Malawi PMTCT Participant Manual

Module 10Management of PMTCT Services

After completing the module, the participant will be able to:

  • Explain the goals and objectives of PMTCT services.
  • Describe the five steps of the programme cycle.
  • Describe implementation of PMTCT services.
  • Correctly define monitoring.
  • List PMTCT service indicators.
  • Utilize tools for monitoring PMTCT services.

After completing the Practical Attachment, the participant will be able to:

  • Provide core PMTCT services.
  • Provide group education in PMTCT.
  • Provide post-test counselling.
  • Provide infant feeding counselling and support.
  • Perform whole blood rapid test for HIV
  • Provide counselling on ARV prophylaxis and therapy.
  • Assess the clinical stage of a client with HIV.
  • Provide referrals for HIV-related prevention, care, treatment and support services for HIV infected and affected women, their partners and their children.
  • Record and report PMTCT information using standard MOH tools.
  • Apply Universal Infection Prevention measuresin the health care setting.

UNIT 1 Introduction to Management of PMTCT Services

After completing the unit, the participant will be able to:

  • Explain the goals and objectives of PMTCT services.
  • Describe the five steps of the programme cycle.
  • Describe implementation of PMTCT services.

PMTCT services in Malawi

PMTCT services in Malawi were initiated in 2001, when they were piloted in EmbangweniMissionHospital, Thyolo and ChiradzuluDistrictHospitals. In 2003 the PMTCT program was officially launched by the Ministry of Health.

Goals

The goals of the national PMTCT programmeare to:

  1. Prevent paediatric HIV infections; and
  2. Reduce HIV related morbidity and mortality among children, women and their families.

Objectives

The objectives of the national programme are to:

  1. To provide HIV pre-test counselling to 100% of the women attending ANC clinics.
  2. Increase the proportion of pregnant women undergoing antenatal HIV testing and receiving their status to at least 80% of those attending ANC.
  3. Increase the proportion of HIV positive pregnant women receiving a complete course of ARV prophylaxis to at least 80%,
  4. Increase the proportion of HIV-positiveeligible women initiating antiretroviral treatment (including ART) or cotrimoxazole prophylaxis during pregnancy to at least 70% of the those HIV-positive women identified.
  5. Increase by at least 20%, the proportion of mothers who practise exclusive breastfeeding for six months.
  6. Increase the proportion of HIV-positive mothers who practise early cessation at six months to at least 25% of those identified.
  7. Increase to at least 70% the proportion of HIV-exposed infants identified in PMTCT settings who begin cotrimoxazole prophylaxis at 6 weeks as per WHO guidelines.
  8. Support the enrolment and ART of at least 50% of eligible HIV infected children

The five-year PMTCT scale up plan has been developed in line with the ART and HTC scale up plans to increase access and uptake of HIV services and strengthen linkages to other services.

Malawi’s PMTCT scale-up plan for 2006-2010 is based on the following four prongs (or elements) of a comprehensive approach (see also Module 2):

  • Primary prevention of HIV infection in the general population, among women of childbearing age and their partners, especially in young people and pregnant women
  • Prevention of unintended pregnancies among HIV-infected women
  • Prevention of transmission of HIV infection from HIV infected pregnant women to their infants during pregnancy, labour, and delivery and post-natal through breastfeeding
  • Provision of care, treatment and support to HIV-infected women, children and theirfamilies

The National and District PMTCTScale-Up Plans for 2006-2010 focus on the following areas:

  • Policy and strategy development
  • Capacity building (human resources)
  • Planning, monitoring and evaluation and research
  • Procurement and Supply management
  • Infrastructure development
  • Partnership

PMTCT as a targeted HIV response

Delivery of comprehensive PMTCT services, integrated into Reproductive Health requires a targeted response involving all stakeholders. The PMTCT Officer in the HIV/AIDS Unit of the Ministry of Health is responsible for planning and coordinating delivery of PMTCT services nationally in collaboration with local NGOs and international development partners.

