1. Planning for Transition from Opti on B to B+: Rwanda Experience MUGWANEZA Placidie, Coordinator of HIV prevention Unit/RBC/MOH ART in pregnancy, breastfeeding and beyond, Johannesburg, June 18-20, 2012

2. OUTLINE Rwanda context History of PMTCT guideline and regimen changes in Rwanda Roadmap and timelinefrom option B to option B+ Current Program: areas for Improvement Experience with Site supervision Next steps

3. RWANDA CONTEXT East African country of 26,338 km2 Population: ~10 m. inhabitants Administrative framework –4 provinces and Kigali City Council –30 districts –415 sectors/cells/villages Generalized HIV epidemic –3% prevalence in general population –3,7% prevalence among women Rapid scale up of HIV services –456 PMTCT sites (82%) –372 ART sites (70%) RWANDA

4. PMTCT REGIMENS IN RWANDA PeriodPMTCT RegimenEligibility criteria for ART for life 2002 - 2005NVP 200 CD4 2005-2010AZT+NVP 350 CD4 2010Option B for pregnant women with CD4>500(HAART until 18 months postpartum) 500 CD4 (while nonpregnant adults eligible at CD4<350) April 2012Option B+All HIV + pregnant women

5. 2. Recommendation from scientific workshop: shift from option B to B+ TRANSITION FROM OPTION B TO B+ May 2011 September 2011 March- April 2012 7- Tools revision (adherence register, indicators, Q&A and BCC) 3.Revision and approval of the guidelines February March 2012 5. Training of Health providers, launching of B+ Ongoing 1- Launch of the EMTCT National campaign

6. BUILDING ON EXISTING HEALTH SYSTEMS Integrated service delivery model High coverage of health facilities providing both PMTCT and ART Integrated HIV training ( ART & PMTCT) Coordinated procurement and distribution system & ARV quantification Strong coordination and service provision structures already in place National district ; facility community; ART PMTCT Task shifting already in place Strong political commitment

7. HIGH COVERAGE OF INTEGRATED HIV SERVICES Source: RBC;

8. Increasing Proportion of HIV-infected Pregnant Women Receiving HAART during Pregnancy Source: Trac Net database, RBC/IHDPC

9. ARV REGIMENS FOR PMTCT Option B (adopted November 2010): Women with CD4 < 350: TDF/3TC/NVP Women with CD4 > 350: TDF/3TC/EFV Option B+ (Adopted April 2012) All women : TDF/3TC/EFV Infant: Daily NVP up 6 weeks

10. ONGOING AREAS FOR IMPROVEMENT ANC attendance Only 38% attend ANC before the 4 th month of pregnancy Need for ongoing mentorship for nurses at PMTCT sites Retention and ART Adherence for pregnant and lactating women ARV quantification and forecasting at district level Rapid turnaround of EID results to sites for early treatment Follow-up of ART patients at PMTCT standalone sites –Linkages to treatment for male partner and children –Follow-up of mother after the breastfeeding period

11. Supporting Program Implementation and Quality through Site Supervision: Example of Track 1.0 Transition Planning Identify and notify sites to be supervised Establish a schedule Define the resource needed (e.g HR, transport… Provide tools and train supervisors Implementation Use standard tool Identify strength and weakness Provide feedback Documentation

12. May Jun e July Aug. Sept Oct. Nov. Dec. Jan. Feb. March April May June July Aug. Sept. 20102011 Cohort 1 Transition 18 Sites Cohort 2 Transition 6 Sites Cohort 3 Transition 46 Sites C1 BaselineC1 6- Month Follow-Up C1 12-Month Follow-Up C2 BaselineC2 6-Month Follow-Up C3 BaselineC3 6-Month Follow-Up TIMELINE FOR TRACK 1.0 SITE MONITORING

13. SITE VISITS & DATA COLLECTION Teams visit all transitioned sites at baseline and every 6 months November 2009-December 2010: CDC-led with MOH/partner participation January 2011-Present: MOH led with CDC participation Management Capacity Interview health center director, accountant, data manager, ART and PMTCT nurses and lab technicians Abstract data from quarterly PBF evaluations Clinical Performance Abstract clinical performance data from national HIV monitoring system (TRACNet) and Track 1.0 reports

14. Mean HIV PMTCT Performance Results for Health Facilities at Baseline, 6 and 12 Months after Transition

15. FEEDBACK: DISSEMINATION WORKSHOPS Held at district hospitals for facilities in their catchment after each round Facilitated by MOH Agenda : –District-specific results –Site specific results, small group discussion –Action planning to address identified gaps

16. LESSONS LEARNED Accompanying MOH on routine site visits builds site- and central-level capacity Decentralization of site visits could improve MOH efficiency, follow-up of recommendations Involvement of all relevant MOH departments improves follow-up on recommendations

17. NEXT STEPS Finalize and disseminate revised tools Accelerate accreditation process for PMTCT standalone sites to offer ART Evaluate retention and adherence for mother-infant pair Reinforce the PMTCT M&E (e.g: Revision of PMTCT indicators, program evaluation) Establish ARV pharmacovigilance system Reinforce capacity of health providers through training, supervision and mentorship