Implementing pMTCT programs in a post-conflict context: The case of Bouak é , C ô te d’Ivoire Julia Robinson, MSW MPH April 5, 2009

Bouak é , C ô te d’Ivoire

(very!) Brief history of the conflict Period of colonization by the French until 1960s 1970s-80s: “Paris of West Africa” 1999: Failed military coup 2000: Contested election 2002-??: Civil War Bouaké was the rebel stronghold

Period of colonization by the French until 1960s

1970s-80s: “Paris of West Africa”

1999: Failed military coup

2000: Contested election

2002-??: Civil War

Bouaké was the rebel stronghold

Effects of the conflict Destruction of health care sites Health care workers fled the region Fragmentation of services HIV care decentralized to NGO delivery

Destruction of health care sites

Health care workers fled the region

Fragmentation of services

HIV care decentralized to NGO delivery

NGOs in Bouake, Cote d’Ivoire (2007)

Health care workers fled the region

Goals/objectives of study (1) Goals: provide baseline information for program development and, given a limited capacity to deliver care, suggest strategies to implement integrated pMTCT services in the public health sector

Goals:

provide baseline information for program development and,

given a limited capacity to deliver care, suggest strategies to implement integrated pMTCT services in the public health sector

Goals/objectives of study (2) Objectives: describe existing ANC and HIV services available to pregnant women in Bouaké, both in the public and private sector service delivery arenas; describe the referral and follow up systems currently operating in the project area and the barriers that may prevent pregnant women to access HIV care; and describe patient flow through the health system from the perspective of a pregnant woman accessing ANC and HIV services.

Objectives:

describe existing ANC and HIV services available to pregnant women in Bouaké, both in the public and private sector service delivery arenas;

describe the referral and follow up systems currently operating in the project area and the barriers that may prevent pregnant women to access HIV care; and

describe patient flow through the health system from the perspective of a pregnant woman accessing ANC and HIV services.

Methodology Nov-Dec 2007 Informant interviews Records reviews Registers, MOH data, UNICEF data Patient flow map

Nov-Dec 2007

Informant interviews

Records reviews

Registers, MOH data, UNICEF data

Patient flow map

Patient flow analyses 3 scenarios HIV negative seeking ANC HIV positive not eligible for treatment HIV positive eligible for treatment and seeking follow up services Cost, loss to follow up noted

3 scenarios

HIV negative seeking ANC

HIV positive not eligible for treatment

HIV positive eligible for treatment and seeking follow up services

Cost, loss to follow up noted

Patient flow analyses 3 scenarios HIV negative seeking ANC HIV positive not eligible for treatment HIV positive eligible for treatment and seeking follow up services Cost, loss to follow up noted

3 scenarios

HIV negative seeking ANC

HIV positive not eligible for treatment

HIV positive eligible for treatment and seeking follow up services

Cost, loss to follow up noted

The grand prize! 8 visits, 5 sites 1 week – 1 month (or more??) A total nightmare!

8 visits, 5 sites

1 week – 1 month (or more??)

A total nightmare!

Discussion Fragmentation of care Public system provides ANC, NGOs provide HIV care Causes: post war, NGO proliferation and competition, inadequate HR in public sites Loss to follow up – unknown? HCW report only 20% of women return for results Causes: referrals, stigma, costs

Fragmentation of care

Public system provides ANC, NGOs provide HIV care

Causes: post war, NGO proliferation and competition, inadequate HR in public sites

Loss to follow up – unknown?

HCW report only 20% of women return for results

Causes: referrals, stigma, costs

Recommendations Integrated scale up of pMTCT in ANC Onsite testing using rapid tests to cut out loss to follow up Better collaboration between MOH and NGOs HIV care integrated into general care at public health sites

Integrated scale up of pMTCT in ANC

Onsite testing using rapid tests to cut out loss to follow up

Better collaboration between MOH and NGOs

HIV care integrated into general care at public health sites

15 months later… Integrated pMTCT in 18 Bouake health facilities More than 12,000 women tested for HIV, sero-prevalence rate of 5.7% CD4 sample transportation system set up at all sites PLWHA support groups at health facility sites

Integrated pMTCT in 18 Bouake health facilities

More than 12,000 women tested for HIV, sero-prevalence rate of 5.7%

CD4 sample transportation system set up at all sites

PLWHA support groups at health facility sites

Progression and possibility Expansion to other districts Expansion of activities within VB Greater integration with TB programs, inpatient wards, malnutrition units…

Expansion to other districts

Expansion of activities within VB

Greater integration with TB programs, inpatient wards, malnutrition units…

Thank you! Acknowledgments MOH Vall é e du Bandama HAI-Seattle HAI-CI UNICEF-CI The Kon é family

Acknowledgments

MOH Vall é e du Bandama

HAI-Seattle

HAI-CI

UNICEF-CI

The Kon é family

Questions?