Overview  of  Implementation  of  LLAPLa  in  Tanzania    Dr  MD  Kajoka  Na+onal  PMTCT  Coordinator  TANZANIA  

Presentation  Layout  

•  Background  

•  Roll  out  of  Life  Long  ART  to  pregnant  and  Lacta+ng  women  •  Achievements  •  Challenges  •  Future  Plans  

Background  Information  

•  Total   popula+on   (year   of  es+mate):45  million  (1)  

•  Annual   number   of   expected  pregnancies:  1.8  million  (2)  

•  Adult  HIV  Prevalence:  5.1%  (3)  

•  HIV  prevalence  among  pregnant  women;  5.4%  (4)  

•  Es+mated   number   of   HIV+  Pregnant  women:  100,000  (5  

•  Propor%on  making   at   least   one  ANC  visit;  96%  (6)  

•  Maternal   Mortality   Ra+o:  454/100,000  (6)      

•  Infant  Mortality   Rate:   51/1,000  (6)  

•  Under   Five   Mortality   Rate:  81/1,000  (6)  

•  MTCT  rate  15%  (2013)  

Key  1,  Na+onal  Popula+on  Census  2012  2,  Na+onal  projec+ons  3,  Tanzania  HIV  and  Malaria  Indicator  Survey  2012  4,  Na+onal  ANC  HIV  surveillance  2010  5,  Spectrum  Projec+ons  6,  Tanzania  Demographic  and  Health  Survey  2010  

Key  1,  Na+onal  Popula+on  Census  2012  2,  Na+onal  projec+ons  3,  Tanzania  HIV  and  Malaria  Indicator  Survey  2012  4,  Na+onal  ANC  HIV  surveillance  2010  5,  Spectrum  Projec+ons  6,  Tanzania  Demographic  and  Health  Survey  2010  

Key  1,  Na+onal  Popula+on  Census  2012  2,  Na+onal  projec+ons  3,  Tanzania  HIV  and  Malaria  Indicator  Survey  2012  4,  Na+onal  ANC  HIV  surveillance  2010  5,  Spectrum  Projec+ons  6,  Tanzania  Demographic  and  Health  Survey  2010  

Key  1,  Na+onal  Popula+on  Census  2012  2,  Na+onal  projec+ons  3,  Tanzania  HIV  and  Malaria  Indicator  Survey  2012  4,  Na+onal  ANC  HIV  surveillance  2010  5,  Spectrum  Projec+ons  6,  Tanzania  Demographic  and  Health  Survey  2010  

Key  (1)  Na%onal  Popula%on  Census  2012,  (2)  Na%onal  projec%ons,  (3)  Tanzania  HIV  and  Malaria  Indicator  Survey  2012,  (4)  Na%onal  ANC  HIV  surveillance  2010,    (5)Spectrum  Projec%ons,  (6)  Tanzania  Demographic  and  Health  Survey  2010  

 

Fundamental  shift  in  thinking?    

SD-­‐NVP  (L&D)  

Short  course  AZT  (ANC  +  L&D)  

OpIon  A    or    

OpIon  B  (ANC,  L&D,  postpartum)  

PMTCT  =  Maternal  treatment  

 +    infant  

follow-­‐up?  (overlapping  treatment  and  MNCH  con+nuum)  

CoordinaIon:  Ministry  of  Health  and  Social  Welfare  

PMTCT/C&T  -­‐TWG:  MoHSW  -­‐  RCH,  UN,  USG  partners,  EGPAF,  CHAI,  NACOPHA,  TACAIDS,  MUHAS,  MSD,  Private  Sector  ,    Co  chaired  by  PMTCT  Co/  C&T      

 Sub  teams 1.  Guidelines and Model of

care 2.  Community interventions 3.  Advocacy and resource

mobilization 4.  Logistic and Supply Chain 5.  Monitoring and evaluation 6.  Policy  and  guidance    

