2009 Moldova: Evaluation of the Prevention of Mother to Child Transmission services in the Republic of Moldova
Author: Stela Bivol, national independent consultant and Zhanna Parkhomenko, international independent consultant. Institution: Ministry of Health; National Centre of Health Management
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Republic of Moldova has made significant progress in the implementation of PMTCT goals outlined in the Declaration of Commitment of UN General Assembly Special Session on HIV/AIDS (UNGASS) and Dublin Declaration. Excellent results had been achieved in decreasing mother-to-child transmission rate from 10% in 2004 to 1.7% in 2008. The centralized model of provision of PMTCT services, with four institutions providing specific interventions of ARV prophylaxis and care during delivery proved to be effective while the number of cases was low. Yet, as the epidemic is evolving and the number of HIV-positive women that give birth is increasing, this model becomes ineffective and there is a need of decentralization, in order to move services closer to HIV-positive women. The evaluation was performed by a national team under the supervision of a working group established at the Ministry of Health and an international independent consultant.
The objectives of the evaluation were: a) to assess the current status of the PMTCT services in the Republic of Moldova, including policies, leadership and coordination, and legal and M&E framework; b) to evaluate the quality of PMTCT services provided to HIV-positive pregnant women and their babies; c) to assess the knowledge, attitudes and behaviors of health care workers; d) to evaluate the referral system between various services within health care, as well as linkages with other services (harm reduction, self-support groups, social assistance).
Quantitative and qualitative methods were applied in collecting data from health facility managers, health providers in maternities and primary health care sector and HIV-negative and HIV-positive women that gave birth in the past two years.
Findings and Conclusions:
The notable successes were achieved in coverage with services for pregnant women, counseling and testing, provision of ARV prophylaxis to pregnant HIV-positive women and newborns as well as supply of milk formula and early detection by PCR. However, there are still a number of gaps observed, as well as areas for future developments: oversight mechanism, management & coordination, sustainability and continuum of service provision, access and quality of services.
While largely consistent with the international standards, separate legislative provisions, (including adoption of children from/into families affected by HIV/AIDS) contain some discriminatory provisions, which may limit basic freedoms and may violate confidentiality and privacy rights.
There is weak leadership, coordination and monitoring mechanism of the National HIV programme supported by government and civil society sectors. PMTCT data requires urgent revision and creation of one consolidated M&E System to satisfy all information needs.
The results of the study show that although more than half of health providers have received training in PMTCT, HIV and VCT, their actual knowledge, skills and attitudes are still very low. The computation of the integrated indicators showed that while most respondents of Maternity Health Service Providers have correct knowledge about HIV transmission and protection methods against HIV (73.2%), the level of basic knowledge about PMTCT –Delivery is much more reduced, with a total number of 25.6% of the total sample having correct knowledge about PMTCT. The areas where health providers score best are antenatal and intranatal care and feeding counseling to HIV-positive women and basic knowledge of HIV transmission and prevention. At the same time, they lack basic knowledge about actual risks of HIV transmission and about the effectiveness of timely and comprehensive PMTCT measures.
Health providers have showed widespread intolerant attitudes to PLWH in both social and professional situations and they often break confidentiality in professional settings. Less than half (42.6%) of maternity health providers admitted that they personally have disclosed the status of their HIV-positive patients, usually to their colleagues, sometimes to the Center of Preventive Medicine or rarely to patient’s family members. Over half (55.7%) of respondents felt they had high level of knowledge about stigma and discrimination, yet this knowledge did not translate in tolerant attitudes in either day-to-day life or at work. A total percentage of 0.3% of maternity health workers had social accepting attitudes towards PLWH and 1.4% had professional tolerant attitudes towards HIV-positive patients.
Health providers miss to use VCT as a unique opportunity for direct primary prevention of HIV in the population of women of reproductive age at its full potential. Most interviewed pregnant women have been tested twice for HIV during pregnancy, but most did not receive complete or quality counseling from either physician or VCT counselor, showing that the HIV counseling is mostly formal.
While medical services are provided to HIV-positive women at different levels, the linkages between the medical system and social services or services provided by NGOs are very weak and not institutionalized.
• Revise and further adjust national HIV legislation in order to remove existing discriminatory provisions and aligning it with the universal human rights approach. To ensure its further implementation at the service level with relevant regulatory systems in place (namely, the law on HIV and the law on adoption).
• Approve a mechanism of referrals between medical, social care systems and public sector and NGOs that provide care and support to HIV positive mothers and their infants. Reflect it in relevant normative documents.
• Strengthen leadership of coordination and oversight mechanism of the National Programme to Prevent and Combat HIV/AIDS and STIs (2011-2015 by approving an organisational and management structure with clear distribution of functions and responsibilities among stakeholders
• Revise and approve unified M&E system, adding essential, internationally recognized indicators, including PMTCT cost effectiveness.
• Review training curriculum and work on an integrated training module on PMTCT and VCT, and infection control, emphasizing skills development and change of attitude.
• Approve PMTCT training programme, including VCT and supervision system, for education of health care system personnel, with required coordination of activities through a responsible MOH Department.
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