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AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania
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AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at Health Facilities in Tanzania

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In guidelines released in 2010, the World Health Organization recommends that health facilities integrate prevention of mother-to-child transmission (PMTCT) with maternal, newborn, and child health …

In guidelines released in 2010, the World Health Organization recommends that health facilities integrate prevention of mother-to-child transmission (PMTCT) with maternal, newborn, and child health (MNCH) services to improve patient follow-up and adherence. This report describes the results of an assessment conducted across 70 randomly sampled PMTCT facilities in 14 regions of Tanzania, and the effect of integration on health quality.

www.aidstar-one.com/focus_areas/pmtct/resources/report/assessment_integration_pmtct_within_mnch_services_health_facilities_tanzania

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  • 1. |ASSESSMENT OF THEINTEGRATION OF PMTCT WITHINMNCH SERVICES AT HEALTHFACILITIES IN TANZANIA______________________________________________________________________________________SEPTEMBER 2012This publication was made possible through the support of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)through the U.S. Agency for International Development under contract number GHH-I-00-07-00059-00, AIDS Support andTechnical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1.
  • 2. ASSESSMENT OF THEINTEGRATION OF PMTCTWITHIN MNCH SERVICES ATHEALTH FACILITIES INTANZANIAThe authors views expressed in this publication do not necessarily reflect the views of the U.S. Agency forInternational Development or the United States Government.
  • 3. AIDS Support and Technical Assistance Resources ProjectAIDS Support and Technical Assistance Resources, Sector I, Task Order 1 (AIDSTAR-One) is funded by theU.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for InternationalDevelopment (USAID) under contract no. GHH-I-00–07–00059–00, funded January 31, 2008. AIDSTAR-One is implemented by John Snow, Inc., in collaboration with Broad Reach Healthcare, Encompass, LLC,International Center for Research on Women, MAP International, Mothers 2 Mothers, Social and ScientificSystems, Inc., University of Alabama at Birmingham, the White Ribbon Alliance for Safe Motherhood, andWorld Education. The project provides technical assistance services to the Office of HIV/AIDS and USGcountry teams in knowledge management, technical leadership, program sustainability, strategic planning, andprogram implementation support.Recommended CitationBlazer, Cassandra, Bisola Ojikutu, Karen Schneider, and Molly Higgins-Biddle. 2012. Assessment of theIntegration of PMTCT within MNCH Services at Health Facilities in Tanzania. Arlington, VA: USAID’s AIDSSupport and Technical Assistance Resources, AIDSTAR-One, Task Order 1.AcknowledgmentsThe AIDSTAR-One team wishes to thank the Tanzania Ministry of Health and Social Welfare for theircooperation and facilitation during data collection for this study. Thanks to Dr. Elizabeth Stringer of theUniversity of North Carolina, Chapel Hill, for her contributions and review of the data collection tools. TheAIDSTAR-One team is also grateful for the support, facilitation, and review by Dr. Patrick Swai of the U.S.Agency for International Development/Tanzania, Dr. Patrick Rwehumbiza of the U.S. Centers for DiseaseControl and Prevention/Tanzania, Dr. Neema Rusibamayila, Dr. Debora Kajoka, Dr. Moke Magoma, andDr. Jema Bisimba. AIDSTAR-One would like to thank members of the Tanzania Prevention of Mother-to-Child Transmission Interagency Technical Team for their input. The team is grateful to Leopold Wami andthe data collection team for logistics, operational management, and data collection. Finally, the team expressesgratitude to the facility staff who provided the information that serves as the foundation of this report.
  • 4. AbstractBackground: In Tanzania in 2009, 68 percent of HIV-positive pregnant women received prevention ofmother-to-child transmission of HIV (PMTCT) prophylaxis. Integrating PMTCT services with maternal,newborn, and child health (MNCH) programs has been promoted by the World Health Organization toincrease access to services. The goal of this study is to determine the impact of integration on qualityindicators within the PMTCT cascade.Methodology: In this study a level of integration (LOI) rating system was developed to measure the degreeof PMTCT and MNCH integration at the site level. The scale ranked sites from 0-20 with higher scoresindicating greater service integration. A cross sectional survey capturing service delivery factors associatedwith integration was administered to personnel at PMTCT sites randomly sampled from 14 regions stratifiedby volume and site type in October and November of 2011. Aggregate site level process and outcome datawas collected from implementing partners for the previous 12 months. Correlations between variables weretested using nonparametric methods, including the Spearman rank correlation test (p < 0.05) and theWilcoxon-Mann-Whitney test (p < 0.05).Results: From the site assessments of 70 facilities, median LOI score was 12 (range 0.5-20). Hospitals hadthe highest median LOI scores (16.5) followed by health centers (14.75) and dispensaries (10). Higher LOIscores were positively correlated with quality of care indicators: percent tested for HIV and received results inantenatal care (ρ = 0.33, p = 0.02), percent who received more effective combination antiretroviral therapyfor PMTCT prophylaxis in antenatal care (ρ = 0.40, p = 0.002), percent initiating antiretroviral therapy fortheir own health in antenatal care (ρ = 0.52, p < 0.0001), and percent who initiated exclusive breastfeeding (ρ= 0.30, p = 0.02). Level of integration was not correlated with the percent of infants receiving antiretroviraltherapy prophylaxis.Conclusions: Integration of PMTCT and MNCH may increase access to PMTCT services. Efforts should betargeted toward improving integration at lower level, community facilities in Tanzania.AIDSTAR-OneJohn Snow, Inc.1616 Fort Myer Drive, 16th FloorArlington, VA 22209 USAPhone: 703-528-7474Fax: 703-528-7480E-mail: info@aidstar-one.comInternet: aidstar-one.com
  • 5. CONTENTSAcronyms............................................................................................................................................................................ ixIntroduction ........................................................................................................................................................................ 1 Background..................................................................................................................................................................... 1 Purpose ........................................................................................................................................................................... 2Methods ............................................................................................................................................................................... 5 Data Collection Methods............................................................................................................................................ 5 Sampling Strategy .......................................................................................................................................................... 6 Team Training and Pilot Study................................................................................................................................... 7 Field Work Protocols and Survey Respondents ................................................................................................... 8 Assessment Limitations ............................................................................................................................................... 8Findings ............................................................................................................................................................................... 11 General Site Characteristics .................................................................................................................................... 11 HIV Testing and Counseling ..................................................................................................................................... 12 PMTCT Guidelines and Protocols .......................................................................................................................... 13 Family Planning ............................................................................................................................................................ 15 CD4 Testing ................................................................................................................................................................. 16 Antiretroviral Therapy for Women’s Health....................................................................................................... 17 Labor and Delivery ..................................................................................................................................................... 19 Exposed Infant Follow-up ......................................................................................................................................... 19 Community Linkages.................................................................................................................................................. 21 Patient-Provider Ratio ............................................................................................................................................... 22 Training ......................................................................................................................................................................... 22 Supervision ................................................................................................................................................................... 22 Commodities ............................................................................................................................................................... 25 Monitoring and Evaluation ........................................................................................................................................ 27Integration Analysis ......................................................................................................................................................... 29 Level of Integration Score Methodology ............................................................................................................... 29 Integration Analysis Findings .................................................................................................................................... 31Conclusions and Recommendations ........................................................................................................................... 35References ......................................................................................................................................................................... 37Appendix A: Power Analysis ......................................................................................................................................... 39Appendix B: Sample of 70 Selected Facilities ............................................................................................................ 41Appendix C: Interviewees by Title, per Facility ....................................................................................................... 43 vii
  • 6. Appendix D: World Health Organization PMTCT Treatment Guidelines and Protocols, 2010 ................. 45Appendix E: Tanzania National Recommendations—Antiretroviral Prophylaxis Regimens for PMTCT,2007 .................................................................................................................................................................................... 47Appendix F: Descriptive Statistics on Reporting Sites ............................................................................................ 49viii