The National AIDS Commission (NAC) is responsible for the overall coordination of the HIV response in Malawi and supports the Ministry of Health in policy and strategy formulation.A PMTCT Technical Working Group(TWG) consisting of all stakeholders was established to guide the planning and implementation of PMTCT services in Malawi.

See Appendix 10-A includes a description of the organization of PMTCT services. Appendix 10-B provides further information about the supervision of PMTCT services.

The role of the PMTCT Officer is to provide technical and programmatic oversight for PMTCT as follows:

  • Coordinate the development of policy and guidelines
  • Develop technical documents
  • Coordinate planning, implementation and monitoring of PMTCT services
  • Assist with information, education and communication (IEC) and social mobilization activities at district level
  • Mobilize resources for PMTCT
  • Collaboration with development partners, NGOsand private sector

A diagram of the PMTCT programme as part of the reproductive health services, linked to other existing services and community structures is in Appendix 10-C.

Programme cycle

To build and sustain quality PMTCT services, health care workers and their supervisors have to plan for and develop internal quality improvement programmes, facilitate implementation of the programme and routinely evaluate the program. The programme cycle is a process that begins with assessing a situation and then designing, implementing, monitoring, and evaluating the programme in response to a need. Each of these steps applies to the PMTCT service and requires the support and skills of HCWs to ensure successful outcomes.

The programme cycle can be compared to the five-step process used when caring for a client. The HCW:

  • Assesses the client's health by taking a medical history, performing a physical exam, and making the diagnosis
  • Designs a client treatment plan
  • Implements the treatment plan
  • Monitors the client's progress
  • Evaluates the success of the treatment plan using lab tests, re-examination, and client self-report

Assessing

(Refer to the PMTCT Guidelines and PMTCT Site Assessment Tool.) The first step of the programme cycle is to analyse the problem by conducting a needs assessment or situational analysis. The assessment identifies existing gaps in PMTCT service implementation such as infrastructure, staffing, training, or supplies.

Planning

The next step is to plan (i.e., decide on location, size, staffing, services to be offered, policies, etc) a specific PMTCT site that will respond to the needs identified in the assessment. Planning involves making national, district, zone, and facility level decisions such as:

  • Identifying staffing issues—who and how many should be trained
  • Examining logistical issues—physical space, client flow, equipment, and supplies
  • Establishing programme guidelines
  • Developing a budget to cover costs
  • Outlining a programme management plan
  • Setting goals and objectives to be achieved within a specified period

Implementing

The third step is implementing PMTCT services according to the plan. This involves using standard procedures for service provision, training staff, and integrating PMTCT into existing healthcare services.

A pilot phase that introduces the new programme at a healthcare facility helps to identify problems before the programme is fully implemented.

Monitoring

Monitoring PMTCT services involves asking questions about the services offered and the service delivery process. This includes gathering data on a monthly basis to determine if the services are meeting objectives. The Health Management Information System (HMIS) ensures coordinated data gathering on pre-determined health indicators.

Evaluating

The final step is to evaluate the PMTCT services by comparing outcomes over time to goals and objectives. Often, the basis for an evaluation will be data collected as a part of monitoring of PMTCT services. Lessons can be learned throughout the evaluation process. Determining why something did not work provides clues for resolving problems and improving services.

PMTCT service implementation

Successful PMTCT services require the support and cooperation of the entire health team. Team members include:

  • Doctors
  • Clinical officers
  • Medical assistants
  • Nurses and nurse-midwives
  • Nutritionists
  • Pharmacists and Pharmacy technicians
  • Laboratory personnel
  • Health Surveillance Assistants
  • Assistant statisticians (HMIS)
  • Social workers
  • Administrative and support staff

Delivery of PMTCTservices can take place at all health facilities and settings where ANC, maternity, postnatal, family planning and under-five services are provided:

  • Central hospitals
  • District and CHAM hospitals
  • Rural and community hospitals
  • Health centres (both government and CHAM)
  • Private hospitals, clinics, non-governmental organizations (NGOs) with maternity services

Logistical issues such as private rooms for post-test counselling, adequate space for group education counselling sessions, supplies and equipment, and running water and electricity may pose challenges. Urban settings differ from rural settings, and availability of transport to and from the health facilities will have an impact on the uptake of services.

