The document summarizes best practices in Rwanda's PMTCT (prevention of mother-to-child transmission) program. It discusses bottlenecks identified in the program's review, including lack of integration and coordination. Strategies to address these included creating a single coordinating body, decentralizing planning, and integrating PMTCT services into maternal and child health platforms. These changes led to successes like improved coverage, but challenges remain around multi-sector engagement and decentralization. Lessons include the importance of community involvement, public-private partnerships, and performance-based financing to motivate health workers.

1. Best Practices in Rwanda PMTCT
Program
Dr Brenda Asiimwe-Kateera
Rwanda

2. Outline of Presentation
• Background
• PMTCT program review and bottlenecks
• Strategies and Structure
• Successes and Challenges
• Sustainability and Replication
• Lessons Learned

3. • National HIV prevalence has been stable at 3% since 2005
• HIV prevalence among pregnant women is 3.3%
• 10,000 HIV positive pregnant women are expected to access PMTCT services
annually
0
1
2
3
4
5
6
7
8
9
15-19 20-24 25-29 30-34 35-39 40-44 45-49
PercentHIVpositive
Women
Men
HIV Prevalence by Sex HIV Prevalence by Age
Source: RDHS 2005 & RDHS 2010 Source: RDHS 2010
Rwanda HIV Epidemiological situationRwanda HIV Epidemiological situation

4. National PMTCT Program Milestones
1999-2015
PMTCT
pilot
• National PMTCT
program (sd-NVP)
• Initial sites
expansion
• More Efficacious ARV introduced
• ART program decentralized
• EID pilot
• Transition to More
Efficacious Regimens
• Decentralization of CD4
count
1999 -
2000
2001-2004 2005-2006 2007-2008 2009- 2010
• Task-shifting policy
• Option B PMTCT regimen
in Nov 15th
2010
• eMTCT goal in NSP
2011- 2015
• Launching of eMTCT by First
Lady
• eMTCT strategy and action
plan
• Option B+ in 2011
• PMTCT program 6-week
Impact study

5. Emergency Response to HIV
In 2001, HIV programs coordinated by two bodies
– Necessary for the emergency response to the
epidemic
– PNLS , CNLS (NACC) for policy, resource
mobilization and HIV awareness
– TRAC for guideline development and
implementation of biomedical HIV interventions.
In 2010/2011 HIV and AIDS response was reviewed:
– CNLS and TRAC coordination functions
– Implementation of PMTCT program

6. Finding of the review and solutions
CNLS and TRAC Functions
• Great response to HIV
emergency & high scale-up of
HIV services including PMTCT
• Coordination bottlenecks
– Duplication of efforts in
coordination and inefficiency
– limited ownership at sub-national
levels
Solution to the bottlenecks
1. Having one coordinating
board
2. Decentralized planning
and implementation
These solutions called for
‘Effective Leadership in
Planning and
Implementation of PMTCT
programs’
HIV Overview in Rwanda

7. Findings of the review and solutions
PMTCT Programme Implementation
• Good coverage but gaps in:
– HIV testing among pregnant
women and their male partners of
at least 31%
– ARV for PMTCT among HIV positive
pregnant women of 24%
– ARV prophylaxis among exposed
infants of 22%
• Implementation bottlenecks
– Inadequate integration of PMTCT
services in the MNCH services
– Unavailability of routine offer of
PMTCT services in the private
sector
Solution to the bottlenecks
Integration of PMTCT service
at different levels:
•National planning process
including private sector
•MNCH platform
•Community
These solutions enabled
‘Achieving Universal Access
to Integrated PMTCT services’
HIV Overview in Rwanda

8. BP 1: Effective Leadership in Planning and
Implementation of PMTCT programs
Strategy 1:
•Creation of Rwanda Biomedical Center (RBC) under the
Ministry of Health.
•Parliament endorsement of RBC
•Inclusion of RBC as coordination body into national policy and
strategic documents
• HIV division within RBC mandated to:
– coordinates policy and strategy development,
implementation of HIV programs
– oversees multi-sectoral response

9. BP 1: Effective Leadership in Planning and
Implementation of PMTCT programs
Strategy 2:
•Engagement of districts teams on their eMTCT data.
– Led to development of district specific eMTCT
operational plans including district capacity building plan
– National level support for quality data analysis and use
for improvement of services delivery.
•Creation of District coordination structures
– District health management unit under the leadership of
the vice mayor of social affairs coordinates HIV activities
– The district hospital health team was mandated to
provide PMTCT technical support to the health centers.