  • 7. ACRONYMSANC antenatal careART antiretroviral therapyARV antiretroviralAZT azidothymidineAZT+3TC azidothymidine + lamivudineCRS Catholic Relief ServicesDBS dried blood spotsDOD U.S. Department of DefenseEGPAF Elizabeth Glaser Pediatric AIDS FoundationHAART highly active antiretroviral therapyHTC HIV testing and counselingICAP International Center for AIDS Care and Treatment ProgramsLOI level of integrationMDH Management and Development for HealthMNCH maternal, newborn, and child healthPCR polymerase chain reactionPEPFAR U.S. President’s Emergency Plan for AIDS ReliefPMTCT prevention of mother-to-child transmissionsdNVP single-dose nevirapineUNAIDS Joint United Nations Programme on HIV/AIDSWHO World Health OrganizationUSAID U.S. Agency for International Development ix
  • 8. x
  • 9. INTRODUCTIONEach year, approximately 430,000 babies are born to HIV-infected mothers (World HealthOrganization [WHO] 2010a). Over 90 percent of HIV infections in young children and infants are aresult of mother-to-child transmission (WHO 2010a). Prevention of mother-to-child transmission(PMTCT) interventions can reduce transmission from 25 to 35 percent to less than 5 percent (WHO2010b).The Joint United Nations Programme on HIV/AIDS’ (UNAIDS’) campaign to end mother-to-childtransmission by 2015, which calls for a reduction in HIV infections in children by 90 percent and areduction in maternal deaths related to HIV by 50 percent, will require increased resources devotedto PMTCT, increased capacity of health care workers, new technologies, and improved access toquality interventions for women, children, and families. Tanzania’s PMTCT program is a flagshipeffort in the UNAIDS Countdown to Zero campaign (UNAIDS 2011). Program leaders and nationallevel stakeholders have shown their commitment to the campaign by promoting strategies thatenable increased access to and improved quality of maternal and child health care, particularly forthe HIV-exposed and infected. One of those strategies is integrating PMTCT interventions withinmaternal, newborn, and child health (MNCH) services.Prevention of mother-to-child transmission and MNCH services are traditionally implemented asseparate programs: they are supported by vertical funding streams, may be located in different areasof a single facility, and are often staffed separately. In guidelines released in 2010, WHOrecommended that health facilities integrate PMTCT with MNCH services to improve patientfollow-up and adherence (WHO 2010c). Also, the U.S. Global Health Initiative prioritizes integratedhealth service delivery with an emphasis on a women- and girl-centered approach. Integration ofPMTCT within MNCH offers the opportunity to target women for HIV prevention services, todecrease attrition, to share resources and information, and to ultimately prevent mother-to-childtransmission of HIV.BACKGROUNDTanzania has a generalized HIV epidemic with a 6.2 percent prevalence (UNAIDS 2008) among alladults and a 6.8 percent prevalence among women (TACAIDS, ZAC, NBS, OCGS, and MacroInternational Inc. 2008). In 2008, an estimated 1.3 million adults and children were living with HIVin Tanzania, with about 10 percent of those being children under age 18 (United Republic ofTanzania 2010). Women and girls are more likely to be living with HIV than men and boys, and 8.2percent of pregnant women are infected (National AIDS Control Programme 2007). Every year,between 70,000 and 80,000 infants are at risk of acquiring HIV during pregnancy, labor and delivery,or through breastfeeding (United Republic of Tanzania 2010).The 2007 Tanzania National PMTCT Guidelines advance PMTCT/MNCH integration, providingspecific guidance and practical applications for integrating PMTCT services during antenatal care(ANC), reproductive and child health, and postnatal care (United Republic of Tanzania Ministry ofHealth and Social Welfare). The WHO HIV/MNCH Technical Working Group developed anoperational definition for integration that this report endorses. Integration is defined as “the 1
  • 10. organization, coordination, and management of multiple activities and resources to ensure thedelivery of more efficient and coherent services in relation to cost, output, impact, and use(acceptability)” (U.S. President’s Emergency Plan for AIDS Relief [PEPFAR] 2011, 5). Effectiveintegration requires coordination at multiple levels, within and among government and partneragencies, including policies and guidelines, administration and governance, funding, humanresources, information systems, and commodity supply chains. Integration may also require servicedelivery by a multidisciplinary team, which is often supported by several partners and provided in amutually reinforcing manner at the facility, community, and household levels. Integration may needto be incremental. It can also be conceptualized in terms of patient experience at the service deliverylevel (as illustrated in Figure 1) through a continuum of care: from a woman of childbearing agethrough pregnancy, delivery, and beyond. The recommended package should be accessible,affordable, and acceptable to women and children, and is most effective if provided early and if it isaccessible throughout the continuum of care.Figure 1. The Lifecycle Continuum of CareSource: PEPFAR 2011, 5Funding for the national PMTCT program in Tanzania is predominantly provided by PEPFAR,through its agencies that are responsible for implementing the plan. These agencies include the U.S.Agency for International Development (USAID), the U.S. Centers for Disease Control andPrevention (CDC), and the U.S. Department of Defense (DOD). Other sources of funding haveincluded the Global Fund to Fight AIDS, Tuberculosis and Malaria (for test kits, reagents, andantiretroviral [ARV] drugs), UNITAID (for pediatric ARVs), and the government’s own internalresources through the Ministry of Health and Social Welfare, the Prime Minister’s Office, and theRegional Affairs and Local Government office. In 2007, in an effort to expand access to healthservices to the most remote regions of the country, the National AIDS Control Programimplemented a regionalization strategy for PEPFAR implementing partners, wherein partners wereasked to coordinate and deliver PMTCT services in close partnership with regional and districtmedical offices in up to five geographical regions (PEPFAR 2010). This resulted in expansion of thePMTCT program in rural areas and in dispensaries and health centers, which are the facilities wherethe most Tanzanian women receive primary care.Despite notable expansion of the PMTCT program, the development of several guidelines andprotocols for improving access to PMTCT interventions across the continuum of MNCH services,and a considerable number of women accepting HIV testing and counseling (HTC), in 2009, onlyapproximately 68 percent of women who tested positive for HIV received antiretroviral therapy(ART) for PMTCT, and only about 15 to 20 percent of children who tested HIV-positive throughDNA polymerase chain reaction (PCR) received ART (PEPFAR 2010).PURPOSEThe purpose of this report is to assess the U.S. Government-supported PMTCT program inTanzania, focusing on identifying programmatic achievements and challenges, defining and2
  • 11. measuring the level of integration at health facilities, and examining the association between the levelof integration and health outcomes. 3
  • 12. 4
  • 13. METHODSUSAID/Tanzania contracted AIDSTAR-One for the purpose of documenting and assessing thelevel of integration of the U.S. Government-supported PMTCT program. A cross-sectional surveytool capturing service delivery factors associated with PMTCT/MNCH integration was administeredto key personnel at 70 randomly sampled PMTCT sites.DATA COLLECTION METHODSThe Ministry of Health and Social Welfare, with support from PEPFAR through USAID, the U.S.Centers for Disease Control and Prevention, the U.S. DOD, and other funding partners, operatesapproximately 3,626 PMTCT facilities (United Republic of Tanzania 2010). A facility-based rapidassessment of PMTCT facilities was conducted among 70 randomly sampled facilities in Tanzania.At each site, the data collection team administered a site assessment tool 1 and conducted a facilitywalk-through 2 to capture existing infrastructure information. One recorder from each team tooknotes during the interview and the walk-through. Data were entered at the end of each day into anAccess database created for this project.The site assessment tool was created by PMTCT experts at John Snow, Inc., in collaboration withpartner agencies. Some components of the tool were adapted from instruments developed by FHI360, the Linkages Project (implemented by the Academy for Educational Development), and thePMTCT Effectiveness in Africa: Research and Linkages to Care and Treatment (PEARL) study.This tool examined the extent of PMTCT and MNCH integration via specific program dimensionssuch as protocols and guidelines, staffing, training, service delivery, laboratory services, supply chain,and monitoring and evaluation. The facility walk-through (adapted from an FHI 360 template) is astandard facility checklist to capture the availability of specific infrastructure at each site. Both toolsyield an aggregate score that was used in statistical analysis.In addition, the PMTCT implementing partners were asked to submit site level data on 33 indicatorsrelated to ANC, labor and delivery, HIV testing, PMTCT and ART (mothers and infants), andfamily planning for the 70 randomly selected facilities. All implementing partners submitted data,with the exception of the U.S. DOD which was providing technical assistance at five of the facilitiesin the sample. While site assessments were completed for 70 health facilities, indicator data wereonly collected for 65 facilities. Using the data, AIDSTAR-One then calculated facility-levelpercentages, for example, to determine the percent of pregnant women in ANC who tested positivefor HIV. AIDSTAR-One also reviewed the indicators for data quality issues (e.g., missing data,numerator larger than the denominator, etc.) and requested clarifying information from theimplementing partners. Some implementing partners provided updated data; others did not.Indicators with data quality issues were considered missing and excluded from the analyses.1 Tool available at http://www.aidstar-one.com/sites/default/files/PMTCT_Site_Assessment_Tool_Sept2011.doc.2 Tool available at http://www.aidstar-one.com/sites/default/files/Facility_WalkThrough_Questionnaire_Oct2011.doc. 5
  • 14. SAMPLING STRATEGYThere are seven main U.S. Government-supported PMTCT implementing partners in Tanzania:1. Catholic Relief Services (CRS; through AIDSRelief)2. The International Center for AIDS Care and Treatment Programs (ICAP)3. U.S. DOD4. Deloitte (through TUNAJALI)5. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)6. EngenderHealth7. Management and Development for Health (MDH).AIDSTAR-One contacted the implementing partners located in Tanzania before drawing the sampleand asked for an enumerated list of their affiliated facilities and the average volume of ANC patientsat these facilities. This list included 1,245 facilities, which served as the sampling frame or universefor the study. AIDSTAR-One used the United Republic of Tanzania Ministry of Health and SocialWelfare’s Online Health Facility Registry 3 to obtain information on the type of facility (dispensary,health center, district hospital, other hospital, regional hospital, referral/consultation hospital, orother), ownership (government, voluntary/religious, parastatal, private, or other), operational status(operational, not operating, or under construction), and region/district 4 for the sample of facilities.The determination of the number of facilities to be sampled was based on a power calculation thatindicated the minimal number of facilities necessary to conduct the statistical analyses used (linearregression) to examine the results with 80 percent power and a medium effect size (see AppendixA). The power calculation was conducted using G*-power 3.1.2, an online power calculator(University of Kiel, Germany). All sampling analyses were performed in SAS version 9.2 (SASInstitute, Inc., Cary, NC).SAMPLING PROCEDUREThe goal of the sampling procedure was to include facilities with different ANC patient volumelevels from all of the major PMTCT implementing partners across Tanzania (see Figure 2 for a mapof survey site locations). Volume was categorized as low (50 to 99 patients), moderate (100 to 199patients), and high (≥ 200 patients), and was based on information gathered from implementingpartners. Facilities with fewer than 50 patients seen in the past month were excluded because theirvolume of ANC patients was too low to provide useful information for this assessment. Facilitieswere subsequently sampled by implementing partner and volume to ensure that all partners wererepresented and that the distribution of patient volume within each partner of the sample matchedthat of the greater list of facilities. The sample was selected using a stratified cluster samplingprocedure.The number of facilities selected from each implementing partner was proportional to theimplementing partner’s representation in the enumerated facility list. Appendix B shows thestratification by implementing partner and volume. To ensure that there were an adequate number3 www.moh.go.tz/health_facility_registry/4 Information on facilities residing on Pemba and Unguja islands was not included in the Tanzanian health facility registry.6
