Retention and Adherence in PMTCT Programs: Namibia Experience

1. Retention and Adherence in PMTCT Programs: Namibia Experience Karen Toivo Chief Health Program Administrator Workshop on ART in Pregnancy, Breastfeeding, and Beyond Johannesburg, South Africa. June 18-20, 2012

2. Demographic Profiling of HIV burden in pregnancy

3. Background • Namibia launched the PMTCT programme in 2002 and has scaled up to all regions • Access to services has remained good (95% ANC, 81% facility deliveries; 93% DPT1 coverage and over 95% HIV testing: quality gaps still exist in reaching universal level coverage and targets • High facility utilization but missed opportunities; While over 90% of exposed children receive ARV prophylaxis, less than 10% receive cotrimoxazole due to non reporting • Namibia is a breastfeeding population, still exclusive breastfeeding for 6 months is less than 10% • Current HIV prevalence among pregnant women is 18.8% and puts Namibia on 5 highest globally

4. Development process for the Follow Up Mechanism for HIV Exposed Infants 2008 - 2011 Op Research concepts and design Improved access Sampling and identification of regions Reviews and discussions on expansion or roll out Development of Referral and follow up tools Modeling in 4 high volume districts Improved Quality Orientation and Training Increased linkages 2 1 3 4 Implementation, systems strengthening + partnership, joint monitoring, building HR capacity of the 4 districts Pre-testing and refining the tools and approaches Preparatory phase Review of approaches and roll out discussions; platforms for elimination Assets A local Consultant reviewed the available referral and follow up systems in the country and presented to MOHSS The MOHSS with support from UNICEF adapted and pre-tested the recommended tool and applied in 3 high volume districts Implementation of the innovative approaches and leveraging of technical and funding support from other partners (GFATM, USG/PEPFAR) Roll out discussions as a platform for elimination

5. Why children drop out of care Pilot innovative tools and elements A facility based child monitoring and referral tool specific for children exposed to HIV appointment schedules, services required during each visit and outcomes at each stage Mobile phones and air time provided to the health facilities, to SMS and remind/notify clients Child Health Passport revised to capture relevant data from the mother’s passport Follow-up of defaulting clients by community health promoters Intensified support for supportive supervision of districts and community level interventions • High mobility of clients (within and between regions) • Inefficient referral and tracking systems • Inadequate access to health facilities (Long distance, Transport costs, Cultural acceptability, Attitude of facility staff • Poor patient recording system • Long waiting times and queues at health care institutions • Limited numbers of trained community counselors • Children left with grandparents/guardians

6. Reducing drop outs from PMTCT Continuum, Oshana Region, Namibia 88%

7. Eliminating Paediatric transmissions, Oshana 74% 66%

8. Linking exposed/infected infants to treatment, Oshana region, Namibia

9. Use of Follow Up Channels Phone calls and sms were critical channels for notification and reminder contacts. A follow-up ratio of 1:3 ANC attendees was observed from total 1672 contacts made during FY2010 for 5240 ANC1 attendees (1601 during FY 2011 for 5312 ANC 1 attendees). Personal messages and home visits by community partner (TCE Volunteers) were crucial for follow up of defaulters not traceable via phone channels

10. Key Challenges • Defaulter clients • due to migration from one site to another • Inaccurate telephone contacts of clients • Caretakers/grandmothers are not informed of the HIV exposed status of the babies • mothers are not coming for follow-up especialy at 14 days • Some children who defaulted are only captured at immunization clinic or growth monitoring programme • Slow rolling out of the programme (post-natal infant follow-up) to other regions including DNA/PCR test. • limited number of community partners for community support and tracking of defaulters for HIV-Exposed babies • Data quality and management issues

11. Key Considerations for Replication • Adequate technical and funding support • Capacity development of program managers and care providers at facility level including community care providers • Decentralized support for planning, monitoring and supervision • Continued engagement with community partners and structures • Engagement of the private sector

12. Thank you!Tangi Unene