV or syphilis or both) – Feedback and discussion sessions with stakeholders (Minister of Health, managers and service delivery) – Final report produced by the external team with recommendations and final conclusions Country pilots

PILOT IMPLEMENTATION In two countries (St. Lucia & Chile) External team of experts (6-10) in the areas of MCH, HIV, STI, laboratory, epidemiology, health systems. One week of field work: 1) interviews with policy makers, program managers, service providers, civil society, clients;2) field visits to service delivery sites: 3) verification and recalculation of data on local and national level.

LESSONS LEARNED Pilots indicated validity of the methodology to understand the national program, verify the data, and identify (potential) issues and challenges. Estimated cost of country validation: $ 15,000- $ 20,000 (depending on size). Considering the required investment and formal commitment for dual EMTCT, only country requests for validation of EMTCT of both HIV and syphilis will be considered.

PAHO emphasizes reporting on elimination impact and coverage targets based on “real” data. Some countries might have gaps, in particular in coverage data due to various reasons, including significant private sector. Acceptable modalities to assess these data gaps: – Special studies – Sufficient private sector representation in assessment samples? – Others Data gaps

The Regional Validation Committee Established as a high level Committee convened by the PAHO Director (May 2014). Membership: regional experts: independent experts, representatives from UN partners, representatives from regional technical organizations Main role is to provide regional oversight of the validation process, coordinate country evaluation exercises, and determine whether a candidate country can be recommended for validation.

CURRENT STATUS Ongoing refining of the methodology and tools, including development of approaches for small population sizes. Ongoing application of the tools for program assessments upon request of countries in 2013 and Preparations for first round of formal country validations (Cuba, Bahamas and others)

CONCLUSIONS Region of the Americas has longstanding and formal commitments for elimination of congenital syphilis and vertical transmission of HIV. Dual EMTCT is imminent for some countries in the region. Validation requires establishment of formal and credible regional structures and processes aligned with global.

ACKNOWLEDGEMENTS – Dr. Massimo Ghidinelli (PAHO/WDC) – Dr. Sonja Caffe (PAHO/WDC) – HAYASHI, Chika (WHO/HIV Department) – Regional Committee for Validation of Elimination of Mother-to-Child Transmission of HIV and Congenital Syphilis (RVC)Members