  • 15. of facilities sampled from each partner, the sample size was rounded up from 68 facilities to 70facilities. The total number of facilities randomly sampled was 70 with at least one facility sampledfrom each volume level of each implementing partner, except for Deloitte because there were zerohigh volume facilities for this partner.In some instances, facilities selected by random sampling had to be removed from the cohortselected and replaced by an alternate site for reasons such as no longer providing PMTCT services,no longer operating, no staff at the facility upon arrival of the data collection team, not located instated location, or logistically impossible to reach during the assessment period. In these cases (n =5), implementing partners and the district health management teams were contacted to suggest areplacement facility with similar characteristics (e.g., size, type, PMTCT services provided, location,and implementing partner).Figure 2. Map of Tanzania by Region and PEPFAR PMTCT Implementing Partner: SurveySite Selections IndicatedTEAM TRAINING AND PILOT STUDYAIDSTAR-One contracted a Tanzania-based monitoring and evaluation organization, JLConsulting, to coordinate logistics of the assessment and provide qualified individuals for datacollection. Eighteen monitoring and evaluation associates were contracted through JL Consulting tocomprise six teams of three individuals. Each team was comprised of one clinician and two 7
  • 16. additional individuals who were trained in research methods and data collection. A seniormonitoring and evaluation associate acted as the team leader on each team.Assessment training was conducted by a senior HIV/AIDS advisor at John Snow, Inc., on October26 and 28. The training addressed: an introduction of PMTCT; PMTCT/MNCH integrationcomponents; clinical review of terms, drug names, and HIV transmission; study goals and objectives;study methods; the site assessment and walk-through tools; roles and responsibilities of teammembers; database software, including data entry; and logistics.On October 27, the six teams were deployed to six MDH sites in Dar es Salaam that were notincluded in the sample to pilot the tools (Mwananyamala Hospital, Mbande Dispensary, KimaraDispensary, Buguruni Health Center, Chanika Dispensary, and Mbagala Rangi Tatu Dispensary).Four of the six teams were accompanied by senior AIDSTAR-One or JL Consulting staff. Eachteam debriefed at the end of the pilot, discussed what worked and challenges, and suggestedrevisions to the tools. Some revisions were made to the site assessment and walk-through tools, andthe team reconvened on October 28 to discuss revisions, challenges, and receive training on dataentry. The teams were deployed to the sample sites on Saturday, October 29.FIELD WORK PROTOCOLS AND SURVEYRESPONDENTSUpon arrival to a region, the team reported to the regional medical officer and the district medicalofficer in the district where the facility is located as a courtesy call. In addition, teams liaised withcoordinators from the implementing partners who assisted with locating facilities.At each facility, the teams introduced themselves and the project to the staff in-charge who was amedical officer, clinical officer, or nurse. After describing the tool to the staff in-charge, the datacapturers asked to interview staff with expertise in each area of interest. Respondents were selectedby the staff in-charge and included clinical officers, nurses, or medical assistants (see Appendix C forlist of interviewees). For questions requiring additional specialized input, laboratory and pharmacyleadership were queried.The tool was administered in Swahili, with all data capturers fluent in Swahili. An average of 3.5hours were spent at each site.ASSESSMENT LIMITATIONSThere are several limitations to this analysis. The sample size was small due to funding limitations.Although appropriate calculations were made to assure appropriate power, findings may not begeneralizable to all sites in Tanzania. In addition, aggregate data obtained from implementingpartners was utilized as opposed to collecting patient level data at each site, which may haveprovided more reliable indicator estimates.Much of this assessment was dependent on responses from survey respondents who were site staff.Survey respondents were primarily selected by the leadership at each site. It is possible that there wasinherent selection bias in that process. Data from key informants who were not selected but whomay have been able to provide important information may not have been captured. Data capturerswere also limited to administering the survey to staff available on that day. Input from staff who mayhave provided critical information but who were not present on the day of the assessment was not8
  • 17. obtained. In addition, staff turnover is known to be high, and responses were not stratified based onthe length of employment at the particular site. Lastly, staff responses may suffer from recall bias.Though these limitations exist, they are inherent to assessments of this nature. Gaps in knowledgehave been identified and should be explored further. The results of this assessment can be used todraw some general conclusions about PMTCT services and PMTCT/MNCH integration inTanzania. 9
  • 18. 10
  • 19. FINDINGSFindings from the site assessment and facility walk-through tools are detailed in the followingsection.GENERAL SITE CHARACTERISTICSSeventy sites supported by seven implementing partners and programs across 48 districts and 14regions of Tanzania were assessed (see Appendix B). Of the sites visited, 58.6 percent weredispensaries, 28.6 percent were health centers, and 12.9 percent were district hospitals or other typesof hospitals, including one site which was a regional hospital. Most of the facilities in the sample arelocated in rural areas (64.3 percent), whereas 22.9 percent are in urban locations, and 12.9 percentare located in peri-urban or suburban areas. The estimated population covered by all facilities was4,191,394. Tables 1 and 2 provide sample description by implementing partner, site type, andvolume.Table 1. Sample by Implementing Partner and Site TypeImplementing Dispensary Health Center Hospital OverallPartner (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %CRS (AIDSRelief) 18 43.9% 4 20.0% 0 0% 22 31.4%U.S. DOD 2 4.9% 2 10.0% 1 11.1% 5 7.1%EGPAF 14 34.2% 7 35.0% 0 0% 21 30.0%EngenderHealth 1 2.4% 2 10.0% 3 33.3% 6 8.6%Deloitte (TUNAJALI) 1 2.4% 1 5.0% 2 22.2% 4 5.7%ICAP 1 2.4% 4 20.0% 1 11.1% 6 8.6%MDH 4 9.8% 0 0% 2 22.2% 6 8.6%Table 2. Sample by Volume and Site TypeVolume Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %50 to < 100 (low) 22 53.7% 8 40.0% 6 66.7% 36 51.4%100 to < 200 (moderate) 14 34.1% 6 30.0% 2 22.2% 22 31.4%> 200 (high) 5 12.2% 6 30.0% 1 11.1% 12 17.1% 11
  • 20. HIV TESTING AND COUNSELINGHIV testing and counseling is a basic service that should be integrated within ANC and labor anddelivery (see Table 3 for HTC services offered by site type). All sites (70) offer HTC at ANC, and95.7 percent (67 sites) offer HTC as an integrated service within ANC during regular clinic hours,testing every woman at her first prenatal care visit. Sixty-five percent (45 facilities) use an opt-inapproach to testing (defined as “the client is explicitly asked for consent to test and it must begiven”), whereas 34 percent (24 facilities) use an opt-out approach (defined as “all women accessingANC are tested unless they explicitly refuse”). Of note, opt-out and opt-in were specifically definedby the data capturer who administered the survey. Facilities reported using both group andindividual pre-test counseling, but the majority of sites use group pre-test counseling (91 percent).Pre-test counseling is offered across all sites at ANC, although some facilities also have voluntarycounseling and testing or a care and treatment clinic on-site where patients are referred for HTC.Post-test counseling is offered for individuals or couples at all sites.Every facility queried utilizes rapid test kits and provides results to women the same day as the test.All sites (70) reported that if the first rapid test is positive, a second confirmatory test is conducted.If the second test is negative, 48.6 percent (34 sites) conduct a third tie-breaker rapid test. Seventeenpercent (12 sites) stated that if the rapid test is positive, the confirmatory procedure is to referpatients to another facility. This is likely due to stockout of HIV test kits. Ninety percent (63 sites)routinely offer HTC to partners as part of the PMTCT program. Only one site reported not havingany type of disclosure support system in place for women who test positive.Table 3. HIV Testing and Counseling Services Offered, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Test women at ANC 41 100% 20 100% 9 100% 70 100%Offer HTC during regular clinic 39 95.1% 19 95.0% 9 100% 67 95.7%hoursUse opt-out approach* 17 41.5% 5 25.0% 2 22.2% 24 34.3%Offer pre-test counseling at ANC 41 100% 20 100% 9 100% 70 100%Use rapid tests 41 100% 20 100% 9 100% 70 100%Administer second confirmatory 41 100% 20 100% 9 100% 70 100%test (when first test indicatespositive result)Administer third tie-breaker test 14 34.1% 13 65.0% 7 77.8% 34 48.6%Refer women for confirmatory 9 22.0% 2 10.0% 1 11.1% 12 17.1%HIV testRoutinely offer HTC to partners 36 87.8% 19 95.0% 8 88.9% 63 90.0%Offer disclosure support for 41 100% 19 95.0% 9 100% 69 98.6%women who test positive* Opt-out approach: all women accessing ANC are tested unless they explicitly refuse.12
  • 21. Several challenges to implementing quality HTC were captured through qualitative responses. Lowmale partner involvement was identified as a common problem (70 percent of respondents). Otherchallenges cited included: test kit and equipment shortages (54 percent of sites), patient denial ofHIV test results (30 percent), patient reluctance to disclose HIV status to partners (28 percent), lackof trained staff or high workload (28 percent), discordant couples (24 percent), and stigma or patientfear of isolation (14 percent).PMTCT GUIDELINES AND PROTOCOLSRespondents were asked to identify which PMTCT guideline was used to guide management ofpatients; data collectors did not require verification such as by observing a paper copy. Most sites (75percent) reported using the National Guidelines of Tanzania 2007; one reported using WHO 2006guidelines; one site reported using WHO 2010 guidelines; one site did not know; and 13 reported“other,” including seven sites that use the revised National Guidelines of Tanzania 2010. (SeeAppendices D and E for WHO 2010 PMTCT guidelines for ARV prophylaxis and Tanzania’s 2007national PMTCT guidelines for ARV prophylaxis, respectively.)Survey results reveal that only two facilities of those sampled do not offer ARV prophylaxis. Table 4shows regimens of ARV prophylaxis offered to ART-ineligible HIV-positive pregnant women. Mostfacilities offer azidothymidine (AZT) from 14 weeks gestation (65.7 percent), single-dose nevirapine(sdNVP; 84.4 percent), and azidothymidine + lamivudine (AZT+3TC; 71.4 percent) at labor anddelivery for ART-ineligible women. Less than half of the sites reported offering twice dailyAZT+3TC for seven days postpartum. Only 10 percent (seven sites) offer triple drug therapystarting at 14 weeks gestation and continued until delivery or until one week after infant exposure tobreast milk. Eleven percent (eight facilities) noted that they offer daily AZT or triple drug therapyfrom 28 weeks gestation.Table 4. Regimens of ARV Prophylaxis Offered to ART-ineligible HIV-positive PregnantWomen, by Site Type* Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %sdNVP 31 75.6% 19 95.0% 9 100% 59 84.4%Daily AZT from 14 weeks 29 70.7% 14 70.0% 3 33.3% 46 65.7%gestationAZT+3TC during labor and 27 65.9% 17 85.0% 6 66.7% 50 71.4%deliveryTwice daily AZT+3TC for seven 15 36.6% 9 45.0% 4 44.4% 28 40.0%days postpartumTriple ARV prophylaxis from 14 3 7.3% 2 10.0% 2 22.2% 7 10.0%weeks gestation until one weekafter all breastfeeding has endedOther† 1 2.4% 4 20.0% 3 33.3% 8 11.4%* Note: The reported numbers and percentages for each regimen are not mutually exclusive.† Of facilities who reported offering “other” regimens, seven offered daily AZT from 28 weeks gestation, and one offered triple-drug therapyfrom 28 weeks gestation. 13
