New insights into Research and Evidence on how Investments in PMTCT and Paediatric AIDS have contributed to Health Systems Strengthening Rene Ekpini E.

New insights into Research and Evidence on how Investments in PMTCT and Paediatric AIDS have

contributed to Health Systems Strengthening

Rene Ekpini ESenior Adviser

UNICEF, New York

Pre-conference meeting of Health Systems Experts, HIV Researchers and Implementers

Cape Town, South Africa, 17-18 July 2009

PMTCT, best model of combination prevention and treatment

acceleration

Primary preventionPrimary

prevention

Prevention of HIV

transmission from an

HIV-infected woman to her

infant

Prevention of HIV

transmission from an

HIV-infected woman to her

infant

Care, support and treatment

for HIV-infected women,

their infants and their families

Care, support and treatment

for HIV-infected women,

their infants and their families

Prevention of unintended pregnancies

among HIV-infected

women

Prevention of unintended pregnancies

among HIV-infected

women Individuals,

families and

communities

Individuals, families

and communities

3

PMTCT and paediatric HIV care, support and treatment: an opportunity

to improve MNCH services

PMTCT and paediatric HIV care, support and treatment: an opportunity

to improve MNCH services

Reaching MDGs 4,5 and 6 requires a paradigm shift

from the rhetoric of “the good, the bad and the ugly” toward the

prospect of using scaling up of PMTCT and paediatric

HIV care, support and treatment as an opportunity

to improve maternal and child health and survival

Reaching MDGs 4,5 and 6 requires a paradigm shift

from the rhetoric of “the good, the bad and the ugly” toward the

prospect of using scaling up of PMTCT and paediatric

HIV care, support and treatment as an opportunity

to improve maternal and child health and survival Maternity of

InongoMaternity of Inongo

0 20,0

00

40,0

00

60,0

00

80,0

00

100,0

00

120,0

00

140,0

00

160,0

00

Botswana

Mozambique

Haiti

Cote d'Ivoire

Rwanda

PMTCT Total prevention Care & Treatment

Expenditure in Care and treatment, Prevention and PMTCT in selected

countries

Source: UNAIDS 2008 Global Report

Source: UNAIDS 2008 Global Report

Building up PMTCT on weak health systems in resource-limited settings

9196

6874

60.5

43.4

0

20

40

60

80

100

120

Malawi Zambia

1+ visit 4+ visits Births with skilled attendant

Sources: 1- ANC coverage: Antenatal care in developing countries-Promise, achievements and missed opportunities – An analysis of trends, level and differentials, 1990-2001 updates 2- Skilled attendant at birth 2006

Coverage of antenatal care and skilled attendant at birth

50

65

32

47

1721

1216

0

10

20

30

40

50

60

70

Malawi Zambia

HIV T&C ARV for PMTCTInfant ARV for PMTCT CTP for infant by 2 months

Coverage of PMTCT services

From proof of principles to implementation at large scale

• Expansion of quality antenatal and delivery care

• Expansion of provider initiated HIV testing and counselling in antenatal, delivery and child health care settings

• Scaling up more efficacious ARV regimens for PMTCT, including building capacity for CD4 cell count and ART for pregnant women

• Cotrimoxazole prophylaxis for HIV-infected pregnant women, HIV-infected mothers and their infants as a standard of care

From proof of principles to implementation at large scale

• Scaling up early infant diagnosis and ART for infants

• Scaling up innovations to service delivery, including use mobile phone technology to expand EID and ART for infants

• Strengthening national M&E systems

8

2.2

25 25

19.5

17.2

0

5

10

15

20

25

30

Sd-NVP AZT/ Sd-NVP

tra

nsm

issi

on

ra

te (

%)

In PMTCT programme Outside PMTCT pg All

Current system performance (KZN province)

Attend ANC clinic 92%

Counseled and tested for HIV, CD4 75%

Get ARVs (pre- and perinatal) 50%

Adapted from Pierre Baker & Nigel RollinsAdapted from Pierre Baker & Nigel Rollins

8

2.2

25 25

11.1

6.1

0

5

10

15

20

25

30

Sd-NVP AZT/ Sd-NVP

tra

nsm

issi

on

ra

te (

%)

In PMTCT programme Outside PMTCT pg All

95% efficiency of the system (KZN province)

