Author: Schwarendruber, A.; Msamanga, G.
The goals of the UNICEF-sponsored PMTCT pilot project in Tanzania were to obtain local experiences and determine the feasibility of integrating PMTCT within routine ANC and MCH services, and to reduce the number of children infected with HIV through MTCT by at least 50% among children whose mothers benefited from interventions during the pilot project period. Five sites, including four referral hospitals and one regional hospital, began implementing PMTCT services April-September, 2000. Two of the referral hospitals also supervised and supported two health centers to implement PMTCT services. The main activities of the pilot project included: VCT for new ANC attendees using rapid testing; short-course AZT, beginning at 36-weeks to HIV-positive pregnant women; infant feeding counseling; modified obstetric care; monitoring and follow-up, including HIV testing of exposed children at 15 and 18 months of age.
At the request of the Tanzanian Ministry of Health, consultants from the US Centers for Disease Control and Prevention Global AIDS Program and Tanzanian counterparts conducted an evaluation December 2-10, 2002, in order to inform the development of national PMTCT services. Specifically, the terms of reference called for the review of PMTCT service provision and utilization at the pilot sites; site management, coordination and logistics; and impact of the pilot project. The main objectives of the evaluation, therefore, were to:
To meet the objectives of the evaluation, the team gathered information through a variety of activities:
A preliminary debriefing was held on December 10, 2002, in Dar es Salaam with the MOH, representatives of the pilot sites, UNICEF and other partners supporting PMTCT efforts in Tanzania. Preliminary results from this evaluation were also presented in a plenary session at the 2nd Multisectoral AIDS Conference in Arusha on 19 December 2002. This provided a valuable forum for feedback and further exchange of perspectives.
Findings and Conclusions:
Coverage and Performance: The three regional and district health facilities implementing PMTCT as part of the pilot project reported more new ANC clinic attendees than all four of the referral hospitals. The vast majority of women delivering at the pilot sites were of unknown HlV-status. Across all sites, the evaluation team noted large differences in counseling rates (9-56%), high acceptance and good use of HIV rapid testing (78-84%), and low short-course AZT uptake and adherence (8-20%). Infant follow-up was limited and potentially biased, so the effectiveness of the pilot project could not be determined.
Coordination and Management: The team found that referral hospitals have limited capacity to coordinate PMTCT activities at the regional and district levels, given their separate administrative systems. Sites had varied success in coordinating with donor-partners. The team also found that not all staff assigned to ANC and labor wards had received PMTCT training; supervision and ongoing training was limited; and training manuals needed to be updated and substantially improved.
Implementation of Services: The voluntary "opt-in" strategy to counseling and testing impeded coverage. Significantly, all sites successfully implemented rapid HIV testing to give same-day results. Although counselors were generally well-motivated and supportive of the project, counselors appeared to lack skills and lacked program materials, job aids and scripts for HIV-related counseling, infant feeding, family planning, primary prevention, and ongoing supportive counseling. There was no standardized PMTCT monitoring system. There were many data inconsistencies and staff reported that the collection forms were burdensome and redundant. In addition, the data was not compiled locally or centrally in an accessible database and were not available to provide feedback to the pilot sites. The team noted very low community awareness of PMTCT and a lack of IEC strategies and materials.
Utilization of Services: Fear of stigma and discrimination, and fear of abandonment due to a lack of male involvement in education, counseling and other PMTCT services were prominent barriers to women's uptake of PMTCT services at all sites. Specific procedures, such as patient flow, and protocols, such as only providing short-course AZT to women when they presented at ANC clinics at 36 weeks gestation, also adversely affected women's utilization of services.
Despite a number of significant challenges identified in the PMTCT pilot project, the team concluded that the pilot project demonstrated that it is feasible to implement and scale-up PMTCT services in Tanzania, and recommends that the next steps should be to improve PMTCT services at the pilot sites, expand PMTCT coverage to all 21 regions in mainland Tanzania, and to effectively monitor the reduction of HIV MTCT. To meet these objectives, the team recommends to:
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HIV/AIDS - PMTCT
Tanzanian Ministry of Health, CDC Global AIDS Program, Medecins du Monde, GTZ