  • 22. Table 5 shows regimens and integration with ANC. Single-dose nevirapine for prophylaxis isdispensed or obtained within ANC or the labor ward at 80 percent of the sampled facilities (56 sites)or elsewhere at the same facility at 2.9 percent of facilities (two sites). Antiretroviral prophylaxis withmore efficacious regimens is offered at ANC at 80 percent of facilities (56 sites), and offeredelsewhere at the same facility at 5.7 percent of facilities (four sites).Table 5. Regimens of ARV Prophylaxis Offered to ART-ineligible HIV-positive PregnantWomen Integrated with ANC Services, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %sdNVP for prophylaxis for womenIntegrated with ANC 29 70.7% 18 90.0% 9 100% 56 80.0%Offered at ANC at different 0 0% 1 5.0% 0 0% 1 1.4%day/timeOffered elsewhere at the same 2 4.9% 0 0% 0 0% 2 2.9%facilityNot offered 10 24.4% 1 5.0% 0 0% 11 15.7%Among those that responded “not 3 30.0% 0 0% 0 0% 3 27.3%offered,” referral providedARV prophylaxis with more efficacious regimensIntegrated with ANC 33 80.5% 15 75.0% 8 88.9% 56 80.0%Offered at ANC at different 0 0% 1 5.0% 0 0% 1 1.4%day/timeOffered elsewhere at the same 0 0% 3 15.0% 1 11.1% 4 5.7%facilityNot offered 8 19.5% 1 5.0% 0 0% 9 12.9%Among those that responded “not 5 62.5% 1 100% 0 0% 6 66.7%offered,” referral providedQualitative data revealed several common challenges to providing PMTCT to HIV-positive women,including: equipment and/or drug shortages (30 percent of sites); stigma or patient fear of isolation(19 percent); patients lost to follow-up (19 percent); patient denial of HIV test results (17 percent);patient reluctance to disclose HIV status to their partner (17 percent); patient refusal of medicationor do not follow medication instructions (13 percent); staff shortage (11 percent); and lack ofpartner involvement (10 percent). Additionally, challenges to integrating PMTCT within ANCservice delivery can be found in Table 6.14
  • 23. Table 6. Challenges Integrating PMTCT within ANC ServicesChallenge Number of Sites Percentage of SitesStaff shortage 37 53%High workload 25 36%Building too small/too few rooms 17 24%Equipment/supplies/drug shortages 17 24%Staff training 8 11%Ninety-three percent of facilities (65 sites) offer ARV prophylaxis for HIV-exposed infants (seeTable 7). Four facilities reported not providing delivery services and referring all HIV-positive casesfor delivery and HIV-exposed infant follow up. Two sites do not provide any prophylaxis, forwomen or infants, and one site will begin providing services for children in 2012. All three of thesesites have been referring all positive clients elsewhere for care and treatment.Table 7. Regimens of ARV Prophylaxis Offered for HIV-exposed Infants, by Site Type* Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %sdNVP at birth only 27 65.9% 14 70.0% 5 55.6% 46 65.7%sdNVP at birth and daily until 28 68.3% 16 80.0% 5 55.6% 49 70.0%one week after breastfeeding hasendedARV prophylaxis for infants 37 90.2% 19 95.0% 9 100% 65 92.8%(sdNVP or AZT)*The reported numbers and percentages for each regimen are not mutually exclusive.Most facilities determine patient adherence with the use of ARV prophylaxis for the mother andinfant by patient self-report at ANC or at postpartum visits (88.6 percent of facilities). Twentyfacilities determine adherence by checking pharmacy records or the ANC card, 17 sites are linkedwith outreach where patients are asked about adherence outside of ANC or the postpartum visit, 2sites request that patients bring their drugs to postpartum visits, and 2 sites that offer ARVprophylaxis do not follow up on adherence. Of the 70 sites assessed, 44 percent (31 sites) offerhighly active antiretroviral therapy (HAART) to eligible HIV-positive pregnant women who needtreatment for their own health.FAMILY PLANNINGAlthough almost all of the facilities (98.6 percent or 68) reported offering family planning counselingto every woman who tests positive for HIV, 18.6 percent (13 sites) reported zero HIV-positivewomen using family planning methods, and 25.7 percent (18 sites) reported zero women living withHIV using long-lasting family planning methods (see Table 8). 15
  • 24. Table 8. Family Planning Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Offer family planning counseling to 39 95.1% 20 100% 9 100% 68 97.1%every HIV-positive womanOffer family planning counseling to 40 97.6% 19 95.0% 8 88.9% 67 95.7%every woman who comes for ANCZero HIV-positive women using 8 19.5% 3 15.0% 2 22.2% 13 18.6%family planning methods“Do not know” number/percent of 10 24.4% 9 45.0% 4 44.4% 23 32.9%HIV-positive women using familyplanning methodsZero use of long-lasting family 13 31.7% 4 20.0% 1 11.1% 18 25.7%planning methods by HIV-positivewomen“Do not know” number/percent of 1 2.4% 1 5.0% 0 0% 2 2.8%HIV-positive women using long-lasting family planning methodsThese findings represent the extent of what was obtained from facilities regarding family planningduring the assessment. It is suggested that a more comprehensive assessment of family planningofferings and uptake across Tanzanian health facilities is undertaken. Funders, the Ministry ofHealth, and implementing partners might also prioritize collection of family planning indicators,including uptake, during monitoring and evaluation supportive supervision visits and in monthlyreports.CD4 TESTINGOf the 70 health facilities providing PMTCT services, 15.7 percent (11 sites) have the ability to runCD4 tests on-site, 27.1 percent (19 sites) draw blood for CD4 testing on-site and send the specimento a lab offsite for analysis, then provide results to the woman back at the initial ANC facility, and57.1 percent (40 facilities) refer for all aspects of CD4 testing. Eighty-one percent of the facilitiesthat draw blood for CD4 testing on-site deliver results within one week of testing, whereas 13percent take up to two weeks. Three percent take up to one month to deliver results.Forty-three percent of facilities (30 sites) draw blood somewhere at the facility to conduct CD4testing, whether it is conducted on-site or the specimen is sent to a lab for testing. Of those 30facilities, 13 draw blood for CD4 testing during normal ANC clinic visits, 12 offer CD4 blood drawat ANC but at a different time, and 5 refer women elsewhere on-site for CD4 blood draw (see Table9). Forty-four percent of facilities (31 sites) provide the results of CD4 testing on-site; 14 deliverresults during normal ANC clinic visits, 14 deliver results at ANC at a different time, and at 3facilities women go somewhere aside from ANC at the same facility to receive their results.16
  • 25. Table 9. CD4 Testing Integration with ANC Services, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Blood drawn for CD4 countIntegrated with ANC 5 12.2% 6 30.0% 2 22.2% 13 18.6%Offered at ANC at different 3 7.3% 4 20.0% 5 55.6% 12 17.1%day/timeOffered elsewhere at the same 2 4.9% 3 15.0% 0 0% 5 7.1%facilityNot offered 31 75.6% 7 35.0% 2 22.2% 40 57.1%If not offered, referral provided 28 90.3% 7 100% 1 50.0% 36 90.0%Results of CD4 deliveredIntegrated with ANC 6 14.6% 7 35.0% 1 11.1% 14 20.0%Offered at ANC at different 4 9.8% 5 25.0% 5 55.6% 14 20.0%day/timeOffered elsewhere at the same 1 2.4% 1 5.0% 1 11.1% 3 4.3%facilityNot offered 30 73.2% 7 35.0% 2 22.2% 39 55.7%If not offered, referral provided 24 80.0% 7 100% 0 0% 31 79.5%ANTIRETROVIRAL THERAPY FOR WOMEN’SHEALTHForty-four percent of facilities (31 sites) offer HAART to eligible HIV-positive pregnant womenwho need treatment for their own health, although eligibility criteria varies across sites. Twenty-seven facilities provide HAART for women with a CD4 count less than 350, and four offer HAARTfor those with a CD4 count less than 200 (see Table 10). Of the 39 facilities that do not provideHAART for women’s health, 36 report referring patients to a separate facility for treatment. Of the31 facilities that provide HAART for women’s health, 19 offer treatment within the ANC clinic atthe same time as ANC services, 5 offer at the ANC clinic but at a different time (not integrated inthe normal ANC visit), and 7 facilities provide treatment elsewhere at the same facility (see Table11).Sixty-eight percent of the 31 facilities offering HAART for women’s health initiate treatment withinone week of determining eligibility. Twenty-six percent initiate HAART between two weeks and onemonth. At one site (three percent of those offering HAART for women’s health), women must waitmore than one month for treatment, and at another site, providers initiate treatment once thewoman understands the importance of adherence to treatment. Interviewees reported severalreasons for not offering HAART for women’s health, including a lack of trained staff (reported by94.6 percent of sites), no care and treatment clinic (86.5 percent), and inadequate infrastructure (8.1percent). 17
  • 26. Adherence support for mother-infant pairs is offered at 93 percent of facilities (65 of 70). Sixtyprovide treatment adherence support at regular ANC visits, four offer it at a different time withinthe ANC clinic, and at one facility, women can receive adherence support elsewhere at the facility.Forty-four percent of facilities (31 of 70 sites) discuss treatment and support options with HIV-positive pregnant women within ANC during normal hours, five sites provide this at a differenttime, three provide counseling elsewhere at the facility, and 31 facilities do not provide any sort oftreatment and support counseling on-site. Of the 31 who do not provide counseling, 30 offer areferral to a different facility to discuss treatment options.Table 10. HAART Initiation for Women’s Health, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Facilities that provide HAART for 8 19.5% 16 80.0% 7 77.8% 31 44.3%womens own healthHAART initiation criteria among sites offering ART for women’s healthWHO staging* 6 75.0% 11 68.8% 4 57.1% 21 67.7%CD4 count < 350* 8 100% 13 81.3% 6 85.7% 27 87.1%CD4 count < 200* 2 25.0% 2 12.5% 0 0% 4 12.9%Other (facility refers women to 1 2.4% 0 0% 0 0% 1 1.4%nearby care and treatment clinic forART initiation, except on some dayswhen staff from care and treatmentclinic offer ART in the facilityoutpatient department)* Responses are not mutually exclusive.Table 11. Integration of HAART for Women’s Health with ANC Services, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Facilities that provide HAART for 8 19.5% 16 80.0% 7 77.8% 31 44.3%womans own healthHAART offered for womens healthIntegrated with ANC 7 17.1% 6 30.0% 6 66.7% 19 27.1%Offered at ANC at different day/time 0 0% 5 25.0% 0 0% 5 7.1%Offered elsewhere at the same 1 2.4% 5 25.0% 1 11.1% 7 10.0%facilityNot offered 33 80.5% 4 20.0% 2 22.2% 39 55.7%If not offered, referral provided 31 93.9% 4 100% 1 50.0% 36 92.3%18
