A young mother gets HIV-tested during a postnatal consultation at Sainte Bernadette Health Centre in Lubumbashi.Crdit : Benoit Almeras-Martino / UNICEF, 2014.

A FUTUREWITHOUT HIV

Introducing Option B+ to prevent Mother-To-Child Transmission in Katanga

Although HIV / AIDS prevalence appears to be relatively moderate in the Democratic Republic of Congo1, knowledge of mother-to-child (MTCT) HIV transmission is limited2, reflecting the lack of structures having the capacity to conduct the prevention of MTCT through appropriate care.3.

Screening rate is very low: about 8 congolese citizens out of 10 do not know their serological status, according to the Demographics and Health Survey conducted in 2013 by UNICEF and its partners.

In 2012, ten years after the official start of Prevention of Mother-

To-Child Transmission of HIV (PMTCT) activities, the

government launched a national plan for the Elimination of Mother-To-Child Transmission of HIV

1 1,2% HIV prevalence rate DHS 20132 26% of congolese women aged 15-49 have knowledge of PMTCT EDS 20133 26,2% is covered with PMTCT care according to the PNLS (National Plan to Fight Against AIDS)

(eMTCT) in 2017, with the support of UNICEF. The plan was launched coincidentally with new recommendations from the World Health Organization calling for the transition from Option A to Option B+ to improve the PMTCT in developing countries.

Since September 2013, a pilot project aims at rolling out Option B+ in several Katanga Health Zones, with the support of UNICEF. Katanga was chosen due to its greater exposure to HIV/AIDS (the provinces main commercial roads are oriented towards Southern Africa) and suspected risky behaviors around its mining sites.

The pilot project is implemented through the Optimizing HIV Treatment Access Among Pregnant Women (OHTA). UNICEF leads this initiative in 4 African countries, thanks to Norway and Sweden funding4.

4 DRC, Malawi, Uganda and Ivory Coast are concerned.

CONTEXT

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Option B+ combines three molecules in a single tablet - facilitating treatment continuity for the HIV-positive patients

SCREENINGPeople attending antenatal consultation1 are encouraged to have a better knowledge of their serological status. If they are interested, they have a personal interview with a health professional and accept or refuse to be tested.

The screening takes about ten minutes - if the result is positive, the patient is immediately put under antiretroviral treatment.

Children born from HIV-positive mothers are tested using dried blood spot (DBS) at 6, 9 and 18-months. HIV-positive children are immediately placed under antiretroviral therapy.

ANTIRETROVIRAL TREATMENTOption B+ antiretroviral treatment combines three molecules in one pill, which has to be taken every day as soon as the patients HIV status is 1 Free HIV tests are also offered during postnatal care and preschool consultation,

discovered.

Unlike Option A2 and Option B, Option B+ does not necessitate testing the number of CD4 cells of the patient - thus accelerating the initiation of antiretroviral treatment.

STORAGE AND PROVISION OF ANTIRETROVIRAL TREATMENTAntiretroviral drugs are stored at a Regional Distribution Center.Stock of antiretroviral treatment is distributed on a quarterly basis to the participating health facilities based on their expected monthly consumption.

PATIENTS ACCOMPANIMENTIn each Health Center, nurses in charge of Maternal and Child Health and peer-educators monitor patients compliance to the treatment.

Patients participate in support groups, which allows them to learn tips on how to use the antiretroviral 2 Favoured by DRC since 2010 due to its lower cost.

treatment; to share their personal experience related to the disease; and the difficulties they encounter in everyday life.

If patients participation is considered as being too low, peer educators and community volunteers conduct home visits.

PATIENTS MONITORINGEvery health structure involved monitors the number of tested persons; the number of HIV+ diagnosed persons; and eventually, the number of persons who effectively comply with the antiretroviral therapy.

Data gathered is synthetized and shared with the various health subdivisions in order to evaluate Option B+ implementation; continuity of the antiretroviral treatment of HIV-positive patients; and possible MTCT cases.

DESIGN:HOW IT WORKS

In developing its eMTCT strategy in 2012, the Congolese Ministry of Health has decided to adopt a Test / Treat approach. The transition towards Option B+ is expected to be one of its key elements.

A FUTURE WITHOUT HIV Introducing Option B+ to prevent Mother-To-Chi ld Transmission in Katanga

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If the result is negative, then it means you and your baby are both OK. If the result is inconclusive, we should set another appointment to test you again. If the result is positive, then the health centre will provide you with antiretroviral therapy but you still have a choice: do you want to take the test?

Inside Sainte-Bernadette Health Centres small interview room, tension rose slightly, as

Safi initially came to the Health Centre to immunize her sixth child. During the consultation, she was offered counselling about HIV/Aids prevention. She accepted it... and now she has to decide if she wants to know her own serological status. Its obviously not an easy decision. Yet Safi overcomes her initial embarrassment.