Development of a PMTCT Implementation Work Plan facilitates the provision of effective and quality services in a PMTCT facility. Malawi’s PMTCT Plan is part of the MOH’s HIV/AIDS Unit’s Work Plan, which was derived from the District Implementation Plan in 2006. PMTCT is an integral part of District Implementation Plans.

UNIT 2Monitoring and Evaluation of PMTCT services

After completing the unit, the participant will be able to:

  • Correctly define monitoring.
  • List PMTCT service indicators.
  • Utilize tools for monitoring PMTCT services.

Exercise 10.1 Data management: small group discussion

Purpose / To provide an opportunity for participants to consider ways to improve data flow and management in their settings
Duration / 30 minutes
Instructions /
  • Designate one person within your small group to record the group’s answers to each of the following questions:
  • Who is responsible for completing register information in your clinical setting?
  • What forms or cards are you currently using?
  • Where is the information stored and who has access to it?
  • Who provides weekly or monthly reports on the data?
  • Who does the report go to and when?
  • Then discuss how the data collected help the mother access other needed services such as:
  • ARV therapy, care and support
  • HIV testing for her infant
  • Assistance with infant feeding and nutritional support
  • What is the biggest challenge to collecting data in your setting?
  • What is one way to improve the data collection process in your setting?
  • How do we link women from L&D to postpartum services and child health clinics, and how do we strengthen the linkages?
  • How do we strengthen linkages with community resource persons to support postpartum services?

Monitoring

Definition
Monitoring is routine tracking of key parts of a programme using recordkeeping and regular reporting.

Programme monitoring

  • Input: The resources that are expected to be used in the programme. They include finance, personnel (number, type and training), and materials.
  • Process: Ensuring that the programme activities are being done as plannedand with the right resources.
  • Output: Ensuring the targets are being met.

PMTCT programme monitoring will help:
  • Assess whether the programme is meeting its established targets.
/ Example: If a national PMTCT programme target is for at least 80% of ANC attendees to be tested for HIV and post-test counselled, then the following would need to be monitored to assess if the target has been met: the percentage of ANC attendees tested for HIV, the percentage of ANC attendees tested for HIV who were post-test counselled.
  • Identify and improve problem areas in a PMTCT programme.
/ Example: If monitoring data shows that 50% of ANC attendees are tested for HIV and received their result in the post-test counselling session (far short of the 80% target), then discussion needs to explore barriers and strategies to address barriers to increase HIV testing.
  • Improve efficiency of the use of PMTCT programme resources.
/ Example: If, in the above scenario, it was recognized that the update of testing was low because women had to travel from the health centre where they were receiving ANC care and HIV pre-test counselling to the rural hospital, 2 miles away, for their rapid HIV test. Then, discussion could center on initiating rapid testing at the health centre so that women could be tested at point-of-care by the nurse or counsellor who provided the pre-test counselling. Identification of the problem is the first step to addressing it.

Monitoring data assists in continuous assessment of programme performance.

