Equity focused bottleneck analysis and development of costed evidence informed national plan for MTCT elimination: United Republic of Tanzania Dr. Deborah M. Kajoka December 7 th, 2011 OWN, SCALE-UP & SUSTAIN The 16 th International Conference on AIDS & STIs in Africa 4 to 8 December 2011, Addis Ababa

CONTENT OUTLINE Overview of the PMTCT Program PMTCT service uptake Equity Bottleneck analysis Lessons learnt Future plans

Overview of Mother-child transmission of HIV Population:44,502,629 (NBS 2010) 1,8m deliveries per year 50% health facility deliveries HIV prevalence rate of 6.9%(pregnant women) Contraceptive prevalence rate: 27% Fertility rate of 5.4 births per woman 25% are un-intended Unmet contraceptive need:25%

PMTCT Performance Overview Started in 2000 as pilot project 2004 started scale up. 4,301 sites by December 2010 (93% of RCH sites) 1 PMTCT integrated into RCH services, 1: PMTCT report Dec 2010, 2: 2010 DHS

PMTCT service uptake Pregnant women attending ANC 92% Testing uptake among estimated pregnant women 85% 70% HIV+ pregnant women utilize any form of ARV prophylaxis. 57% of HIV exposed babies received prophylaxis

Equity Focused Bottleneck analysis MoHSW with the support from UNICEF, engaged consultants to conduct bottleneck analysis (October – December 2011) Bottleneck analysis tool developed globally used to conduct the analysis and 7 tracer interventions were selected for the four prongs Tracer Interventions – Primary prevention of HIV, FP, Quality ANC, PMTCT, Exclusive BF, EID, C&T for HIV pregnant Mothers

Equity Focused Bottleneck analysis Broad areas for analysis included Supply determinants - Commodities, Human Resource, Geographical Access and Geographical facility Coverage Demand determinants- include Service Utilization, Continuity and Quality of Services

Equity Focused Bottleneck analysis Preliminary results were shared with key stakeholders. Some key Findings included – Regional disparities for absolute unmet needs (ANC, HIV testing, CD4, ARVs, and EID) and the 7 tracer interventions – Late ANC booking and continuity visit 4 – Low FP utilization, continuity and quality, Weak follow up system for HIV infected women within facility and in community – Lack of system for identification HIV exposed babies in Immunization and under-five clinics – Inadequate CD4 testing capacity at all levels – Inadequate skilled staff – Shortage of commodities

Unmet needs for HIV testing

Unmet needs for CD4

Unmet needs for ARVs

Tracer :Provision of Quality ANC

Prevention of unintended Pregnancies among women of Reproductive Age

Development of eMTCT Plan Based on Bottle Neck analysis information – Review of PMTCT scale up plan is in progress – Revised eMTCT targets (Spectrum) – eMTCT plan being developed – Costing going on concurrently – Plan to be finalised by end 2011 and to be Launched early 2012

Strategic Interventions Implement new initiatives – Use of mobile phones for the follow ups of clients Integrate with EPI programme (outreach) Institute point of care machines to lower levels for CD4 Scale up Integrated Logistic Management System (ILMS) Expand pre service training of health workers to respond to HR shortage Expansion of psychosocial support services to pregnant women, their partners and families through NGOs Deploy CHWs for MNCH including PMTCT services

What is needed to reach the targets 2015? – model based Key Model Inputs & Outputs Tanzania National Data, 2010 Tanzania National Data, 2011 Tanzania National Projection, 2012 Tanzania National Projection, 2013 Tanzania National Projection, 2014 Tanzania National Projection, 2015 Perinatal Data Inputs ANC uptake 96%97%98% HIV Testing uptake/ known HIV+ status 86%90%94%95%98%99% HAART 11.0%15%20%35%40% WHO 2006 regimens 39%55%30%0% Option A/Option B 1 0% 40%50%53%58% Sd-NVP 20%10%0% Women on no ARVs 30%20%10%15%7%2% Perinatal MTCT Outputs 6 week MTCT (among all HIV+ women in Tanzania) 10.62%7.88%4.30%4.48%2.80%1.80% Post-partum Data Inputs % of infants breastfeeding 2 93% Average duration breastfeeding (months) 12 MTCT Outputs Breastfeeding MTCT rates 15.10%14.50%7.95%4.25%3.07%2.34% Cummulative MTCT rates (among all HIV+ women in Tanzania) 25.71%22.37%12.25%8.73%5.87%4.14%

Lessons learnt Country Leadership, ownership and involvement of all players on the ground is key to elimination agenda New opportunity to re-look at the programme to further accelerate the implementation of the eMTCT – what do we do differently

Lessons learnt Understanding key bottlenecks helps in programme focusing. Good Bottle Neck analysis relies on availability of adequate data at all levels Strong linkages with other RCHs/HIV and community interventions is key Clear guidance and TA from IATT has enabled the country to systematically develop the eMTCT costed plan

Future plans Finalize, launch and accelerate implementation of costed National eMTCT plan – PEPFAR Funds an opportunity Support regional and district eMTCT plans based on National plan Formation of accountability structures for eMTCT at National, Regional and district levels (Political commitment) Conduct an Impact Assessment

Acknowledgement MoHSW UNICEF – Country and Regional Office USG – PEPFAR, GF, UNITAID, CHAI National Task Team and Sub teams for eMTCT Inter Agency Task Team (IATT) PMTCT secretariat

The 16 th International Conference on AIDS & STIs in Africa, Addis Ababa OWN, SCALE-UP & SUSTAIN ASANTE SANA! Thank You!