She nods, whispers an almost inaudible Ndio1, thus agreeing to take the test. Her choice is far from being surprising. Nine women2 out of ten accept to take the test before or after giving birth.

On the opposite side of the table, Leon Mulimbi, one of Sainte-Bernadette lab technicians, put on latex gloves, unwraps the single use test and cleans the tip of Safis middle finger.

1 Yes in kiswahili.2 among women attending the health structures during their pregnancy.

With mechanical precision, Leon stings the finger, gets a drop of blood to put on the single use test. Well know the result in 5 to 10 minutes you can wait outside.

When Safi comes back to the room, it almost feels as if centuries have passed. Her angst seems so strong that you can almost feel it so its not hard to imagine Safis relief when Leon announces that the test turned negative.

Today your test turned negative. Neither your baby nor you have HIV, and thats very good news. That also means you have to remain cautious so you dont get infected. Else you will put your health and your future childrens health at risk. You should also talk to your husband so he gets tested he should know his serological status too.

In the Democratic Republic of the Congo, 78% of women and 84% of men never took HIV-tests, according to the 2013 Demographics and Health Survey.

Between October 2013 and August 2014, 47595 women were counselled and tested in the six health zones targeted by UNICEF within the Option B+ implementation project.

HIV SCREENING, FIRST STEP TO PREVENT MOTHER-TO-CHILD TRANSMISSION

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In order to harmonize Option B+ implementation, UNICEF 1) carr ied out a mapping of the PMTCT interventions led in Katanga; 2) and actively supported the revital izat ion of the Maternal, Neonatal and Chi ld Health (MNCH) Working Group to coordinate future interventions of the various stakeholders involved1.

With the support of UNICEF, Option B+ has been introduced in six health zones2. To date, 106 health faci l i t ies in six areas targeted effectively provide PMTCT care3 thus improving the populat ions coverage.

Before implementing Option B+, 26 focus groups and six community forums were conducted in six health zones in order to identify local problems and solut ions needed to increase HIV prevention and screening.

In order to faci l i tate the transit ion to Option B+, 169 healthcare providers were trained on the integration of this PMTCT new approach standards.

297 healthcare providers in PMTCT-ready health faci l i t ies were trained

1 PNLS, PNSR, PEPFAR, PARSS, GAVI are among the MNCH Work-ing Group members2 Option B+ has been extended to additional 8 health zones3 Compared to 57 health facilities

to adapt their knowledge to the requirements of Option B+.

The 6 health zones management teams were trained at the new guidel ines regarding the transit ion towards Option B+.

In every health zones, 80 community stakeholders (20 Community relays, 20 peer-educators, 40 health personnel) were trained at PMTCT care under Option B+ standards, in order to faci l i tate sensit izat ion and patients accompaniment.

From October 2013 to August 2014, 47,595 women were counseled and screened4. 1190 were tested posit ive to HIV.

1225 HIV-posit ive women were put on antiretroviral therapy fol lowing the Option B+ protocol. On a sample of 618 HIV-posit ive women, 463 have been continuing their treatment for more than 6 months (75% retention rate).

4 pendantduring antenatal consultation, preschool consultation or after giving birth.

I N T E RV I E WAlbertine is a HIV-positive mother of

three who lives in Lubumbashi since 2010.

I took the test in 2008. I lived in Mwene Ditu (Kasa Oriental) at the time. I had several miscarriages over a short time span and so the doctor

asked me to take a HIV test.

Thus I learnt I was HIV-positive. My husband took the test. He also had HIV. We

didnt accept our serological status at first. We decided not to follow our treatment.

We then moved to Lubumbashi. Our status was deteriorating and we attended the health center more and more over time.

At the health center, we met people who actually cared for us, loved us and gave us advices. The nurses convinced us to get back to the antiretroviral treatment. We quickly noticed that our health was improving. We take the pill every evening with my husband. We support each other.

We had our third child in 2013. Thanks to God and the treatment, he was born without HIV. We were so happy when we learned that yet we are still afraid about testing his two brothers.

My only wish for the future is that my children grow up as responsible persons, attached to their lives.

DELIVER: WHAT HAS BEEN ACHIEVED

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LOCAL AUTHORITIES INVOLVEMENTEvery activity is conducted with the approval and part icipation of local pol it ical, administrat ive and health authorit ies. Option B+ deployment and coordination is carr ied out by the Provincial Health Division and the National Programme for the Fight against AIDS (PNLS).

COORDINATED ACTIVITIESFol lowing UNICEFs mapping of PMTCT activit ies and the reactivation of MNCH Working Group, stakeholders activit ies are conducted joint ly in order to enhance their consistency; and to effectively respond to the health authorit ies pr ior it ies.

