Policy Changes That Have Increased Uptake Along the Cascade: Highlights from Cameroon

Policy Changes that have Increased Uptake along the Cascade:Highlights from Cameroon Banso Baptist Hospital The first two PMTCT sites in Cameroon (Feb 2000) Mbingo Baptist Hospital Tih Pius MuffihMPH, PhD Cameroon Baptist Convention Health Board

PRESENTATION OUTLINE Background Early beginnings Implementation strategies Use of support groups to enhance NVP uptake Progress made New strategies adopted in 2005 Use of TBAs in PMTCT Conclusion 2

1. THE CBC HEALTH BOARD One of 3 arms of the Cameroon Baptist Convention (Church, Education, and Health) Mission: The Cameroon Baptist Convention Health Board seeks to assist in the provision of care to all who need it as an expression of Christian love… Health services started 1938 as missionary activities; Health Board created in 1975 AIDS Care and Prevention Program created in 1999 First PMTCT provider in Cameroon (Feb 2000) 4

2. PMTCT IN CAMEROON Observed increased number of HIV infections in the patient population PMTCT was then initiated to prevent mother to child HIV transmission No prior experience in PMTCT Assistance from external sources like Johnson & Johnson, Abbott Fund, EGPAF, USAID 5

1. FIRST STAFF & FIRST SITES Trained two nurses as counselor trainers Began in February 2000 with two sites On-site training of staff and initiating activities Only 5 sites by Dec. 2000 and 9 sites by Dec. 2001 No other PMTCT services existing elsewhere in the country at that time to share experiences Adopted group training in 2002, scaled up to 58 sites 7

2. JUNE 2002 INTERNATIONAL CONFERNECE Organized by the CBCHB, UNICEF, EGPAF and MOH Attended by experts from EGPAF, UNICEF, CDC, MOH, WHO and other health care providers in the country This was a strategy to launch PMTCT services in the country Sharing of the CBCHB PMTCT experience First national guidelines for PMTCT drafted Mandate for PMTCT scale-up in Cameroon given to CBCHB by MOH 8

C. IMPLEMENTATION STRATEGIES 9

1. PARTNERSHIPS, WHY? Limited resources for health activities FBOs have deep roots in and significant impact on society. Work with the poorest of the poor HIV/AIDS pandemic requires collaboration of public and private sectors to combat it MOH and the CBCHB share in providing healthcare and social services in the country HIV/AIDS is a priority health domain for both 10

2. Private-Private-Public Partnerships Provider network Private non-profit Public Private for profit Good neighbor policy 11

3. PUBLIC-PRIVATE PARTNERSHIPS Indispensable, cost-effective, unavoidable The CBCHB signed a partnership accord with the public sector (MOH) Mutual respect and fair treatment of each other Complies with the national health policy Performance is paramount, not money nor political gain The CBCHB complements, not competes, with the public sector EGPAF ILA facilitated this partnership 12

4. BOTTOM UP APPROACH“USE WHAT YOU HAVE TO DO WHAT YOU HAVE TO DO” Community-determined health care approach Community-based, from periphery to central facilities Public health approach Realistic response to crisis Staff trained and responsibilities delegated Service delivery decentralized Use of existing systems/structures Compare with other PMTCT programs’ top-down medical approach 13

5. Faith-Based Organization as Credible Providers HEALTH FAITH AND HIV 14

FOUR-TIER ADVOCACY STRATEGY International National Provincial/Regional Community 15

6. PROCEDURE FOLLOWED AT ANC 1stAntenatal Clinic - Group counseling by maternity/counselor staff, reviewing 4-5 routine antenatal lab tests (Hb, UA, Syphilis, + Blood Type, HIV) Interactive group discussion of HIV test: Emotional response if positive, how to disclose to spouse, potential of living many years if HIV+ if maintain healthy lifestyle and reduce exposure, availability of free NVP for PMTCT, opt-out strategy. Individual pretest counseling Rapid HIV testing on-site if consent, same day results Prenatal exam while awaiting for HIV test results Individual post-test counseling Information on mother’s NVP dose at onset of labor Emphasis on baby’s dose within 72 hours of life 16