The purpose of monitoring

  • Monitoring ofinputsprovides information about:
  • Staff availability and roles
  • Utilization of resources
  • Supply of resources
  • Monitoring of processesprovides information about:
  • Training of staff
  • Quantification, ordering, storage and distribution of drugs and supplies
  • Clinic processes, e.g., HIV testing is routinely offered by nurse
  • Collaboration and communication, e.g., referral mechanism established between ANC clinic and the L&D ward
  • Monitoring of outputsprovides information about:
  • The PMTCT services received by women, children and their families
  • Success in meeting training targets
  • Success in meeting service targets (e.g. percentage of women tested for HIV, percentage of partners tested for HIV, percentage of women who took ARVs, etc)

Methods of monitoring

Monitoring requires the systematic collection, analysis, and use of information. This can be achieved with the following methods:

  • Observing the provider client interaction and recording information
  • Checking supplies against inventories, e.g. stock list
  • Examining recordse.g. ANC and Maternity Registers
  • Discussing progress and problems with staff and community
  • Collecting data routinely, including surveys and operational research

Monitoring and evaluation in Malawi

Data collected through monitoring of services underpins the evaluation of services at a facility, district or national level.

Health facility level

The HCW and other stakeholders routinely collect and analyse PMTCT information used for clinical and administrative management. This information helps to assess:

  • Whether the PMTCT service is meeting the targets
  • Progress being made in implementing PMTCT services at new sites
  • Linkages and referral to other programmes
  • Quality of programme implementation, which will trigger corrective action

District level

  • Regular analysis and synthesis of the aggregate data from each health facility providing PMTCT services
  • Collection and analysis of additional data, which cannot be collected during the clinical and administrative management processes. These data will come from special studies e.g. quality of counselling, client satisfaction, and assessment of client-provider interaction
  • Supportive supervision
  • Procurement and supply management and monitoring consumption

National level

Supervisors, coordinators and health planners measure the impact of PMTCT services, the benefits to the target population, and the cost and sustainability of the services. They accomplish this using the following methods:

  • Reviewing quarterly aggregatedata from districts providing PMTCT services
  • Collection and analysis of additional data from special studies onservice utilization and quality of PMTCT service provision
  • Assessment of the programme’s impact on final outcomes (infant HIV transmission rates)
  • Operational research as part of monitoring and evaluation to inform the performance of the programme

Data collection

HMIS is a public health planning and information system. It tracks a number of national health indicators at all health facilities in Malawi. PMTCT data will be collected as an integral part of HMIS. HCWs are responsible for managingdata related to PMTCT.

PMTCT sites are required to use the following tools for data management:

  • Health Passports and Registers
  • Standard Monthly Reporting Forms

Tips for good data collection practice
Once familiar with the registers and forms used for data collection, the following tips help ensure good data collection practices:
  • Understand the data to be collected. Before you record information, make sure that you understand the data requested.
  • Record the data every time. Record on the appropriate form each time you see an
    HIV-positive client, prescribe an ARV medication, receive a test result, provide a referral, or engage in any PMTCT activity.
  • Record all the data. Make sure you have provided all the information requested on the monitoring form. Doing so may require noting when you did not provide a service or that a service was refused by the client.
  • Record the data in the same way every time. Use the same definitions, the same rules, and the same tests for reporting the same piece of information over time. When it is not possible to record the data in the same way, make a note that describes the change.
Within your clinical setting, determine who is responsible for recording data and provide the support needed to ensure that data are consistently and reliably recorded.

Registers are used in the health facility to recorddata on a daily basis. HMIS data are collected monthly by each health facility in the country and sent to the DHO. This data is then sent to the national HMIS unit to be aggregated at the national level. PMTCT data will be sent to the HIV/AIDS Unit. Quarterly bulletins and annual record reviews are prepared using the monthly data.

Figure 10.1 PMTCT data collection and reporting procedure

Recording HIV information on Mothers and Child Health Passports

HCWs should use the national codes for recording HIV information in Mother and Child Health Passports.

PMTCT service indicators

Definition
PMTCT indicators are measures that determine to what extent PMTCT interventions are achieving programme objectives. Indicators measure efforts (input), effectiveness (process) and change (output). The process and output components are also known as performance indicators.

Indicators are developed from the analysis of key aspects of programme activities. Indicators measure the availability and quality of services and monitor progress towards PMTCT service goals. Indicators allow for the tracking of progress and identification of obstacles to the implementation of PMTCT services. See Table 10.1 for key national PMTCT indicators.