  • 27. LABOR AND DELIVERYSixty-four facilities have labor and delivery wards. Sixteen facilities reported zero deliveries for HIV-positive women on average per month, and five did not know (mean deliveries for HIV-positivewomen per month: 4.7; minimum: 0; maximum: 55). All of the facilities with labor and deliverywards reported testing women of unknown status at labor and delivery (see Table 12). Ten facilitiesoffer caesarean sections for HIV-positive women at delivery. Sites not offering caesarean sectionsprovide referrals for women who want to explore that option.Table 12. PMTCT Integration at Labor and Delivery, by Site Type, among Sites that OfferLabor and Delivery Dispensary Health Center Hospital Overall (n = 37) (n = 19) (n = 8) (n = 64) n % n % n % n %Test women of unknown status at labor 37 100% 19 100% 8 100% 64 100%and deliveryDispense ARVs for HIV-positive women 31 83.8% 19 100% 8 100% 58 90.6%at labor and deliveryDispense ARVs for HIV-exposed infants 29 78.4% 18 94.7% 7 87.5% 54 84.4%at labor and deliveryOffer caesarean section for HIV- 1 2.7% 2 10.5% 7 87.5% 10 15.6%positive womenElective caesarean section for HIV- 1 2.7% 2 10.5% 1 12.5% 4 6.3%positive women where possibleEXPOSED INFANT FOLLOW-UPEighty-seven percent of facilities (61 sites) identify exposed infants at their first postnatal visit atreproductive and child health services. Infants of infected mothers also have their exposure statusrecorded on child health cards, and 80 percent of facilities identify children this way. In addition,18.5 percent of facilities (13 sites) noted that community health workers also identify children whoare symptomatic. Facilities reported monitoring and following up with mother-infant pairs atpostpartum clinics (97 percent), pediatric clinics (33 percent), pediatric HIV clinics (11 percent),ART clinics (27 percent), infant feeding counseling sessions (59 percent), and growth monitoringsessions in communities (30 percent).Forty-one facilities obtain dried blood spots (DBS) for PCR testing of infants between 4 and 6weeks of age (see Table 13). All of the sites in the sample send specimens to a central lab for testingand provide results back at the initiating facility. Of the 41 sites that obtain DBS for PCR, 36 offerthat service at the same time as the normal ANC, four offer it at a different time within ANC, and atone facility, DBS collection occurs elsewhere on-site (see Table 14). 19
  • 28. Table 13. HIV Testing for Exposed Infants, by Site Type* Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Facilities offering DBS collection for 16 39.0% 16 80.0% 9 100% 41 58.6%PCR testingDBS for PCR at four to six weeks† 14 34.1% 14 70.0% 9 100% 37 52.9%DBS for PCR at less than 18 months if 6 14.6% 10 50.0% 2 22.2% 18 25.7%baby is symptomatic†DBS for PCR at 18 months† 5 12.2% 8 40.0% 3 33.3% 16 22.9%Serologic testing at 18 months 7 17.1% 4 20.0% 3 33.3% 14 20.0%Serologic testing at < 18 months if 1 2.4% 1 5.0% 0 0% 2 2.9%mother’s status is unknownNo tests available for exposed infants 22 53.7% 4 20.0% 0 0% 26 37.1%* All sites that offer PCR testing collect the DBS on-site and send the sample to an offsite lab for testing.† Response choices are not mutually exclusive.Table 14. Integration of DBS for PCR within ANC, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Facilities offering DBS collection for 16 39.0% 16 80.0% 9 100% 41 58.6%PCR testingDBS sample taken for PCRIntegrated with ANC 15 36.6% 12 60.0% 9 100% 36 51.4%Offered at ANC at different day/time 1 2.4% 3 15.0% 0 0% 4 5.7%Offered elsewhere at the same facility 0 0% 1 5.0% 0 0% 1 1.4%Not offered 25 61.0% 4 20.0% 0 0% 29 41.4%If not offered, referral provided 23 92.0% 4 100% 0 0% 27 93.1%Postnatal services offered to exposed infants at facilities in the sample include: early ART (47percent); treatment adherence support (54 percent); nutrition counseling (91 percent); cotrimoxazolepreventive treatment (93 percent); tuberculosis screening and diagnosis (43 percent); tuberculosisprevention including isoniazid prophylaxis (13 percent); tuberculosis management and treatment (24percent); and psychosocial support (94 percent; see Table 15). All facilities promote exclusivebreastfeeding for HIV-positive women, HIV-negative women, and women of unknown status. Mostfacilities provide follow-up support and lactation management: 22 sites use home visits and 62 sitesfollow up at postnatal care. Six sites report not providing any lactation management or follow up towomen who are HIV-positive. Three facilities supply infant formula to women who are HIV-positive, if requested. The majority of sites provide follow up to mother-infant pairs at a postpartumclinic (see Table 16).20
  • 29. Table 15. Postnatal Services for Children Born to HIV-positive Mothers, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Early ART 17 41.5% 10 50.0% 6 66.7% 33 47.1%Treatment adherence support 18 43.9% 14 70.0% 6 66.7% 38 54.3%Nutrition counseling/support and 37 90.2% 18 90.0% 9 100% 64 91.4%infant feedingCotrimoxazole preventive treatment 37 90.2% 19 95.0% 9 100% 65 92.9%Tuberculosis screening and diagnosis 9 22.0% 14 70.0% 7 77.8% 30 42.9%Tuberculosis prevention, including 4 9.8% 3 15.0% 2 22.2% 9 12.9%isoniazid prophylaxisTuberculosis management and 8 19.5% 7 35.0% 2 22.2% 17 24.3%treatmentPsychosocial support 40 97.6% 17 85.0% 9 100% 66 94.3%None of the above 1 2.4% 0 0% 0 0% 1 1.4%Table 16. Follow up of HIV-positive Mother-Infant Pairs, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Postpartum clinic 40 97.6% 19 95.0% 9 100% 68 97.1%Pediatric clinic (general) 14 34.1% 8 40.0% 1 11.1% 23 32.9%Pediatric HIV clinic 2 4.9% 4 20.0% 2 22.2% 8 11.4%ART clinic 5 12.2% 10 50.0% 4 44.4% 19 27.1%Nutrition/infant feeding counseling 31 75.6% 6 30.0% 4 44.4% 41 58.6%sessionsGrowth monitoring sites in the 15 36.6% 5 25.0% 1 11.1% 21 30.0%communityOther (“when come to other 1 2.4% 0 0% 0 0% 1 1.4%services”)COMMUNITY LINKAGESFacilities were asked about their knowledge of a range of services provided at the community level,and linkages between the facility and community. Forty-four percent of facilities (31 sites) reportedthat community-based organizations or community health workers provide information to womenin the community about PMTCT, and 33 percent of facilities reported that local community-basedorganizations or individuals provide referrals for PMTCT from the community to the facility. Otherservices that facilities reported were available to its communities include: psychosocial support (57 21
  • 30. percent), breastfeeding support (34 percent), home-based clinical services for people living with HIV(44 percent), socioeconomic support (35 percent), growth monitoring for infants (27 percent),immunization follow-up (27 percent), and family planning (38.5 percent). Sixteen percent of facilities(11 sites) reported linkages to community organizations that follow up with women who do notreturn for HIV test results, and 20 percent (14 facilities) reported a community linkage with anorganization that follows up with women who do not return for sdNVP.PATIENT-PROVIDER RATIOA patient-to-provider ratio was generated using the number of ANC patients seen at each site on theday of the assessment (data collected in the site assessment tool) and the number of providers(medical officers, clinical officers, PMTCT nurses, maternal and child health care/ANC nurses, andmidwives) observed by the data collector during the site walk-through on the day of the assessment(data collected in the facility walk-through tool). The median ratio of patients seen in ANC to ANCproviders seen during the walk-through was four ANC patients to one ANC provider (mean: 6.6;standard deviation: 7.9). The patient-provider ratio was not correlated with the PMTCT-ANCintegration score (the integration score is described in detail later; Spearman correlation coefficient:0.19, p = 0.11).Fifty-three percent of facilities (37 sites) reported that staff shortages were a primary challenge tointegrating PMTCT services with ANC or other programs, and 35.7 percent (25 sites) noted that ahigh workload was also a challenge. Sixty percent of facilities (42 sites) reported that increasing thenumber of staff would be a welcome assistance needed to improve integration. Twenty-eight percentof facilities (14 sites) reported that a lack of trained staff or high staff workload was a challenge forproviding HTC, and 11 percent (8 sites) reported that staff shortage was a challenge for providingPMTCT to HIV-positive women. Staffing is an issue for logistics management at four percent offacilities (three sites).TRAININGEleven percent of facilities (eight sites) noted that a lack of staff training or capacity building was achallenge to integrating PMTCT with ANC or other programs, and 34.3 percent of facilities (24sites) noted that the provision of staff training would improve integration at the site. Six percent offacilities (four sites) reported lack of staff training as a challenge to providing PMTCT to HIV-positive women. Table 17 shows types of training received by health care workers in the past year.SUPERVISIONEighty-nine percent of facilities (62 sites) reported that supervision for the PMTCT clinical nursingstaff is provided on a regular basis, and 74 percent of facilities (52 sites) noted that supervision wasprovided in the last three months. Of those who reported regular supervision, 40 sites reported thata supervisor observed staff at work, 51 sites reported that a supervisor provided feedback on staffperformance, 59 noted that the supervisor discussed problems staff encountered, and 60 reportedthat the supervisor checked staff members’ reports.22
  • 31. Table 17. Number of Facilities Reporting Health Care Workers Receiving Training in theLast Year by Cadre and Training, and by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Training on PMTCTMedical officer/clinical officer 15 36.6% 8 40.0% 5 55.6% 28 40.0%Registered nurse 9 22.0% 9 45.0% 5 55.6% 23 32.9%Enrolled nurse/midwife 22 53.7% 15 75.0% 9 100% 46 65.7%Counselor 0 0% 4 20.0% 2 22.2% 6 8.6%Lab technician 0 0% 7 35.0% 3 33.3% 10 14.3%Medical assistant 18 43.9% 9 45.0% 1 11.1% 28 40.0%Training on HTCMedical officer/clinical officer 22 53.7% 8 40.0% 5 55.6% 35 50.0%Registered nurse 8 19.5% 8 40.0% 4 44.4% 20 28.6%Enrolled nurse/midwife 21 51.2% 13 65.0% 9 100% 43 61.4%Counselor 1 2.4% 4 20.0% 2 22.2% 7 10.0%Lab technician 2 4.9% 8 40.0% 4 44.4% 14 20.0%Medical assistant 14 34.1% 7 35.0% 1 11.1% 22 31.4%Training on ARTMedical officer/clinical officer 14 34.1% 10 50.0% 5 55.6% 29 41.4%Registered nurse 6 14.6% 7 35.0% 5 55.6% 18 25.7%Enrolled nurse/midwife 15 36.6% 14 70.0% 6 66.7% 35 50.0%Counselor 0 0.0% 6 30.0% 1 11.1% 7 10.0%Lab technician 1 2.4% 3 15.0% 1 11.1% 5 7.1%Medical assistant 10 24.4% 5 25.0% 1 11.1% 16 22.9%Training on ART during pregnancyMedical officer/clinical officer 19 46.3% 6 30.0% 4 44.4% 29 41.4%Registered nurse 6 14.6% 7 35.0% 4 44.4% 17 24.3%Enrolled nurse/midwife 17 41.5% 13 65.0% 6 66.7% 36 51.4%Counselor 1 2.4% 2 10.0% 1 11.1% 4 5.7%Lab technician 0 0% 3 15.0% 2 22.2% 5 7.1%Medical assistant 10 24.4% 3 15.0% 1 11.1% 14 20.0% 23
  • 32. Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Training on care of HIV-exposed infantsMedical officer/clinical officer 13 31.7% 5 25.0% 4 44.4% 22 31.4%Registered nurse 7 17.1% 7 35.0% 3 33.3% 17 24.3%Enrolled nurse/midwife 13 31.7% 13 65.0% 8 88.9% 34 48.6%Counselor 1 2.4% 2 10.0% 1 11.1% 4 5.7%Lab technician 0 0% 0 0% 1 11.1% 1 1.4%Medical assistant 11 26.8% 2 10.0% 1 11.1% 14 20.0%Training on breastfeeding for HIV-positive womenMedical officer/clinical officer 12 29.3% 5 25.0% 3 33.3% 20 28.6%Registered nurse 8 19.5% 6 30.0% 5 55.6% 19 27.1%Enrolled nurse/midwife 17 41.5% 13 65.0% 7 77.8% 37 52.9%Counselor 1 2.4% 2 10.0% 1 11.1% 4 5.7%Lab technician 0 0% 1 5.0% 1 11.1% 2 2.9%Medical assistant 12 29.3% 2 10.0% 0 0% 14 20.0%Training on nutrition counseling for HIV-positive women and childrenMedical officer/clinical officer 13 31.7% 4 20.0% 2 22.2% 19 27.1%Registered nurse 7 17.1% 7 35.0% 1 11.1% 15 21.4%Enrolled nurse/midwife 17 41.5% 9 45.0% 6 66.7% 32 45.7%Counselor 1 2.4% 2 10.0% 0 0% 3 4.3%Lab technician 0 0% 0 0% 0 0% 0 0%Medical assistant 11 26.8% 2 10.0% 0 0% 13 18.6%Training on early infant diagnosis/DBSMedical officer/clinical officer 6 14.6% 4 20.0% 3 33.3% 13 18.6%Registered nurse 6 14.6% 5 25.0% 4 44.4% 15 21.4%Enrolled nurse/midwife 15 36.6% 10 50.0% 9 100% 34 48.6%Counselor 1 2.4% 3 15.0% 0 0% 4 5.7%Lab technician 0 0% 4 20.0% 3 33.3% 7 10.0%Medical assistant 7 17.1% 4 20.0% 0 0% 11 15.7%24
  • 33. COMMODITIESAvailability of drugs and commodities was low at many facilities (see Table 18). Twenty-four percentof facilities (17 sites) listed supplies and drug shortages as a major challenge to integrating PMTCTservices with ANC or other programs. Thirty-one percent of facilities (22 sites) reported thatimproving the availability of supplies and drugs would improve their efforts at integration, and 54percent (27 sites) reported test kit and equipment shortages were a challenge for providing HTC.Table 18. Drug/Supply Availability, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %Rapid test (e.g., Bioline)Currently available 29 70.7% 17 85.0% 9 100% 55 78.6%Stockout in last three months 34 82.9% 14 70.0% 6 66.7% 54 77.1%Site does not carry 0 0% 0 0% 0 0% 0 0%Confirmatory test 2 (e.g., Determine)Currently available 35 85.4% 17 85.0% 9 100% 61 87.1%Stockout in last three months 28 68.3% 9 45.0% 4 44.4% 41 58.6%Site does not carry 0 0% 0 0% 0 0% 0 0%Confirmatory test 3 (e.g., Unigold)Currently available 6 14.6% 7 35.0% 5 55.6% 18 25.7%Stockout in last three months 10 24.4% 10 50.0% 4 44.4% 24 34.3%Site does not carry 29 70.7% 5 25.0% 3 33.3% 37 52.9%NevirapineCurrently available 32 78.0% 17 85.0% 9 100% 58 82.9%Stockout in last three months 21 51.2% 3 15.0% 4 44.4% 28 40.0%Site does not carry 4 9.8% 3 15.0% 0 0% 7 10.0%Viral reagents for other HIV assaysCurrently available 6 14.6% 2 10.0% 2 22.2% 10 14.3%Stockout in last three months 9 22.0% 3 15.0% 1 11.1% 13 18.6%Site does not carry 12 29.3% 4 20.0% 2 22.2% 18 25.7%AZTCurrently available 29 70.7% 19 95.0% 8 88.9% 56 80.0%Stockout in last three months 21 51.2% 7 35.0% 3 33.3% 31 44.3%Site does not carry 6 14.6% 1 5.0% 1 11.1% 8 11.4%AZT+3TCCurrently available 16 39.0% 19 95.0% 8 88.9% 43 61.4%Stockout in last three months 17 41.5% 7 35.0% 2 22.2% 26 37.1%Site does not carry 16 39.0% 0 0% 1 11.1% 17 24.3% 25