10. BP 1: Effective Leadership in Planning and
Implementation of PMTCT programs
Strategy 3:
•Task shifting was introduced and
nurses were trained on ART initiation
•Collaboration between health centers
and community health workers
strengthened.
•Introduction of performance based
financing (PBF) mechanisms linked to
PMTCT was a motivation for the staff
to achieve targets

11. Successes
• Creation of RBC has resulted in better coordination,
resource mobilization and technical support from the
different programmes
• Decentralization and better coordination of eMTCT
services has led to development of district specific
eMTCT plans
• Managers have been empowered to collaborate with
development partners at district level and to leverage
resources in support of action plans.

12. Successes and Challenges
Successes:
• Capacity building of health care workers and PBF has
resulted into a more motivated and efficient health
care workers at the health facility and community level
Challenges:
• Effective multi-sectoral response to HIV
– There is a need for greater participation of
representatives from other sectors in the HIV
response
• Ensuring available of technical support at decentralized
levels.

13. BP 2: Achieving Universal Access to
Integrated PMTCT services
Strategy 1: Integration at
National level
–Improvement of infrastructure of MNCH, equipment and
human resources
– Creation of Public-Private partnerships
Service delivery level,
–Integration of PMTCT into MNCH platform
–Empowerment of managers to re-organize service delivery at
their level and to make decisions on how best to integrate
PMTCT services in MNCH
• Creation of a one-stop model for PMTCT and MNCH services

14. BP 2: Achieving Universal Access to
Integrated PMTCT services
• Community level,
– High level advocacy
for male
involvement to
increase couple
testing, adherence
and retention into
PMTCT services

15. RBC, IHDPC Report, 2011
510 ART sites (96%)
544 VCT sites (99%)
494 PMTCT sites (96%)
Universal access to PMTCT is within reach

16. Male involvement in PMTCT

17. DECLINING TRENDS IN MTCT RATES AT 6 WEEKS AND 18
MONTHS ,
RWANDA 2006-2014
1.
81.6

18. Challenges and Solutions
• Despite the gains made in the Rwanda PMTCT program, challenges
such as
– Reaching out to women not accessing services are some of the
barriers that need to be addressed for the country to go an extra
mile towards eMTCT targets
– loss to follow-up of mother-infant pairs within the continuum of
care
• Implementation of innovative and effective strategies are
needed
– use of technology such as mobile phones for tracking and tracing
of clients. Rwanda is currently facilitating timely transfer of EID
results from laboratory to the health facilities using text
messages
– establishing effective linkages between health facility and
community based services are being considered.
18

19. Lessons learnt
• Successful integration of PMTCT program within MNCH
platform is dependent of a health system that has
demonstrated the capacity to deliver high coverage (over
90%) of child survival interventions such as antenatal care and
immunization.
• The management at the facility level have a critical role in
determine how to re-organisation service delivery to foster
integration
– Integration of services differs according to the level of
health facility and availability of resources.
• Community engagement is critical in ensuring PMTCT is
integrated within the community health care system

20. Lessons learnt
• Public-private partnerships is critical to achieving universal access
to PMTCT service
• The comparative advantage of a sector to deliver services without
losing the multi-sectorial aspect of the response is critical in
deciding which sector should lead on HIV/AIDS response.
• Decentralized planning and implementation is key to program
ownership and in addressing challenges of equitable access and
quality of services.
• Male involvement is an entry point for increased couple testing
and disclosure of HIV results.
• Performance based financing could be a more cost-effective
strategy to address human resource challenges.

21. Replicability
• Countries should decide which sector to take the lead
in coordination of the HIV response without losing the
aspect of multi-sectorial approach to responding to HIV
and AIDS
• Decentralized planning and coordination is easily
replicable by leveraging the existing administrative
structures
• Task shifting and PBF linked to PMTCT indicators would
be a proposed solution to human resource constraints
as opposed to voluntarism.

22. Conclusion
• Delivery of high impact comprehensive eMTCT interventions
through a well-coordinated decentralized system has enabled
Rwanda to achieve high coverage of eMTCT services and low
MTCT rates.
• Task shifting and mentorship are key in ensuring access to quality
comprehensive eMTCT services.
• PBF linked to set results has been instrumental in keeping health
providers motivated to work hard toward achieving desired
results and improve the quality of health services.
• In order to achieve universal access, involvement of private sector
in PMTCT service delivery is critical.
• Performance of MNCH platform as indicated by other CSD
indicators is critical for successful integration of PMTCT services.

23. Acknowledgements
• Beneficiaries- pregnant women and partners
interviewed
• Service Providers
• Managers at the district level
• eMTCT BP documentation review committee
• UNICEF for financial and logistical support

24. Thank you all