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Policy Changes that have Increased Uptake along the Cascade:

Highlights from Cameroon

Tih Pius Muffih MPH, PhD

Cameroon Baptist Convention Health Board

The first two PMTCT sites in Cameroon (Feb 2000)

Banso Baptist Hospital

Mbingo Baptist Hospital

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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

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A. BACKGROUND

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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)

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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

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B. EARLY BEGINNINGS

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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

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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

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C. IMPLEMENTATION STRATEGIES

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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

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2. Private-Private-Public Partnerships

Provider network Private for profit Public

Private non-profit

Good neighbor policy

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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

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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

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5. Faith-Based Organization as Credible Providers

FAITH AND HIV

HEALTH

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FOUR-TIER ADVOCACY STRATEGY

Community

Provincial/Regional

National

International

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6. PROCEDURE FOLLOWED AT ANC• 1st Antenatal 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

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D. USE OF SUPPORT GROUPS TO ENHANCE NVP UP TAKE

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Support Group Activities

“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. Mantho F

(Left): Banso, Mbingo (Right)

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Support Group Activities

•Sharing lessons on nutrition and hygiene to improve on the nutritional status of families are helpful

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

Support Group attending a practical demonstration on nutrition

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Support Group Activities

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

Counselor and Support Group member doing craftwork

Follow up Counselor (standing) visits a Support Group member’s Tailoring workshop

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E. PROGRESS MADE

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Evolution of Sites from 2000-2009

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

50

100

150

200

250

300

350

400

450

5 9

5889

115

180

250

374391

426

Years

Num

ber o

f site

s

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Uptake of Services from 2000-2009

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

# of Facilities

# of ANC Women Receiving HIV Coun-seling

# of Women Who Were Tested

# of Women Who Re-turned for Test Re-sults

# OF Women with an HIV (+) Test

Upt

ake

of se

rvic

es

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F. NEW STRATEGIES ADOPTED IN 2005

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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

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Evolution of Maternal ARV Uptake

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

1,000

2,000

3,000

4,000

5,000

6,00055 14

7 443

460

923

2,59

2

3,67

4

4,57

2 5,00

0

5727

# of Mothers Receiving Nevirapine

The provision of Sd-NVP at first visit (on the day of diagnosis)

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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

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Testing in Labor and Delivery

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

0 0 0 0 0

276

1,19

7

3,60

2

4,15

1

3,29

6

# of women receiving HIV counseling in labour

# of Women tested in Labour

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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

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G. USE OF BIRTH ATTENDANTS IN PMTCT SERVICES

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1. Start of Trained Birth Attendants

• 1980: CBCHB Primary Health Care was begun

• 1984: First birth attendants trained

• 1984-2001: Annual training of TBAs

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TBA Delivery Kit

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2. Barriers to Safe Delivery

• Poor educational standards

• Low income

• Bad or non-existent roads

• Poorly maintained vehicles

• Some traditional beliefs and practices

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2000

2001

2002

2003

2004

2005

2006

2007

2008

0

500

1,000

1,500

2,000

EVOLUTION AT PRIMARY HEALTH POSTS 2000-2008

ANC

TESTED

RESULTS

CBCB-PHCS

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3. Use of Birth Attendants to Enhance PMTCT in Rural Areas

To extend the benefits of short-course ARV to women in rural areas, a challenge

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 delivery

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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

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Rapid Test by Birth Attendants

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5. Preventing Mother to Child Transmission

1 Updating on trends and transmission of HIV

2 Training in the inclusion of fathers in prenatal health care

3 Lessons in basics of counselling and specifics of pre- and post-test HIV/AIDS counselling

4 Preparation of Village Health Workers on NVP administration

5 Health teaching training using demonstrations, role play, games, use of Problem Posing Pictures, songs and discussions

6 Discussions with Birth Attendants regarding methods for identification of orphans for care

Maternal and Child Health provided

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Interactive Group Discussion Led by a TBA

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Imagine all these children without any intervention!

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SUMMARY

• We started PMTCT with no experience

• There were no policies, no protocols

• We started small, from the bottom-up

• Private-public partnerships promoted

• The use of group training, group facilitated counseling, support groups, TBAs, and giving NVP at first ANC visit helped in PMTCT scale-up

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The best time to plant a tree is twenty years ago….

The next best time is now

- African Proverb

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On behalf of the people of Cameroon,I extend our sincere appreciation to:

- EGPAF- USAID- Bill & Melinda Gates Foundation- Abbott Fund- Johnson & Johnson - And many other partners & collaborators

THANK YOU VERY MUCHDISCLAIMER: This program was made possible through support provided by the Office of HIV/AIDS, Global Bureau Center for Population, Health and Nutrition, of the United States Agency for International Development (USAID), through the President’s Emergency Plan for AIDS Relief, as part of the Elizabeth Glaser Pediatric AIDS Foundation's International Family AIDS Initiatives (“Call To Action Project”/ Cooperative Agreement No. GPH-A-00-02-00011-00). Private donors also supported costs of activities in many countries. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.