  • 34. Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %3TCCurrently available 22 53.7% 18 90.0% 7 77.8% 47 67.1%Stockout in last three months 17 41.5% 6 30.0% 2 22.2% 25 35.7%Site does not carry 12 29.3% 1 5.0% 2 22.2% 15 21.4%Efavirenz (EFV)Currently available 9 22.0% 16 80.0% 6 66.7% 31 44.3%Stockout in last three months 8 19.5% 6 30.0% 0 0% 14 20.0%Site does not carry 27 65.9% 3 15.0% 3 33.3% 33 47.1%Stavudine (d4T)Currently available 8 19.5% 14 70.0% 6 66.7% 28 40.0%Stockout in last three months 9 22.0% 5 25.0% 0 0% 14 20.0%Site does not carry 25 61.0% 4 20.0% 3 33.3% 32 45.7%Cotrimoxazole/SeptrinCurrently available 32 78.0% 17 85.0% 9 100% 58 82.9%Stockout in last three months 21 51.2% 8 40.0% 4 44.4% 33 47.1%Site does not carry 4 9.8% 1 5.0% 0 0% 5 7.1%DBS suppliesCurrently available 14 34.1% 14 70.0% 0 0% 37 52.9%Stockout in last three months 8 19.5% 5 25.0% 4 44.4% 17 24.3%Site does not carry 26 63.4% 3 15.0% 0 0% 29 41.4%Phlebotomy suppliesCurrently available 26 63.4% 19 95.0% 9 100% 54 77.1%Stockout in last three months 20 48.8% 8 40.0% 3 33.3% 31 44.3%Site does not carry 4 9.8% 0 0% 0 0% 4 5.7%ARV syrup for infantsCurrently available 24 58.5% 17 85.0% 8 88.9% 49 70.0%Stockout in last three months 21 51.2% 8 40.0% 4 44.4% 33 47.1%Site does not carry 6 14.6% 2 10.0% 1 11.1% 9 12.9%CondomsCurrently available 31 75.6% 16 80.0% 9 100% 56 80.0%Stockout in last three months 13 31.7% 5 25.0% 6 66.7% 24 34.3%Site does not carry 5 12.2% 1 5.0% 0 0% 6 8.6%Needles/syringesCurrently available 38 92.7% 20 100% 7 77.8% 65 92.9%Stockout in last three months 17 41.5% 6 30.0% 3 33.3% 26 37.1%Site does not carry 1 2.4% 0 0% 1 11.1% 2 2.9%26
  • 35. Challenges with logistics and supply chain management systems included: shortages of medicalsupplies, drugs, and/or equipment (41 percent of sites); delay of supply orders (21 percent); lack oftransportation or road infrastructure challenges (16 percent); supply replenishment not containingwhat was ordered (10 percent); and lack of communication (10 percent).MONITORING AND EVALUATIONNinety-three percent of facilities (65 sites) report reviewing data collected on PMTCT and ANCwith staff, and 53 sites note that this is done monthly. Table 19 outlines some of the uses of data atthe facility level as described by key staff.Table 19. Uses of Data Collected on PMTCT, by Site Type Dispensary Health Center Hospital Overall (n = 41) (n = 20) (n = 9) (n = 70) n % n % n % n %To evaluate/assess quality of 6 14.6% 8 40.0% 4 44.4% 18 25.7%services deliveredTo identify trends/status of HIV 12 29.3% 2 10.0% 1 11.1% 15 21.4%in the communityTo identify the quantity of 7 17.1% 3 15.0% 4 44.4% 14 20.0%medication/equipment neededTo identify needs/challenges for 10 24.4% 4 20.0% 0 0% 14 20.0%the clinicTo plan/budget for service 9 22.0% 3 15.0% 0 0% 12 17.1%deliveryTo improve patient/community 7 17.1% 0 0% 2 22.2% 9 12.9%educationTo identify patient attendance 1 2.4% 0 0% 1 11.1% 2 2.9%To identify trends/status of HIV 4 9.8% 3 15.0% 3 33.3% 10 14.3%within facilityTo help follow up with 3 7.3% 2 10.0% 0 0% 5 7.1%patients/identify the rate of lossto follow-upNo use 0 0% 1 5.0% 0 0% 1 1.4%To identify number of HIV- 1 2.4% 2 10.0% 0 0% 3 4.3%positive patientsTo know the number of patients 5 12.2% 0 0% 0 0% 5 7.1% 27
  • 36. 28
  • 37. INTEGRATION ANALYSISLEVEL OF INTEGRATION SCORE METHODOLOGYA level of integration (LOI) rating system was developed to quantify the degree to which PMTCTservices are integrated into MNCH services at the site level. A total integration score (0 to 20) wasassigned for each facility based on the availability of selected PMTCT services within the context ofANC/labor wards. Sites with higher scores were determined to have a higher LOI. The availabilityof the service was determined through interpreting responses on the site assessment tool. Aggregatesite level data for the fiscal year October 1, 2010, to September 30, 2011, were provided byimplementing partners. AIDSTAR-One requested 33 indicators from implementing partners. Of the33 requested, 15 were used in the analysis (two were determined by the analysis team to beunnecessary, four were used as denominators for other indicators, and 12 had less than 45 sitesreporting valid data, which was the cut off for the sample size for each indicator [70 percent of the65 sites reporting data]). Correlations between variables were tested using nonparametric methods,including the Spearman rank correlation test and the Wilcoxon-Mann-Whitney test (significant if p< 0.05). All statistical analyses were completed in SAS version 9.2.The LOI score was calculated using questions from the “Integration of PMTCT withinANC/MNCH” section of the site assessment tool. The question number from the site assessmenttool, as well as the point allocation, are provided (Table 20).Points from each question were summed to produce the total integration score, which potentiallycould range from 0 to 20. The integration score was used in analyses as a continuous variable, andhad a Cronbach’s alpha of 0.76, which determines reliability or internal consistency (i.e., averagecorrelation) of items included in the score (≥ 0.7 is acceptable).An infrastructure score was determined using the facility walk-through tool, as follows:• The first section of the facility walk-through questionnaire includes questions about the services offered at a facility. For each service that was provided, a facility received one point for the infrastructure score. In addition, a facility received one point for the number of days it was open for outpatient adult and/or child health services (Q9). The number of beds for inpatient overnight care (Q10) was not included in the infrastructure score.• The second section of the questionnaire includes questions about basic infrastructure. A facility received one point for each “yes” response in this section and one point for each examining room available for ANC/PMTCT services.• The third section of the questionnaire includes questions about personnel. A facility received one point if any of each type of personnel were observed. In other words, if any medical officers were observed, the facility received one point, and if any clinical officers were observed, the facility received one additional point, etc. Also, facilities received one point if the maternal and child health/ANC nurse(s) was also the PMTCT nurse(s). 29
  • 38. Table 20. Site Assessment Tool Point Allocation Offered during Offered within Offered routine hours the ANC unit elsewhere within the ANC at a different on-site or unit at the time as other not offered same time as services on-site other servicesQ50d: Psychosocial counseling is offered 1 0.5 0(partner disclosure, stigmatization)Q50fp: Family planning counseling 1 0.5 0Q50e: ARV prophylaxis for PMTCT with 1 0.5 0sdNVP for mothersQ50f: ARV prophylaxis for PMTCT with 1 0.5 0more efficacious combinations including dualand triple ARTQ50g: ARV prophylaxis for infants (sdNVP or 1 0.5 0AZT)Q50h: Infant feeding counseling and 1 0.5 0exclusive breastfeeding support for positivesQ50i: Infant formula available for those who 1 0.5 0do not breastfeedQ50j: Blood for CD4 count drawn for 2 1 0positivesQ50k: Results of CD4 returned to patients 2 1 0on-siteQ50l: Treatment and support options 1 0.5 0discussed with women eligible for treatmenton-siteQ50n: ART offered to eligible women for 2 1 0their own health (not PMTCT)Q50o: Exposed infant evaluation conducted 2 1 0in ANC/MNCH on a regular scheduleQ50p: DBS for HIV detection in infants done 2 1 0between 4 and 6 weeks of ageQ50r: Adherence support is available to 1 0.5 0mother-infant pairsQ50s: Cotrimoxazole offered to exposed 1 0.5 0infants30
  • 39. • The fourth section of the questionnaire includes questions about counseling and examination areas. Facilities received one point for having an examination bed or table in the exam room and one point for having a toilet or latrine for both patients and staff.• The fifth section includes questions about equipment and drug storage. A facility received one point for each piece of equipment observed. One point was also awarded for each “yes” response to the drug storage questions.• The last section includes questions about lab facilities. A facility received two points if there was a diagnostic laboratory in the facility. Two points were awarded if a facility conducted HIV rapid tests. For HIV viral load, CD4 count, and PCR, four points were awarded if a facility conducted the test and three points were awarded if a facility collected and sent specimens to another facility.• No points were awarded to a facility in the infrastructure score for a response of “no,” “undetermined,” or “don’t know” to any question in the facility walk-through.INTEGRATION ANALYSIS FINDINGSKey questions driving the analysis included:• What is the relationship between facility type, LOI, and infrastructure score?• What is the correlation between the LOI score and various quality indicators reported for each site?RELATIONSHIP AMONG FACILITY TYPE, LEVEL OFINTEGRATION, AND INFRASTRUCTURE SCOREThe median integration score was 12 (range 0.5 [low LOI] to 20 [high LOI]). As shown in Table 21,hospitals were found to have the highest median LOI score at 16.5 (range 11 to 19) followed byhealth centers at 14.75 (range 7.5 to 19) and dispensaries at 10 (range 0.5 to 20). The differencebetween dispensaries and hospitals and dispensaries and health centers was statistically significant (p< 0.05). Health centers have a significantly higher median LOI score than dispensaries, and hospitalshave a significantly higher median LOI score than both dispensaries and health centers.Table 21. Median Integration and Infrastructure Scores by Type of FacilityIndicators Dispensary Health Hospital Dispensary Health Health Hospital (n = 41) Center (n = 9) vs. Other Center vs. Center vs. Median (n) (n = 20) Median (n) (p value) Dispensary vs. Other Median (n) (p value) Hospital (p value) (p value) Number of new 410.0 (39) 686.5 (18) 884.5 (8) 0.003 0.03 0.1 0.008 patients in ANC Integration score 10.0 (39) 14.75 (18) 16.5 (8) 0.0003 0.003 0.41 0.02 Infrastructure score 47.0 (39) 58.0 (18) 58.0 (8) <0.0001 0.0001 0.62 0.09Wilcoxon-Mann-Whitney test (nonparametric version of t-test) reporting p values; red text indicates significant at p < 0.05. 31
  • 40. QUALITY INDICATORS BY SITE TYPEAs reflected in Table 22, dispensaries had the lowest proportion of HIV-positive mothers whoinitiated exclusive breastfeeding (6.3 percent), followed by health centers (33.3 percent), andhospitals (48.5 percent). Dispensaries also had a significantly lower percentage of HIV-positivepregnant women who received more efficacious regimens for PMTCT in ANC and HIV-positivepregnant women who initiated ARV treatment in ANC than health centers or hospitals, whereashospitals had the highest proportions of both.Table 22. Median Indicator Values by Facility TypeIndicators Dispensary Health Hospital Dispensary Health Health Hospital (n = 41) Center (n = 9) vs. Other Center vs. Center vs. Other Median (n) (n = 20) Median (p value) Dispensary vs. (p value) Median (n) (p value) Hospital (n) (p value)Number of new patients in 410.0 (39) 686.5 884.5 0.003 0.03 0.1 0.008ANC (18) (8)Pregnant women newly 0.2% (39) 0.7% 1.3% (8) 0.0005 0.01 0.31 0.007enrolled in ANC with (18)known HIV-positive statusPregnant women who 58.5% (36) 74.2% 94.4% 0.03 0.1 0.7 0.2received HIV test results in (12) (5)ANCPregnant women who were 2.1% (32) 4.7% 4.2% (4) 0.16 0.17 0.74 0.82tested and received results (16)in labor and deliveryPregnant women who 64.5% (32) 90.8% 94.4% 0.03 0.1 0.6 0.1received HIV counseling (12) (5)and education in ANCPregnant women who 2.1% (32) 7.4% 7.3% (4) 0.08 0.12 0.74 0.36received HIV counseling (16)and education in labor anddeliveryPregnant women who 1.3% (39) 2.7% 5.7% (8) 0.005 0.1 0.04 0.003tested HIV-positive in ANC (18)Pregnant women who 0% (32) 0.3% 0.4% (4) 0.008 0.03 0.67 0.1tested positive in labor and (16)deliveryPregnant women arriving 0.8% (32) 3.3% 12.9% 0.0003 0.002 0.22 0.02in labor and delivery with (16) (4)known positive statusHIV-positive mothers who 6.3% (35) 33.3% 48.5% 0.001 0.01 0.1 0.008initiated exclusive (18) (7)breastfeedingInfected pregnant women 4.5% (35) 4.1% 15.7% 0.7 0.8 0.8 0.8who received sdNVP in ANC (18) (8)32
