1. Management of PMTCT Services
Module 10
Management of PMTCT Services

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

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

43. 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

44. 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

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

46. 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

47. 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

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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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