2. Accelerated transition to Option B+ in a rural Zimbabwean province: Impact of a Decentralised ART System. Tendai E. Nyagura* 1, C. Tshuma 1, S. Mukungunugwa 1, D. Nyamurera 3 1.Ministry of Health and Child Care 2.National AIDS Council, Mashonaland Central Province

3. Evolution of WHO PMTCT ARV Recommendations 2001200620102004 Launch July 2013 PMTCT 4 weeks AZT; AZT+ 3TC, or SD NVP AZT from 28 wks + SD NVP AZT from 28wks + sdNVP +AZT/3TC 7days Option A (AZT +infant NVP) Option B (triple ARVs) Option B or B+ Moving to ART for all PW/BF ART No recommendation CD4 <200 CD4 <350CD4 <500 Move towards: more effective ARV drugs, extending coverage throughout MTCT risk period, and ART for the mother’s health

4. Introduction Zimbabwe adopted of Option B+ in February 2013 National target: 500 facilities to transition to Option B+ by February 2014.

5. Proposed Option B+ Implementation Phasing Launch Event Interim Review and Program Adjustment Post-Rollout Review Preparation Phase NationalProvincialDistrict Early Implementation Phase Early sites implementLate sites prepareSystem strengthening Late Implementation Phase All sites begin to implement System strengthening Central Hosp Civil Society Partner Support

6. Mashonaland Central Province Pop: 1,152,520 (2012 Census) HIV prevalence:14 % (ZDHS 2010/11) Estimated PLWHIV: 161,353 Estimated HIV+ve Preg women 2014: 5,372 (2014 HIV Estimates) 139 public health facilities including 12 hospitals Main economic activities: Agriculture, Mining

7. Preliminary findings: Interim Review of PMTCT Option B+ Implementation in Zimbabwe, August- October 2014.

8. Objective In-depth understanding of how Mashonaland Central province achieved such accelerated Option B+ transition in a short time period

9. Methods A retrospective qualitative review of Option B+ roll out in Mashonaland Central province was conducted in October 2014. Key informant interviews Analysis of training, site assessment reports Desk reviews of relevant documents (including interim review report) Programme data abstraction

10. Results As a strategy to increase access to ART, Mashonaland Central province started decentralisation of ART services to the lowest level health facilities in 2009. Mashonaland Central became the first province in Zimbabwe to achieve 100% ART decentralisation (including ART initiation) to all its eligible public health facilities.

11. Results Preparations for transition to Option B+ began in September 2013 in Mashonaland Central province as was across the country.  Mashonaland Central ART initiation decentralised to 73% of its facilities VS national average 35% at this point. Site readiness (including health worker trainings)to the rest of facilities between September 2013 and February 2014. Mashonaland Central province then simultaneously rolled out Option B+ to 137 health facilities March/April 2014.

12. Preliminary findings: Interim Review of PMTCT Option B+ Implementation in Zimbabwe, August- October 2014.

13. Impact of Option B+ on Maternal ART initiation rates in MC province Acknowledgement: Grapper Mujaranji, Organisation for Public Health Interventions and Development (OPHID)

14. Results All eligible public facilities (137) fell in the early implementation phase of Option B+ National Roll out plan. LESS RESOURCES AND TIME were required for capacitating facilities (systems strengthening). Health workers were already confident in ART initiation. The majority of health workers were already familiar with the national ARVs ordering system (ZADS) HIV health information system already in use Patient follow up mechanisms were mostly in place.

15. Results Quote from Provincial health team member: “Imimi rongekai ikoko otherwise kunoku kaone we have been offering ART in clinics for sometime now saka kungogadzirisa a few things and Option B+ will be in all our facilities” Translated: Get organised up there (National level) otherwise from our end we have been offering ART in clinics for sometime now its just a matter of making a few changes and Option B+ will be in every facility.

16. Conclusion Prior decentralisation of ART services had strengthened the health system in Mashonaland Central province as demonstrated by the accelerated and simultaneous transition to Option B+.

17. Recommendations Decentralisation of HIV services should be prioritised and promoted as it has the potential to catapult the expansion of other prevention, care and treatment services even beyond HIV and AIDS.

18. Acknowledgements MOHCC ⁻National ⁻Mashonaland Central Team NAC Partners- funding and implementing PLWHIV Mash Central communities

19. THANK YOU