  • 41. Indicators Dispensary Health Hospital Dispensary Health Health Hospital (n = 41) Center (n = 9) vs. Other Center vs. Center vs. Other Median (n) (n = 20) Median (p value) Dispensary vs. (p value) Median (n) (p value) Hospital (n) (p value)HIV-positive pregnant 8.3% (35) 34.9% 44.4% 0.01 0.06 0.1 0.03women who received other (18) (6)ARV regimens for PMTCT inANCHIV-positive pregnant 0% (34) 6.6% 28.2% 0.003 0.04 0.1 0.007women initiating ARV (14) (6)treatment in ANCInfants who received only 0% (23) 25.0% 19.4% 0.23 0.3 0.97 0.54sdNVP in labor and delivery (16) (7)Infants who received other 45.8% (22) 89.2% 83.6% 0.26 0.34 0.95 0.55ARV regimens for PMTCT in (16) (7)labor and deliveryInfants born to HIV-positive 0% (35) 12.5% 31.7% 0.02 0.1 0.2 0.02women enrolled in ANC (17) (7)Wilcoxon-Mann-Whitney test (nonparametric version of t-test) reporting p values; red text indicates significant at p < 0.05.IMPACT OF INTEGRATION SCORE ON QUALITY OF CAREINDICATORSAccording to the aggregated monitoring data reported for 65 sites during fiscal year 2011, 48,938pregnant women newly enrolled in ANC in 2011. Of these women enrolled, 2,535 were living withHIV. On average, sites provided 59.9 percent of HIV-positive women with PMTCT prophylaxis in2011 (descriptive statistics from monitoring data are included in Appendix F). Level of integrationwas positively correlated with quality of care indicators, which include: percent tested for HIV andreceived results in ANC (ρ = 0.33, p = 0.02), percent who initiated exclusive breastfeeding (ρ =0.30, p = 0.02), percent who received more effective combination ART for PMTCT prophylaxis (ρ= 0.40, p = 0.002), and percent initiating ART for their own health (ρ = 0.52, p < 0.0001).Integration did not appear to correlate with the percent of women who received sdNVP, the percentof infants who received only sdNVP in labor and delivery, or the percent of infants who receivedother ARV regimens for PMTCT in labor and delivery (Table 23). 33
  • 42. Table 23. Correlation Between Integration and Infrastructure Scores and MonitoringIndicatorsIndicators Integration Score Infrastructure Score (p value) (p value) Integration score – 0.69 (< 0.0001) Infrastructure score 0.79 (< 0.0001) –% of pregnant women who received HIV counseling 0.41 (0.004) 0.47 (0.0007)and education in ANC% of pregnant women who received HIV test results in 0.33 (0.02) 0.44 (0.001)ANC% of HIV-positive mothers who initiated exclusive 0.30 (0.02) 0.31 (0.01)breastfeeding% of infected pregnant women who received sdNVP in 0.003 (0.98) 0.0008 (1.0)ANC% of HIV-positive pregnant women who received other 0.40 (0.002) 0.31 (0.02)ARV regimens for PMTCT in ANC% of HIV-positive pregnant women initiating ARV 0.52 (< 0.0001) 0.50 (0.0001)treatment in ANC% of pregnant women who were tested and received -0.09 (0.54) -0.05 (0.72)results in labor and delivery*% of pregnant women who received HIV counseling -0.03 (0.82) 0.002 (0.99)and education in labor and delivery*% of pregnant women arriving in labor and delivery 0.49 (0.0003) 0.53 (< 0.0001)with known positive status*% of infants who received only sdNVP in labor and 0.02 (0.90) -0.09 (0.55)delivery*% of infants who received other ARV regimens for 0.27 (0.07) 0.25 (0.09)PMTCT in labor and delivery*Spearman (nonparametric) reporting correlation coefficients (p values). Red text indicates significant at p < 0.05.* Labor and delivery analysis only includes those sites with deliveries (n = 59).34
  • 43. CONCLUSIONS ANDRECOMMENDATIONSThe following conclusions and recommendations support continued efforts toward improvingaccess to PMTCT services and increasing PMTCT/MNCH integration in Tanzania’s PMTCTprogram:• Procurement of rapid test kits was noted on the national level as an ongoing issue in Tanzania during the period of this assessment. Once the larger issue is resolved, procurement training and enhanced supply chain management for reliable HTC commodities may mitigate further challenges experienced with HTC.• Male partner participation in HTC was identified as an ongoing challenge to implementing comprehensive HTC services at the site level. Initiatives to increase male participation include offering HTC for partners in more male friendly settings, enhancing counseling to encourage women to include their partners, and offering extended hours for HTC to encourage males to attend after work (Msuya and Mbizvo 2008).• The reported rate of opt-out HTC was low, particularly given that this strategy is emphasized within the Tanzanian National PMTCT Guidelines 2007. Although the rate of opt-out testing was reportedly low, according to implementing partner data, HIV testing rates for women presenting to ANC and labor and delivery are high. The survey was administered in Swahili and definitions were provided, however, there may be variations in how opt-out testing is both understood and conducted at the site level. Further investigation should be undertaken to ensure that opt-out testing is the approach that is uniformly utilized.• Limited data were collected on family planning methods and offerings within this site assessment. A comprehensive assessment of family planning offerings and uptake across Tanzanian health facilities is recommended, along with prioritizing collection of family planning indicators, including uptake, during monitoring and evaluation supportive supervision visits and in monthly reports.• Few sites have the capacity to offer on-site CD4 testing, which may impact the timing of ART for a woman’s own health, as well as long-term retention in care. Program planners may consider prioritizing the continued roll-out of capacity building for CD4 testing at all facility levels, including transport and communication assistance.• Human resource constraints are an ongoing limitation to the provision of care. Task-shifting select duties to lower level staff and/or community health workers may be one strategy for improving human resource constraints. Program planners may also implement ongoing training, support, and communication, and may consider incentives for top performers to improve staff morale and maintain high quality service delivery. 35
  • 44. • Overall, uptake of facility-based delivery remains low. Recommendations to increase skilled delivery include improving linkages between facilities and community-based organizations that provide services for pregnant women, innovative strategies to provide transport or incentives to women who deliver at facilities, and ongoing technical updates for providers who work with HIV-positive pregnant women and exposed infants.• Unreliable supply of drugs and commodities seems to be a salient issue for many facilities and may limit scale-up of high quality service delivery that adheres to national and international standards. Improved supply chain management and ongoing procurement training at the facility level may improve service delivery and overall quality of care.• Few sites report using data to some degree for planning, quality improvement efforts, identifying trends in health outcomes, and assessment. Continued updates and training on the importance of collecting, analyzing, and sharing quality data may further promote data quality and quality improvement efforts.The integration of PMTCT with MNCH offers the opportunity to target women for HIVprevention services, decrease attrition, share resources and information, and ultimately preventmother-to-child transmission of HIV. This assessment explored the relationship between integrationof PMTCT and MNCH and several key quality indicators. Overall, integration levels were highbased on the LOI scale that was developed. Integration is more common at the hospital level, whichis not a surprising finding given that hospitals have greater access to resources in comparison tohealth centers or dispensaries. The analysis suggests that higher levels of integration are correlated toimproved quality of care as measured by a number of indicators provided by the implementingpartners providing support to the sites assessed. This finding suggests that efforts should be directedtoward improving integration at lower level health facilities (i.e., dispensaries and health centers) toimprove quality of care and uptake of PMTCT.36
  • 45. REFERENCESJoint United Nations Programme on HIV/AIDS. 2008. Epidemiological Fact Sheets on HIV and AIDS, 2008 Update. Available at www.who.int/hiv/pub/epidemiology/pubfacts/en/ (accessed July 2012).Joint United Nations Programme on HIV/AIDS. 2011. Countdown to Zero: Global Plan Towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive 2011–2015. Geneva, Switzerland: UNAIDS.Msuya, S. E., and E. M. Mbizvo. 2008. Low Male Partner Participation in Antenatal HIV Counselling and Testing in Northern Tanzania: Implications for Preventive Programs. AIDS Care 20(6):700–9.National AIDS Control Programme. 2007. HIV/AIDS/STI Surveillance Report: January – December 2005: Report Number 20. Dar es Salaam, Tanzania: NACP.Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of Chief Government Statistician (OCGS), and Macro International Inc. 2008. Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS) 2007–08. Dar es Salaam, Tanzania: TACAIDS, ZAC, NBS, OCGS, and Macro International Inc.United Republic of Tanzania. 2010. UNGASS Reporting for 2010 (Tanzania Mainland and Zanzibar). Available at www.unaids.org/es/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountri es/file,33660,es..pdf (July 2012).United Republic of Tanzania Ministry of Health and Social Welfare. 2007. Prevention of Mother-to-Child Transmission of HIV National Guidelines, 2007. Available at www.nacp.go.tz/documents/PMTCT%20GUIDELINES%202007.pdf (accessed July 2012).U.S. President’s Emergency Plan for AIDS Relief. 2010. PEPFAR Tanzania PMTCT Plan Draft FY2010.U.S. President’s Emergency Plan for AIDS Relief. 2011. PEPFAR Guidance on Integrating Prevention of Mother to Child Transmission of HIV, Maternal, Neonatal, and Child Health and Pediatric HIV Services. Available at www.pepfar.gov/guidance/pmtct/158785.htm (July 2012).World Health Organization. 2006. Guidelines on Co-trimoxazole Prophylaxis for HIV-related Infections among Children, Adolescents and Adults: Recommendations for a Public Health Approach. Geneva, Switzerland: WHO.World Health Organization. 2010a. PMTCT Strategic Vision 2010–2015; Preventing Mother-to-Child Transmission of HIV to Reach the UNGASS and Millennium Development Goals. Geneva, Switzerland: WHO.World Health Organization. 2010b. Guidelines on HIV and Infant Feeding 2010: Principles and Recommendations for Infant Feeding in the Context of HIV and a Summary of Evidence. Geneva, Switzerland: WHO.World Health Organization. 2010c. Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Towards Universal Access: Recommendations for a Public Health Approach (2010 Version). Geneva, Switzerland: WHO. 37
  • 46. 38
  • 47. APPENDIX A: POWER ANALYSISAnalysis performed in G* Power 3.1.2Tests to be used - Linear multiple regression: Fixed model, R² increaseAnalysis: A priori: Compute required sample sizeInput:Effect size f² = 0.15α err probability = 0.05Power (1-β error probability) = 0.8Number of tested predictors = 2Total number of predictors = 2Output: Noncentrality parameter λ = 10.2000000Critical F = 3.1381419Numerator df = 2Denominator df = 65Total sample size = 68Actual power = 0.8044183 39
  • 48. 40