Attend ANC clinic 92%

Counseled and tested for HIV, CD4 95%

Get ARVs (pre- and perinatal) 95%

Six building blocks of health systems

• Strong leadership and governance

• Good health-financing system

• Responsive health care force

• Effective, safe, and high-quality health

services

• Equitable access to essential medical

products,

vaccines, and technologies

• Well-functioning health information system

• Strong leadership and governance

• Good health-financing system

• Responsive health care force

• Effective, safe, and high-quality health

services

• Equitable access to essential medical

products,

vaccines, and technologies

• Well-functioning health information system

How investments in PMTCT and paediatric AIDS have contributed to

health systems strengthening

How investments in PMTCT and paediatric AIDS have contributed to

health systems strengthening

Inducing improved governance and policy changes

• Strong political leadership and commitment to ensure that health system goals of access, equity, efficiency and improvement in outcomes are achieved

• Promotion of innovative policies on: - Provider initiated HIV testing and counselling

- access to treatment for women and children

- Abolition of user fees for antenatal and delivery care in some countries

• Revision of the content of the basic package of antenatal and postnatal care to integrate HIV-related services

• Induction of changes in resource allocation including innovative approaches such as performance-based financing

Strengthening programme management, coordination, and

monitoring and evaluation

• Harmonization and alignment of programmes (SRH, Nutrition, MNCH, HIV) and partners through integrated coordination bodies and mechanisms

• Revision/adaptation of national indicators in line with global guidelines, development of M&E tools, and human capacity building for data management, analysis and use

• Setting up mechanisms for information sharing and referrals, including notification of HIV information on child and maternal health cards

• Growing support to impact evaluation and operational research

Addressing shortage in human resources and improving working

conditions • Innovative approaches to addressing insufficient skilled human resources to sustain

expansion of services:

- Task shifting and sharing

- Engagement of PLWH

• Improvement of infrastructure and equipment, optimizing working conditions, and improve efficient delivery of services:

- Rehabilitation and equipment of ANC, delivery care, laboratory and pharmacy facilities

- Reorganization of service delivery mechanisms

• Engagement of civil society, PLWH, male partners and communities (lay counselors, peer support groups, Mother2Mother, post-test clubs)

0

10

20

30

40

50

60

70

80

90

nutritionduring

pregnancy

Familyplanning

Preventionof STIs

Measurefoetal

heart rate

Partographever filled

in

Checkuterine

retraction

Perc

enta

ge

Before PMTCT After PMTCT

Individual counsellingIndividual counselling

Quality of antenatal and delivery care before and after the implementation of

PMTCT; Cote d’Ivoire

Therese Delvaux et al.Therese Delvaux et al.

Impact of PMTCT on institutional deliveries in Rwanda – HIV-positive

women

69%

72%

80%

87%

89%

31%

28%

20%

13%

11%

0% 20% 40% 60% 80% 100%

2004 (N= 412)

2005 (N=499)

2006 (N=966)

2007 (N=1,053)

2008 (N=1,253)

At health facility Home

Bangendanye, L; Price, J.E.; Micomyiza E.; Shumbusho F.; Wesson Bangendanye, L; Price, J.E.; Micomyiza E.; Shumbusho F.; Wesson

In the general population 45% of women delivered at HF (IDHS 2007-08)

In the general population 45% of women delivered at HF (IDHS 2007-08)

25

30

35

21

28

35

12

23

32

34

37

24

28 27

24

21

2826

15

2019

17

2625

HIV-negative

HIV-positive

Proportion of married women age 15-49 with unmet need for contraception,

according to HIV serostatus, selected DHS surveys 2003-2007

The way forward The way forward

Closing the gaps toward virtual elimination of paediatric HIV

infection

1.Closing the funding gaps through resource mobilization and allocation and more efficient use of available resources

2.Closing the gap in access to the best available science for all by scaling up more efficacious ARV regimens for PMTCT, early diagnosis and ART for infants and children

3.Closing the gap in access and equity for the majority of women and children in need through decentralisation and scaling up of innovation to service delivery

Closing the gaps toward virtual elimination of paediatric HIV

infection

4. Closing the gap between health-based approach and communities through engagement of individuals, families and communities

5. Closing the gap with the future by building capacity and setting up appropriate fiscal policies and operational mechanisms to ensure sustainability

6. Closing the knowledge gap through promotion and support to impact evaluation and operational research to inform advocacy, policies and programming

Two Worlds, Two Realities One Hope

Two Worlds, Two Realities One Hope

Before

Rutobwe H.C. Maternity

After