1. How did we miss them? High HIV prevalence among Women testing for the First Time in Labour and Delivery in Zimbabwe Page-Mtongwiza S, Webb, K., Chiguvare, T., Mukungunugwa, S., Engelsmann, B., Mbetu, P. Presented by: Sara Page-Mtongwiza, Director of Programs, OPHID Trust

2. WE KNOW: 1.Early ART initiation among HIV positive pregnant women increases health benefits to mothers and prevents vertical transmission in exposed infants. 2.PMTCT intervention can only be initiated when the HIV serostatus of a pregnant woman is known. 3.The Earlier the Better- Initiation of anti-retrovirals (ARVs) less than 4 weeks prior to delivery is associated with a 5-fold increase in the risk of vertical HIV transmission when compared with maternal ARV initiation at 13 weeks prior to delivery.

3. Background: Families and Communities for the Elimination of Pediatric HIV ( FACE) Objectives:  Provide of technical and other assistance to the national level of the PMTCT, ART and TB programs  Strengthen provision of clinical services for comprehensive HIV Care and Treatment  Strengthen Pediatric and adolescent HIV and sexually and reproductive health (SRH) services  Strengthen and improve generation, dissemination and use of strategic information  Strengthen continuum of care for mother, infant and family

4. Objectives 1.To analyse the HIV positivity rates 1.Pregnant women in antenatal care (ANC) presenting with an unknown status 2.Women presenting in Labour and Delivery with an unknown status. 2.To analyse the HIV positivity rates among pregnant women retested in L&D

5. Description Routine Program Data Analysis – reported through the MOHCC January to June 2015 1494 health care facilities (reporting maternal and chid health sites) Analysed data for four groups: All women enrolled in ANC with unknown status Women enrolling in ANC with known positive status Women tested for HIV for the first time in L&D Women retested for HIV in L&D Chi square tests were used to determine significance in proportion of women testing HIV positive in each care setting.

6. Women booked for ANC N=220 139 Women with Unknown HIV status n=205 478 (93.3%) Women with Known HIV + status n=14 661 (6.7%) Women who received an HIV test n=202 699 (98%) Women already on ART at ANC booking n=12 419 Women unknown status-No record of test n=2779 LESSONS LEARNED: Women booking in ANC (Jan- Jun, 2015) Women who tested positive n=13 923 (6.9%) Women who tested negative n=188 776 (93%)

7. Trend analysis, HIV+ women newly identified in ANC and pregnant women booking with known HIV+ result, Oct 2012 - Sept 2015 7

8. Lessons learned: L&D (Jan-Jun, 2015) Women arriving in L&D with unknown status N=7347 Women tested for HIV n=6407 Women not tested for HIV n=940 HIV positive n=994 (15.5%) HIV negative n=5413 (84.5%) Women retested for HIV in L&D N=15982 HIV positive n=314 (1.94%) HIV Negative n=15668 (98%) Women initiated on ART in L&D n=1171 (88.7%)

9. Analysis We observe a steady increase in the percentage (%) of women who book in ANC with a known HIV status and/or are already on ART, in comparison with those testing positive for the first time in ANC. Proportion of HIV positive women identified and newly tested in L&D (15.5%) compared to those tested HIV positive in ANC (6.9%) was highly significantly different (p<0.001)

10. District Positivity Rate of Women testing for the first time in L&D, Jan-Jun, 2015 N=994

11. Discussion: How Did We Miss Them? 1. Documentation 2. Women who did not book for ANC 3. Women booked for ANC but did not test Stigma Migration- Mobility Religious Preferences Age Lack of Knowledge

12. Conclusions & Next Steps Women presenting with unknown HIV status in L&D should be treated as a key at-risk population for vertical transmission. Need to continue to emphasise the important of early testing and early initiation. Need to invest in regions with high HIV incidence Future research is needed to document and understand the characteristics of women arriving in L&D with an unknown status.

13. Thank You – Tatenda – Siyabonga Ministry of Health and Child Care President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID and Families and Communities for Elimination of Pediatric HIV in Zimbabwe (AID-613- A-12-00003, FACE Pediatric HIV) Health care workers providing services at all public health facilities FACE pediatric HIV: Towards elimination of new HIV infections in Zimbabwe