D. USE OF SUPPORT GROUPS TO ENHANCE NVP UP TAKE 17

Support Group Activities (Left): Banso, Mbingo (Right) “During our meetings we receive education on PMTT, information and communication on HIV/AIDS, sexual issues, writing a will, maternal and infant nutrition, and practical demonstration on food preparation, strategies of living positively and coping with HIV/AIDS, and sharing of individual experiences.” ~Mme. ManthoF 18

Support Group Activities Support Group attending a practical demonstration on nutrition ,[object Object]

Sharing experiences and supporting each other to accept and live positively with HIV/AIDS are key goals19

Support Group Activities Counselor and Support Group member doing craftwork Follow up Counselor (standing) visits a Support Group member’s Tailoring workshop Learning how to make crafts is a way of providing skills for clients to earn a living e.g. knitting of traditional gowns, knitting of traditional caps, gardening 20

Evolution of Sites from 2000-2009 22

Uptake of Services from 2000-2009 23

F. NEW STRATEGIES ADOPTED IN 2005 24

1. Revision of Strategies Following Lessons Learnt Provision of NVP at first visit Greater use of support groups Use of Trained birth attendants (TBAs) for services in rural areas Male partner involvement Move from mono to bi therapy Focus on quality improvement Data review and provision of feedback Testing in the counseling room Testing in labor and delivery 25

Evolution of Maternal ARV Uptake 26

2. Testing in Labor and Delivery A strategy to identify women who hide their cards or did not go for ANC Only started in 2005 High acceptance, up to 4,151 women reached in 2008 Increased chances to offer PMTCT interventions Average of over 90% acceptance to test Prevalence very high from the beginning (37.5%) but has dropped to 9.4% in 2009 Seems to be dropping as women know they can’t avoid being offered a test 27

Testing in Labor and Delivery 28

3. Partner Testing Training of frontline staff Provision of male friendly services Invitation letters given to women for their partners Free testing for HIV Making progress 7,757 partners tested in 2009 29

G. USE OF BIRTH ATTENDANTS IN PMTCT SERVICES 30

1. Start of Trained Birth Attendants 1980: CBCHB Primary Health Care was begun 1984: First birth attendants trained 1984-2001: Annual training of TBAs 31

2. Barriers to Safe Delivery Poor educational standards Low income Bad or non-existent roads Poorly maintained vehicles Some traditional beliefs and practices 33

3. Use of Birth Attendants to Enhance PMTCT in Rural Areas ,[object Object]

Birth Attendants could play a key role in implementing effective interventions in rural settings

With appropriate supervision, training and support, TBAs could offer HIV prevention services and help with ARV prophylaxis at delivery36

4. Tasks for Trained Birth Attendants in PMTCT Identify pregnant women in their communities and facilitate their use of ANC and maternity services Reinforce health messages, including the importance of improved nutrition during pregnancy Supervise directly observed treatment of mother and infant with NVP Offer advice on reducing the risk of HIV transmission to women and their partners Make sure pregnant women and their partners are routinely offered HIV counseling and testing 37

Rapid Test by Birth Attendants 38

5. Preventing Mother to Child Transmission Maternal and Child Health provided ,[object Object],Training in the inclusion of fathers in prenatal health care Lessons in basics of counselling and specifics of pre- and post-test HIV/AIDS counselling Preparation of Village Health Workers on NVP administration Health teaching training using demonstrations, role play, games, use of Problem Posing Pictures, songs and discussions Discussions with Birth Attendants regarding methods for identification of orphans for care 39

Interactive Group Discussion Led by a TBA 40

Imagine all these children without any intervention! 41

Policy Changes That Have Increased Uptake Along the Cascade: Highlights from Cameroon

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