  • 49. APPENDIX B: SAMPLE OF 70 SELECTEDFACILITIESFacility Name Implementing Volume Region Type Estimated HIV Partner Seroprevalence* Among Adults (18+)Chamabanda Dispensary CRS (AIDSRelief) Low Mwanza Dispensary -Gamasara Dispensary CRS (AIDSRelief) Low Mara Dispensary < 1%Kibumaye Dispensary CRS (AIDSRelief) Moderate Mara Dispensary -Kilombero CRS (AIDSRelief) Low Mwanza Dispensary -Lwamgasa Dispensary CRS (AIDSRelief) Low Mwanza Dispensary 1%Mkolani CRS (AIDSRelief) High Mwanza Dispensary -Mondo Dispensary CRS (AIDSRelief) Moderate Mwanza Dispensary -Mugeta Dispensary CRS (AIDSRelief) Moderate Mara Dispensary -Nasa Health Centre CRS (AIDSRelief) Moderate Mwanza Health Center 8%Ngoma “A” Dispensary CRS (AIDSRelief) High Mwanza Dispensary -Nyamagaro Dispensary CRS (AIDSRelief) Moderate Mara Dispensary 1%RAO Health Centre CRS (AIDSRelief) Low Mara Health Center -Walla Dispensary CRS (AIDSRelief) Moderate Mwanza Dispensary -Baga Dispensary CRS (AIDSRelief) Low Tanga Dispensary -Funta Dispensary CRS (AIDSRelief) Low Tanga Dispensary -Kipumbwi Dispensary CRS (AIDSRelief) Low Tanga Dispensary -Kurusanga Dispensary CRS (AIDSRelief) Low Mara Dispensary -Kwamsisi Dispensary CRS (AIDSRelief) Moderate Tanga Dispensary -Manchimwera Dispensary CRS (AIDSRelief) Moderate Mara Dispensary -Ngamiani Health Center CRS (AIDSRelief) Moderate Tanga Health Center -Lyoma Dispensary CRS (AIDSRelief) Low Mwanza Dispensary 3%Nyehunge Health Centre CRS (AIDSRelief) High Mwanza Health Center 3%Mlowo Dispensary U.S. DOD Moderate Mbeya Dispensary 9%Pauline’s Dispensary U.S. DOD Low Mbeya Dispensary 9%Ruhanda Health Centre U.S. DOD High Mbeya Health Center 9%Tukuyu District Hospital U.S. DOD Moderate Mbeya Hospital 9%Utengule Usangu Health U.S. DOD Low Mbeya Health Center 9%CentreIpuli Dispensary EGPAF High Tabora Dispensary 6%Kalunde Dispensary EGPAF Low Tabora Dispensary 6%Lembeli Dispensary EGPAF Low Tabora Dispensary 7%Mwamala Dispensary EGPAF Moderate Tabora Dispensary 7%Usanganya Dispensary EGPAF Low Tabora Dispensary 7%Kansay Health Center EGPAF Moderate Arusha Health Center - 41
  • 50. Facility Name Implementing Volume Region Type Estimated HIV Partner Seroprevalence* Among Adults (18+)Kioga Dispensary EGPAF Moderate Arusha Dispensary -Mbuyuni Health Center EGPAF Moderate Arusha Dispensary -Mkonoo Health Center EGPAF Low Arusha Health Center -Mundarara Dispensary EGPAF Low Arusha Dispensary -Bugisi Health Centre EGPAF Moderate Shinyanga Health Center 24%Bukene Health Centre EGPAF High Tabora Health Center 7%Chela EGPAF High Shinyanga Health Center 9%Ikunguigazi Dispensary EGPAF High Shinyanga Dispensary 7%Ilola Dispensary EGPAF Low Shinyanga Dispensary 6%Malita Dispensary EGPAF Low Shinyanga Dispensary 5%Mbushi Dispensary EGPAF Low Shinyanga Dispensary 2%Mahuta Health Center EGPAF Moderate Mtwara Health Center -Mangaka Rural Health Center EGPAF High Mtwara Health Center 2%Mchihira Dispensary EGPAF Low Mtwara Dispensary -Namajani Dispensary EGPAF Moderate Mtwara Dispensary 7%Ilula Hospital EngenderHealth Low Iringa Hospital 18%Mafinga Hospital EngenderHealth High Iringa Hospital 18%Ngome Health Centre EngenderHealth Low Iringa Health Center 18%Njombe Health Centre EngenderHealth Moderate Iringa Health Center 15%Njombe Hospital EngenderHealth Low Iringa Hospital 15%Sabasaba Dispensary EngenderHealth Low Iringa Dispensary 18%Lugala Hospital FHI 360/Deloitte Low Morogoro Hospital 9%Iguguno Dispensary FHI 360/Deloitte Low Singida Dispensary 2%Ndago Health Centre FHI 360/Deloitte Low Singida Health Center -Singida Regional Hospital FHI 360/Deloitte Moderate Singida Hospital -Ilagala Dispensary ICAP Moderate Kigoma Dispensary -Kakonko Health Center ICAP Low Kigoma Health Center 3%Kiganamo Health Center ICAP High Kigoma Health Center 1%Kigoma International Health ICAP Low Kigoma Health Center 2%CenterUjiji Health Center ICAP Low Kigoma Health Center 2%Mafia District Hospital ICAP Low Pwani Hospital 3%Chamazi MDH Low Dar es Salaam Dispensary 6%Kawe MDH Low Dar es Salaam Dispensary 11%Mbagala Round Table MDH High Dar es Salaam Dispensary -Mico Kasorobo MDH Moderate Dar es Salaam Dispensary -Navy MDH Low Dar es Salaam Hospital -SDA MDH Low Dar es Salaam Hospital -*Missing data indicates that the respondent did not know the HIV seroprevalence of the facility’s catchment area.42
  • 51. APPENDIX C: INTERVIEWEES BY TITLE, PERFACILITYFacility Respondent A Title Respondent B Title Respondent C TitleLyoma Dispensary Assistant Reproductive and Assistant Clinical Officer N/A Child Health CoordinatorChamabanda Dispensary Medical Attendant N/A N/AKipumbwi Dispensary Senior Medical Attendant Clinical Officer Nurse/MidwifeRAO Health Centre Matron Nurse SecretaryKurusanga Dispensary Senior Medical Attendant N/A N/AKilombero Clinical Officer Nurse N/ABaga Dispensary Clinical Officer Medical Attendant Medical AttendantFunta Dispensary Enrolled Nurse Medical Attendant N/AKibumaye Dispensary Enrolled Nurse Assistant Clinical Officer N/AWalla Dispensary Clinical Officer Medical Attendant N/ALwamgasa Dispensary Enrolled Nurse N/A N/ANyamagaro Dispensary Clinical Officer Medical Attendant N/AMondo Dispensary Clinical Officer N/A N/ANasa Health Centre Enrolled Nurse Clinical Officer N/AKwamsisi Dispensary Medical Attendant Enrolled Nurse N/AManchimwera Dispensary Senior Medical Attendant N/A N/AMugeta Dispensary Enrolled Nurse Clinical Officer Laboratory AssistantNyehunge Health Centre Maternal and Child Health Aide N/A N/AClinical Officer Clinical Officer Medical Attendant Enrolled NurseMkolani Clinical Officer Enrolled Nurse Enrolled NurseNgoma “A” Dispensary Enrolled Nurse N/A N/AUjiji Health Center Enrolled Nurse N/A Clinical OfficerMafia District Hospital Registered Nurse, PMTCT In- Enrolled Nurse, PMTCT Enrolled Nurse chargeKakonko Health Center Clinical Officer Enrolled Nurse/Midwife N/AKigoma International Enrolled Nurse N/A N/AHealth CenterIlagala Dispensary Clinical Officer N/A N/AKiganamo Health Center Enrolled Nurse/Midwife Enrolled Nurse/Midwife N/AUtengule Usangu Health Midwife N/A N/ACentreNgamiani Health Center Registered Nurse Registered Nurse Midwife N/APaulines Dispensary Midwife N/A N/ATukuyu District Hospital Registered Nurse Matron Registered Nurse Patron N/AMlowo Dispensary Maternal and Child Health Aide N/A N/ARuhanda Health Centre Midwife Counselor Lab TechnicianMkonoo Health Center Clinical Officer Registered Nurse N/AKalunde Dispensary Enrolled Nurse Medical Attendant N/AUsanganya Dispensary Enrolled Nurse Medical Attendant Medical AttendantIlola Dispensary Clinical Officer Medical Attendant N/A 43
  • 52. Facility Respondent A Title Respondent B Title Respondent C TitleMbushi Dispensary Clinical Officer In-charge Reproductive and Child Health N/A CoordinatorMchihira Dispensary Enrolled Nurse - PMTCT In- Medical Assistant, PMTCT N/A chargeMundarara Dispensary Clinical Officer Senior Nurse Auxiliary N/AMalita Dispensary RCH Coordinator Clinical Officer In-charge Enrolled NurseLembeli Dispensary Medical Attendant Medical Attendant N/ANamajani Dispensary Clinical Officer DRCH Coordinator N/ABugisi Health Centre Registered Nurse In-charge Lab Assistant MidwifeKansay Health Center Assistant Nurse Officer Assistant Nurse Officer NurseMahuta Health Center Enrolled Nurse - PMTCT In- Enrolled Nurse, PMTCT N/A chargeMbuyuni Health Center Enrolled Nurse/Midwife Maternal and Child Health Aide N/AKioga Dispensary Mother Child Health Aide Clinical Officer Enrolled Nurse/MidwifeMwamala Dispensary Clinical Officer Medical Attendant N/AIkunguigazi Dispensary Clinical Officer In-charge Enrolled Nurse Enrolled NurseMangaka Rural Health Nurse Midwife, Reproductive Nurse Midwife, Reproductive and N/ACenter and Child Health, In-charge Child Health second-in-chargeChela Dispensary Registered Nurse DRCH Coordinator N/ABukene Health Centre Clinical Officer In-charge Maternal and Child Health Aide N/AIpuli Dispensary Assistant Medical Officer Enrolled nurse/Midwife N/ASabasaba Dispensary Midwife N/A N/AIlula Hospital Midwife N/A N/ANgome Health Centre Midwife N/A N/ANjombe Hospital Midwife Nurse In-charge N/ANjombe Health Centre Midwife Midwife N/AMafinga Hospital Midwife Enrolled Nurse Medical OfficerIguguno Dispensary Public Health Nurse N/A N/ALugala Hospital Nurse Midwife N/A N/ANdago Health Centre Reproductive and Child Clinical Officer In-charge N/A Health/Public Health NurseSingida Regional Hospital Reproductive and Child Health Public Health Nurse Reproductive and Child Health Clinical Officer NurseChamazi Midwife/PMTCT In-charge Midwife PMTCT N/ASDA Midwife/PMTCT In-charge Midwife, RCH Nurse Midwife, PMTCTKawe Enrolled Nurse, PMTCT Enrolled Nurse, PMTCTNavy Registered Nurse Midwife, Enrolled Nurse, Reproductive and Public Health Nurse, Reproductive and Child Health Child Health Reproductive and Child HealthMico Kasorobo Registered Nurse, PMTCT In- Reproductive and Child Health Reproductive and Child Health chargeMbagala Round Table Registered Nurse, PMTCT In- Public Health Nurse, PMTCT Registered Nurse, Labor In- charge charge44
  • 53. APPENDIX D: WORLD HEALTHORGANIZATION PMTCT TREATMENTGUIDELINES AND PROTOCOLS, 2010 Pregnancy Labor Postpartum Postnatal (Infant) (Mother)2010 Recommendations AZT after 14 sdNVP; AZT+3TC for seven Daily NVP until one(option A) weeks AZT+3TC days week after breastfeeding has finished2010 Recommendations Triple ARVs Triple ARVs Triple ARVs until one Six weeks of daily(option B) after 14 weeks week after NVP breastfeeding has finished2006 Recommendations AZT after 28 sdNVP; AZT+3TC for seven sdNVP; AZT for seven weeks AZT+3TC days daysAlternative (higher risk AZT after 28 sdNVP N/A sdNVP; AZT for sevenof drug resistance) weeks daysMinimum (less N/A sdNVP; AZT+3TC for seven sdNVPeffective) AZT+3TC daysMinimum (less N/A sdNVP N/A sdNVPeffective; higher risk ofdrug resistance)Source: WHO 2010c. 45
  • 54. 46
  • 55. APPENDIX E:TANZANIA NATIONALRECOMMENDATIONS—ANTIRETROVIRALPROPHYLAXIS REGIMENS FOR PMTCT, 2007Regimen Antenatal Intrapartum Postpartum Postnatal Mother InfantRecommended: AZT 300mg AZT 600mg at onset of AZT 300mg twice sdNVP 2mg/kgAZT+sdNVP twice a day labor a day for seven oral suspensionAND starting at 28 or days immediately after weeks or as AND birthSeven-day maternal AZT 300mg at onset of soon as possible 3TC 150mg twice ANDAZT+3TC tail to labor and every three thereafter a day for seven AZT 4mg/kg twicereduce NVP resistance hours until delivery days a day for seven AND days sdNVP 200mg at onset of labor AND 3TC 150mg at onset of labor and every 12 hours until deliveryRecommended if None AZT 600mg at onset of AZT 300mg twice sdNVP 2mg/kgmother presents labor a day for seven oral suspensionduring labor: days immediately afterAZT+sdNVP AND birthAND 3TC 150mg twiceSeven-day maternal a day for sevenAZT+3TC tail or daysbeginning with the AZT 300mg at onset ofaddition of 3TC at the labor and every threeonset of labor to hours until deliveryreduce NVP resistanceMinimum regimen: None sdNVP 200mg at onset of None sdNVP 2mg/kgsdNVP to mother and labor oral suspensioninfantMinimum regimen None None None sdNVP 2mg/kgwhen mother oral suspensionpresents in latelabor:Postnatal infant sdNVPSource: United Republic of Tanzania Ministry of Health and Social Welfare 2007. 47
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  • 57. APPENDIX F: DESCRIPTIVE STATISTICS ONREPORTING SITESIndicator Number of Mean Standard Minimum Maximum Median Sites Deviation ReportingNumber of pregnant women newly 65 752.9 628.85 168.00 4051.00 608.00enrolled in ANCNumber of women seen in labor and 57 321.6 687.80 0 4217.00 90.00delivery% of pregnant women newly enrolled in 65 0.80% 1.1% 0% 4.2% 0.5%ANC with known HIV-positive status% of pregnant women who were tested for 53 61.69% 30.6% 0% 100% 67.5%HIV and received test results in ANC% of pregnant women who were tested 52 6.46% 8.4% 0% 34.4% 3.1%and received results in labor and delivery% of pregnant women who received HIV 49 67.97% 32.7% 0% 100% 79.2%counseling and education in ANC% of pregnant women who received HIV 52 7.00% 8.8% 0% 36.8% 4.4%counseling and education in labor anddelivery% of pregnant women who tested HIV- 65 3.19% 3.5% 0% 15.5% 2.2%positive in ANC% of pregnant women who tested HIV- 52 0.50% 1.0% 0% 4.9% 0%positive in labor and delivery% of pregnant women arriving in labor 52 3.83% 6.1% 0% 27.2% 1.8%and delivery with known HIV-positivestatus% of HIV-positive mothers who initiated 60 24.39% 24.7% 0% 100% 20.7%exclusive breastfeeding% of infected pregnant women who 61 19.93% 29.3% 0% 100% 4.5%received sdNVP in ANC% of HIV-positive pregnant women who 59 29.08% 26.1% 0% 100% 29.3%received other ARV regimens for PMTCTin ANC% of HIV-positive pregnant women 54 10.89% 18.9% 0% 90.4% 0%initiating ARV treatment in ANC% of infants who received only sdNVP in 46 29.32% 36.8% 0% 100% 17.1%labor and delivery% of infants who received other ARV 45 65.09% 39.3% 0% 100% 83.3%regimens for PMTCT in labor and delivery% infants born to HIV-positive women 59 19.52% 31.0% 0% 100% 0%enrolled in ANC 49
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