2015 Pakistan: Evaluation of PPTCT program
Author: Dr. Ayesha Khan
With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System". Within this system, an external independent company reviews and rates all evaluation reports. Please ensure that you check the quality of this evaluation report, whether it is “Outstanding, Best Practice”, “Highly Satisfactory”, “Mostly Satisfactory” or “Unsatisfactory” before using it. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report.
Prevention of HIV transmission from an infected mother to her unborn child (MTCT) has been at the forefront of global HIV prevention activities with the successful results of the short-course Zidovudine and single-dose Nevirapine clinical trials. These relatively simple low cost drugs substantially reduced the transmission risk from 30%-40% to under 5%.
Pakistan initiated the PPTCT programme in 2007 with the policy decision to call it parent to child transmission in order to reduce gender-discriminatory practices and stigma against women and include men as responsible partners/husbands in the transmission chain. UNICEF Pakistan in collaboration with the National and Provincial AIDS Control Programmes set up a Task Force and 5 PPTCT centres within close proximity to already established HIV Treatment and Care Centres (ART centres). The Task Force helped in adaptation of PPTCT guidelines, development of a risk assessment tool to enable an initial “risk” screening process to identify women who may be at higher risk of HIV, and trainings of the PPTCT service providers.
The PPTCT programme followed the global 4 prong approach namely:
- Prong 1 -Primary Prevention of HIV Infection: preventing HIV infection in girls and women, including those who are pregnant or breastfeeding.
- Prong 2 Preventing Unintended Pregnancies in Women with HIV: providing voluntary and informed family planning methods and services to couples with HIV and giving them the options to plan out family size and minimize risks.
- Prong 3 Preventing Vertical Transmission of HIV from Mothers to Their Infants: reducing HIV risks through informed counselling on ART regimens, ARV prophylaxis, and optimal modalities for delivery, breast feeding and infant care practices.
- Prong 4 Providing Care, Treatment and Support for HIV positive Mothers and Children: understanding that beyond pregnancy and delivery women with HIV have evolving needs.
The purpose of the evaluation was to see the extent to which PPTCT programme was successful in reaching HIV positive women and their families with the package of PPTCT services such as counselling, testing, referrals (as needed), ART treatment, safe delivery and breast feeding practices, and early infant diagnosis (EID).
The evaluation also reviewed how the District Family Health Model helped in increasing identification and referrals into PPTCT services, capacity and competencies of PPTCT providers, provider biases, stigma and attitudes, factors that hindered or helped in accessing PPTCT services, gender and rights based design and implementation of PPTCT services, and linkages with relevant MCH programme and HIV Treatment and Care centres for long term sustainability.
The findings of the evaluation will assist HIV programme managers and national/provincial health departments to address placement of centres, practice and capacity gaps in PPTCT programmes according to province specific needs. Most importantly the evaluation seeks to help UNICEF and government stakeholders in increasing programme coverage to reach at least 60% of eligible HIV positive women and their families with responsive services.
The evaluation objectives are:
- Assess the effectiveness, efficiency and sustainability of the PPTCT programme
- Evaluate the efficacy of the HIV risk screening criteria and tool used in the District Family Health Day model
- Assess the referral chain (of at risk women) and linkages with PPTCT services (for HIV positive women), retention rates, and compliance with PPTCT protocols.
- Determine the efficacy and reduction in transmission rates from HIV positive mother to infants born, during labour/delivery, breast feeding, and linkages with Paediatrics care services (for eligible children).
- Estimate the costs of averting HIV infections in infants in Pakistan as a result of PPTCT services.
The PPTCT evaluation used a mixed approach qualitative and quantitative data collection methodology along with triangulation of data received from PPTCT centres. The evaluation focused on coverage, functioning and performance of centres, transmission and survival outcomes of mother-baby pairs, counselling, provider competencies and sustainability of the PPTCT programme as per OECD criteria and the UNICEF TORs (Annex 1). The OECD criteria looks at relevance, effectiveness, efficiency, impact and sustainability. However, for this evaluation, we measured the outcomes (i.e. reduction in MTCT of HIV) of the PPTCT programme instead of impact. The main limitations in measuring impacts are the low numbers of PPTCT beneficiaries and low coverage in eligible populations to have a significant impact on the HIV epidemic or national child survival rates. At this stage, measuring outcomes can help HIV programme planners to better plan future directions and cost implications of the PPTCT programme in saving maternal and infant lives.
Throughout the process we used a participatory approach to develop ownership and engagement of stakeholders for understanding the evaluation and eventually the results. At the initial preparation stage meetings were held between the evaluation team and UNICEF along with the study Reference Group (RG). RG members include representatives from government (NACP/PACPs), UNAIDS, WHO, GFATM, and UNICEF Monitoring and Evaluation Unit. The consultant presented the proposed evaluation methodology and the RG members gave inputs and suggestions. Once the final evaluation design was agreed upon, the consultant shared an Inception Report that was formally circulated to the RG members and UNICEF ROSA for additional suggestions. At the conclusion of the field visits and data collection the draft final report and presentation was shared with the RG and ROSA for feedback.
