PMTCT in Humanitarian Settings: Lessons Learned and Recommendations ART patient files from a flooded clinic in Mozambique drying in the sun © MSF Alice Fay* Save the Children Sarah Karmin UNICEF Gabriel Munene UNHCR Heidi Becher Independent Consultant

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Background Problem  Burden of HIV high in many risk prone, emergency affected and fragile settings  Shortcomings in emergency preparedness  Gaps and barriers in addressing HIV and PMTCT in humanitarian settings (natural disasters, armed conflict /civil disturbance) Consequences  Women and infants lose access to ARVs for PMTCT  Initiation, continuation and scaling up of PMTCT programmes is affected

Objectives 1.Synthesize lessons learned and develop recommendations from PMTCT programmes implemented in humanitarian settings 2.Develop a “How to Guide” from lessons learned on ways to implement PMTCT programmes in humanitarian settings.

Methodology 1.Literature review – peer reviewed and grey literature  Search strategy and results  Search terms and time frame: all 4 prongs of PMTCT, reproductive health & humanitarian contexts between  Sources: Pubmed and Popline, agency websites and unpublished documents shared by agencies  Documents included  Related to PMTCT or ART in humanitarian settings 2. Key informant interviews  58 semi-structured telephone interviews  Humanitarian and development NGOs  UN agencies  Organisations of people living with HIV  Donor agencies

Focus on 3 levels Preparedness Service Delivery Individual level

Preparedness Preparedness and contingency planning mitigate the impact of a shock on PMTCT programmes  Develop a contingency plan  Analyse how regular programmes could be affected by an emergency  Prepare to minimise the risk of disruption of access to PMTCT treatment  Task shifting, task sharing, buffer stock Ex: pre- seasonal flooding, signs for increased risks of violence  Absence of contingency planning can lead to treatment interruptions with risk of treatment failure and ART resistance  CAR 2013/2014 complex emergency  Mozambique 2013 floods, Gaza province: 50% estimated ART interruption in Chokwe district

Service delivery Facility-based services  Pre-position buffer stocks; use NGO buffer stock  Redistribute drugs in case of localised shortage  Access ARVs for temporary health facilities from the national system  (Re)-open PMTCT/ARV providing services as soon as possible  Integrate ARV dispensing in camp health facilities Mobile and community services  Mobile outreach teams and mobile clinics for ARV dispensing  Home dispensing at pre-arranged meeting points  Dispensing ARV through other patients  Facilitate transport  Integrate patient education into community programming

Individual  Patient education  Physical tracing  Patient networks  House to house and community information campaign  Information at camp registration point  Radio, TV messages  Public messaging during mobile clinics, immunisation campaign, food distribution, etc.  Mobile phone tracing  Consider: context, size of cohort, available and most efficient means of communication  Combined methods seem to reach best coverage.

Context-specific priority setting

Impact of shockPreparednessAlternative service delivery method Transport routes for drug supply impassable Facility becomes inaccessible (flooded, looted, etc.) Patients access to health facility impossible Patients flee to other areas Order buffer stock in advance Secure drugs and patient registers in flood safe location (.e.g. 2 nd floor) Provide extra supply of ARVs to patients in advance Provide patient passports & inform patients about alternative treatment sites in advance Set up temporary health facilities in accommodation sites affected population Supply temporary health centres with all commodities needed from district buffer stock

Recommendations  Integrate preparedness and contingency planning into regular PMTCT/ART programming and include PMTCT/ART in general national disaster preparedness plans  Ensure drug and commodities supply in humanitarian settings  Take leadership and support coordination to assure that PMTCT/ART is included in emergency response from the very start in generalised HIV epidemics  Make rapid funding available for PMTCT/ART response in humanitarian emergencies  Organise and adapt service delivery for rapid response in humanitarian settings  Adapt monitoring system for patient cohorts in humanitarian settings

Thank you