HIV SCREENING AMONG PREGNANT WOMENAlmost every pregnant woman agrees to be tested, if they attend the health faci l i t ies during their pregnancy. Women can be tested during the prenatal, postnatal and pre-school consultat ions, thus increasing HIV-testing opportunit ies.

BETTER ORGANIZATION OF HEALTH FACILITIESMonitor ing of HIV-posit ive patients is properly done. Health faci l i t ies

submit monthly reports to the health zones, which synthesize the data gathered for the health authorit ies information.

ARV SUPPLY AND STOCK MANAGEMENTOption B+ faci l i tated ARV storage and stock management within health faci l i t ies.

IMPROVED CONTINUITY OF TREATMENTContinuity of treatment for HIV-posit ive women was eased 1) by the avai labi l i ty of antiretroviral drugs; 2) by the increased coverage of PMTCT-ready health faci l i t ies; 3) and by the community-based organizations better sensit izat ion and accompaniment efforts.

COLLABORATION BETWEEN COMMUNITIES AND HEALTH FACILITIESCommunity stakeholders play a central part within the health faci l i t ies. Peer-educators conduct the monitor ing and support of HIV-posit ive patients within health faci l i t ies. Community relays perform monthly visits to households in order to promote PMTCT services and care provided by the health faci l i t ies.

P E E R - E D U CATO R S , E N C O U R AG I N G R O L E M O D E LSI became a peer educator so I could help seropositive

persons improving their health just like I did. I work within the Health Center, I schedule the patients appointments.

I get in touch with patients directly when I notice that they dont attend the appointments

I made. I try to convince them to continue the treatment for their own sake. My best argument is

my own state: Im the living proof that antiretroviral treatment works. Look at me, Im in perfect shape!

- Patient Binene, peer-educator.

When I learnt I was seropositive, everything fell apart in my life. I got better when I received others advice and this made me want to become a peer-educator myself.

Every month, I run a support group with other seropositive patients. With the help of the new antiretroviral treatment, we can practically live and work like anyone else.

I now want a better job. Id love to run my own business and also, Id like to have two more children.

- Astrid Kabedi, peer-educator, mother of two.

DISCOVER: WHAT IS WORKING

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The governments target is al igned on UNAIDS Three Zeros objective: Zero new HIV infections. Zero discr imination. Zero AIDS-related deaths.

On a short-term perspective, Option B+ wil l be extended to 206 Health Zones in 2015.

UNICEF aims at contr ibuting to scale up Option B+ to every health zone of the country (516) and increasing the number of PMTCT-ready health faci l i t ies.

UNICEF also plans the revital izat ion of local communit ies through a t ightened network of Community Relays and the creation of Community Animation Cel ls (CAC) in every vi l lage.

Both measures would contr ibute to achieve a better sensit izat ion on PMTCT among famil ies. There are two key targets of this renewed commitment to community-based HIV prevention: expanding antenatal consultat ionsattendance among pregnant mothers; and improving HIV screening among men.

Within the health structures, the main chal lenge l ies in the HIV-testing of chi ldren in the absence of decentral ized structures able to analyse the DBS tests results.

To support the future scal ing-up of PMTCT activit ies, capacity bui lding of al l stakeholders is also needed at every step (HIV-testing, treatment, monitor ing and accompaniment of HIV-posit ive patients).

Nadine Muyungu, MDHead of PMTCT division - Katanga Provincial Health Division

In my opinion Option B + is a simplification: it is easier to prescribe the treatment, it is easier to store the medicine, its easier to follow the treatment.

It is also a reason for hope because pregnant women who take the treatment appropriately will not transmit

HIV to their children.

Benjamin ManikaHIV/PMTCT focal point - Kisanga Health Zone (Lubumbashi)

Since the project began, there has been an increase in the use of PMTCT services. The increase in health

facilities involved is the key reason of this increase.

The other positive effect is that were able to do a better monitoring of people living with HIV.

Lily MwanyaPMTCT nurse - Mama Wa Huruma Health Centre (Lubumbashi)

Option B+ made treatment continuity easier for patients. Their condition improved, they sometimes wonder if they are really sick. I think its necessary that we continue raising awareness

about HIV/Aids, especially among men who are reluctant about getting tested.

In Kisanga Health zone in Lubumbashi, the implementation of Option B + resulted in many improvements in the management and monitoring of HIV patients.

DREAM: VISION FOR THE FUTURE

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Noly T. and her son Tshilonda, at Sainte Bernadette Health Center in Lubumbashi. Noly learnt her seropositivity during her pregnancy - shes been following antiretroviral treatment ever since.Crdit : Benoit Almeras-Martino / UNICEF, 2014.

The OHTA initiative is led in collaboration with the Fight Against AIDS National Programme (PNLS) and is funded by the Norwegian Agency for Development Cooperation (NORAD) and the Swedish International Development Cooperation Agency (SIDA).