The key stakeholders actively engaged throughout the process
Findings and Conclusions:
- PPTCT Centres are Functioning (process level) – eight centres were visited as part of the evaluation and all are functioning and focus mainly on Prong 3 by providing a package of relevant PPTCT services: 1) counselling; 2) ART for mothers; 3) safe delivery; 4) Infant diagnosis and ARV prophylaxis. Centres are following WHO 2010 guidelines for Option B/Option B+ and majority of babies are delivered by elective C-sections by trained PPTCT providers (Ob-GYN doctors). PPTCT centres are located within ANC clinics in large tertiary care or district hospitals, and have on average 3-4 staff, and 1-2 rooms.
- Gaps were found in counselling in terms of ad hoc content, short duration, poor documentation of learning, lack of clarity on infant feeding practices, and weak emphasis on early infant testing and diagnosis. PPTCT centres (5/8) lacked counsellors and/or case managers, leading to deficiencies in documentation, missing patient tracking of appointments and follow up, and incomplete patient chart notes or register information (these were tasks previously done by or assigned to case managers).
- The programme has successfully managed to reduce mother to child transmission of HIV from 30%-40% (no intervention) to 1.35% with no maternal deaths reported in any of the 411 HIV+ women/PPTCT beneficiaries (2007-2015) consistent with the goals of the Global Plan 2011-2015.
- PPTCT programme coverage is very low around 1.5% - 3.5% of eligible women as per NACP-UNAIDS Spectrum 2014 estimates. There are 26,000 HIV+ women with an estimated 1720 pregnant per year in need of PPTCT services. The biggest challenge of the PPTCT programme low coverage is accessing women most at risk and enrolling them into care.
- PPTCT provider knowledge is good on Prong 3 safe delivery and ART, and deficient in Prong 2 family planning counselling and rapport building (<6/10 scoring). PPTCT providers have a narrow clinical perspective on the implementation of PPTCT services.
- Decentralisation and Integration of PPTCT versus New PPTCT Centres – with so many competing public health priorities and limited resources, the maximum impact for PPTCT programme to prevent a greater number of new women/mother-baby infections, would be 1) to focus on integration of PPTCT skills and services in outreach and service delivery programmes for PWIDs, SWs and other bridging populations rather than the general population, and 2) Simultaneously health providers including a wider cadre of Ob-GYN doctors and health staff including mid-level providers should be trained and made aware of PPTCT across all provinces (districts) as part of the routine MCH service package.
- Due to low numbers and fixed costs of setting up PPTCT centres, the cost of PPTCT service package is on average $1130 per woman served ($715-$2853). This is well above the costs of other low prevalence, concentrated epidemic countries such as Viet Nam, Nepal, Bangladesh and India. Once again targeting resources and using evidence-based tracking such as which districts/union councils cases are coming from, surveillance estimates, ensuring >80% (universal testing) in ART centres, and risk populations would ensure that scarce resources are used most efficiently.
- Currently this is too broad and a participatory revision with inputs from PLHIV, NGOs and research HIV experts would be a useful exercise.
- Counselling protocols should be developed consistent with standard guidelines by each PPTCT centre according to their specific population needs and language of convenience. IEC materials also should be updated according to new information.
- Referrals from TB, STI, dermatology and other non-ART centre clinics have increased. However, their numbers account for less than1% of the PPTCT users. A broader awareness of HIV recognition and referrals through either trainings or inclusion in medical curriculum would be useful.
Due to low numbers and fixed costs of setting up PPTCT centres, the cost of PPTCT service package is on average $ 1,130 per woman served ($715 - $2,853). This is well above the costs of other concentrated epidemic countries such as Viet Nam, Nepal, Bangladesh and India. Once again targeting resources and using evidence-based tracking such as which districts/union councils cases are coming from, surveillance estimates, ensuring >80% (universal testing) in ART centres, and risk populations would ensure that scarce resources are used most efficiently. Of all the eligible population (i.e. 94,000) less than 6,000 (6.3%) are on ART, and amongst them nearly 60% spouses (mostly women) have yet not been tested for HIV.
The current yield of general population testing even with the risk assessment tool is only 0.8% and is not a cost-effective approach when less than 20% of the risk populations have received HTC in the last one year.
Operational research should be undertaken on the cost effectiveness of different PPTCT activities and between existing models of service delivery by NGOs, PLHIV, and CHBCs to improve service efficiency.
Some countries are now collecting /piloting confidential name-based case reports of HIV infection through a passive and active HIV/AIDS surveillance system. It may be worthwhile for Pakistan to further refine its passive surveillance methodology to newer methods. For example, the US CDC recommends laboratory-confirmed infections of HIV are monitored by respective Health Departments through this active and passive surveillance system. Additionally, regular contact is maintained with the identified public and private clinical sites to help ensure completeness of reporting (active surveillance): and Demographic, exposure, and clinical data are collected on each case and entered into a central database developed by the U.S. Centers for Disease Control and Prevention (CDC).
Full report in PDF
PDF files require Acrobat Reader.