Regional  PEPFAR  PMTCT  IPs,  RHMTs,  CHMTs  

Health  FaciliIes  

Life Long ART to Pregnant and Lactating Mothers (LLAPLa) – Roll-out

Guidance  for  the  roll-­‐out  of  LLAPLa  (OpIon  B+)    Goal:    � 100,000  HIV+  pregnant  &  Lacta+ng  women    on  treatment  by  June  2014    Strategy:    •  All  sites  that  see  >  30  HIV+  Pregnant  &  Lacta+ng  women  per  year  

will  be  priori+zed    •  Regions  priori+zed  according  to  their  HIV  burden  

The roll-out of LLAPLa

� Each  of  the  regions  were  given  specific  target  to  reach  for  HIV  posi+ve  pregnant  and  lacta+ng  mothers  

�   The  roll  out  was  carried  out  in  two  phases  o  Phase  1:  Nine  (9)  regions  started  October  2013  

o  Phase  2:  The  remaining  16  regions  started  February  2014  

 

The roll-out of LLAPLa  • Circular  was  released  by  the  Ministry  to  mark  the  start  of  LLAPLa  

• Advocacy  at  na+onal,  regional  and  district  levels  to  authori+es  

• Review  of  guidelines  and  Training  package  • Refresher  training  to  PMTCT  and  CTC  service  providers    

• Ader  training  follow  up  to  all  facili+es  in+a+ng    LLAPLa  

Logistic  and    Supply  •  Forecas+ng,  quan+fica+on  was  done  using  the  agreed  targets    

• Procurement  via  VPP  –  Global  fund  •  Smart  push  was  done  to  all  Health  Facili+es  ini+a+ng  LLAPLa  

 

Monitoring  and  Evaluation  • Recording  and  repor+ng  

• Harmoniza+on  of    ART  tools  (ART  register,  CTC  1  and  CTC2  cards,  etc)  repor+ng  as  one  

•  The  new  integrated  system  is  capturing  both  pregnant  and  lacta+ng  women  

•  Established  infant  card  that  links  the  baby  to  the  mother    

•  Supervision  and  mentoring  •  Intensifica+on  of  monitoring  and  supervision  first  to  high  volume  sites  

Service  Delivery  • Nurses  ini+ate  ART  at  RCH  clinic  • Couple  counseling  is  done  at  RCH  clinic  • HIV  posi+ve  male  partner  are  enrolled  into  care  and  treatment  

• All  pregnant  and  lacta+ng  mothers  receive  ART  at  RCH  

• Cases  that  requires  more  ahen+on  are  referred  to  CTC  for  management  

• Decentraliza+on  for  pediatric  care  from  CTC  is  ongoing  

Community  Interventions  • Comprehensive  Maternal  and  Newborn  Community  strategy  is  on  use  :  Community  health  workers  are  trained  to  follow  up  Pregnant  /lacta+ng  women  in  the  community  

• Home  based  care  providers  will  also  be  oriented    on  MNCH  issues  

Progress  –  LLAPLA  ….  

3626  

4603  4832   4914  

0  

1165  

0  

500  

1000  

1500  

2000  

2500  

3000  

3500  

4000  

4500  

5000  

Baseline  (2009)  

2011   2012   2013  

Num

ber  o

f  PMTC

T  sites  

Year  

Graph  showing  PMTCT  site  Coverage  

Number  of  ANC  sites  offering  PMTCT  

Achievements    

•  Ownership,  and  accountability  at  all  level  fostered  through  na+onal  and  local  authority  eMTCT  campaigns  championed  by  poli+cal  leaders  

•  Increasing  coverage  of  ART  for  pregnant  and  lacta+ng  mothers  

•  Scale  up  of  EID  services  with  B  plus  plajorm  •  Health  Facility  countrywide  coverage  to  be  

ahained  by  December  2014  •  Declining  trend  of  MTCT  rates  

Challenges  

• Mixed   M&E   system   during   transi+on  period  from  op+on  A  to  B+    

• Adherence  and  reten+on  • Consistent   availability   of   commodi+es  (Logis+cs)  

• Limited  space  in  RCH  clinic  

Future Plans

• To strengthen Mother baby pair follow up through peer support approach

• Empowering communities for behaviour change towards facility utilization

• Promote  other  adherence  improving  interven+ons  (support  groups,  mobile  phone  technology)

• Scale up Point of Care machines to the lower levels, increase viral Load machines

• Adoption of the consolidated guidelines (2013)