VCT and PMTCT programme
Developed by
Romanian Angel Appeal
Rapid Evaluation Findings
Katinka de Vries, MSc MPH
Draft July 2005
Table of contents
1introduction
1.1The objectives
1.2Methods
2BACKGROUND
2.1The HIV/AIDS epidemic and the National strategy
2.1.1National HIV/AIDS strategy 2004-2005
2.1.2Prevention of Mother to Child Transmission
2.2Voluntary HIV Counseling and Testing (VCT)
2.3Importance of PMTCT
2.4Expansion of the VCT and PMTCT programme by Romanian Angel Appeal
3SERVICE ACCESS AND USE
3.1Service use
3.1.1Utilisation profile
3.2Access
3.2.1Test Kits Supply Interruption
3.2.2Reaching ‘high risk’ pregnant women
3.3Referral flows and networks
3.3.1Pregnant women
4COUNSELLING protocol adequacy AND client satisfaction
4.1Overview of counselling guidelines and protocols
4.2Counselling process
4.2.1Observations by local coordinators
4.2.2Informed consent and confidentiality
4.3Client satisfaction
4.3.1Pregnant women satisfaction
5staff performance and training
5.1Project staff, selection and roles
5.2Training of counsellors and supervisors
5.2.1Counsellor training
5.2.2Training of supervisors
5.3Workload and stress
5.4Support and supervision
5.5Counselling specific target groups
5.5.1Supporting Young people in VCT
5.6E Learning modules for health professionals
6PROGRAMME COMMUNICATION
6.1National HIV/AIDS communication strategy
6.2PMTCT and VCT communication materials
6.3General public
6.4Health care workers
6.5PLHA stigmatization and discrimination
6.6Development of strategy and messages
7ISSUES ON program COSTS AND EFFECTIVENESS
7.1Program costs
7.2Outcomes and impact (effectiveness) of the program
7.3Some considerations on cost effectiveness
8Conclusions and recommendations
8.1Background
8.2Aims of the RAA’s VCT/PMTCT programme
8.3Service access and use
8.4Quality assurance tools in place
8.5Client satisfaction is high
8.6Staff performance
8.7Counsellor training
8.8E learning modules for health professionals
8.9Counselling specific groups
8.10Programme communication
8.11Costs
8.12Recommendations to the Romanian decision makers and agencies of influence
ABBREVIATIONS AND ACRONYMS
ANCAntenatalcare- грижа за бременни жени
ARV Antiretroviral (drug)
BCCBehaviourChangeCommunication– Промяна в поведението на комуникациите
CMEContinuousMedicalEducation – постоянно медицинско образование.
CSWCommercial Sex Worker
CTCCounselling and Testing Centre – центрове за консултиране и тестване
FPFamilyPlanning– Центрове за семейно планиране
FGDFocus Group Discussion
CPHDCounty Public Health Department -
GFATMtheGlobalFundtoFightAIDS, TBandMalaria – Глобален фонд за борба със СПИН, туберкулоза и малария
IDUsInjecting Drug Users
IDAInternational Development Association – международно сдружение за развитието
IECInformation, Education Communication
KABPKnowledge, Attitude, Behaviour, Practice- знание, отношение, поведение, практика
MTCTMother to Child Transmission – предаване от майка на дете.
MOH Ministry of Health
NAP National AIDS Programme
OPOpportunistic Infection -
PMTCTPrevention of Mother to child Transmission – превенция на предаването от майка на дете
PLHAPeople Living with HIV/AIDS
QAQuality assurance
RAARomanian Angel Appeal
STI Sexually Transmitted Infection – инфектиране по полов път
TB Tuberculosis
TORTerms of Reference
TOTTraining of Trainers
UNAIDSUNAIDS
UN TGthe UN Theme Group on HIV/AIDS
VCTVoluntary Counselling and Testing
WLHAWomen living with HIV/AIDS
WHO World Health Organisation
ACKNOWLEDGEMENTS
First and most I would like to thank the management of Romanian Angel Appeal for giving me the opportunity to carry out this evaluation. My special thanks go out to the manager Silvia Asandi. I have been very much impressed with her professionalism and the scope and amount of work carried out by her. The visit to the main office in Bucharest and the site visits have been professional and personally an enriching experience.
Special thanks go also to my counterparts and Fidelie.Kalambayi, Laura Popa and Roxana Jiboteanu. They were instrumental to the whole consultancy and their technical support and enthusiasm made this consultancy very gratifying.
I would like to thank all persons interviewed (see annex I) for sharing their valuable insights with me.
This consultant takes sole responsibility for the views and recommendations expressed in this report. While these are based on interviews and discussions carried out during my visit to Romania they do not necessarily reflect the views of the RAA.
Katinka de Vries, DLSHTM, MPH, MSc
HIV/AIDS and Public Health Consultant[1]
1introduction
This report outlines the findings from a rapid external evaluation, of the HIV/AIDS Voluntary Testing and Counselling (VCT) and Prevention of Mother to Child Transmission (PMTCT) Programme of the Romanian Angel Appeal (RAA – It should be noted that this was not a comprehensive evaluation, for instance, only five days were allocated for the field visit in Romania. Also, at the time of the evaluation, the programme had been in operation only for eight months.
RAA requested this evaluation to assist current discussions about the integration of these services into the structure and budget of the national HIV/AIDS health system. It is important to note that the VCT/PMTCT services which are described in this evaluation are newly established, the first 10 were opened in October 2004 and 8 just opened in April -May 2005 an other 2 are about to open in July. The reader has to bear in mind that no firm conclusions can be drawn yet on such a new service delivery programme.
1.1The objectives(Цели)
The objectives for this evaluation consultancy were formulated as follows:
- To evaluate the quality and effectiveness of the VCT services developed by RAA according to the international standards and guidelines.
- To formulate conclusions and recommendations for RAA and it’s stakeholders regarding the development of the services.
- To evaluate the methodology, the operational aspects (including the costs) of the VCT (including PMTCT) services developed by RAA.
- To evaluate the counsellors’ training and requirements.
- To evaluate the implementation of quality assurance tools in the counselling and testing centres.
- To draw up a report on the evaluation of the VCT and PMTCT services implemented by RAA, and to formulate recommendations to RAA.
- To make recommendations to the Romanian decision makers (i.e. Ministry of Health, National AIDS Commission, etc.) regarding the opportunity of financial taking over and development of the VCT and PMTCT model as part of the national HIV/AIDS programme.
1.2Methods
Prior to the country visit the consultant reviewed relevant documentation on RAA’s VCT/PMTCT programme including protocols and guidelines. During the period between 12th and 19th of June the consultant visited Romania to learn more about the programme. Interviews were conducted with national and international stakeholders in Bucharest. Site visits to VCT and PMTCT services took place in Bucharest, Brasov and Sibiu. Annex 1 provides a detailed list of the VCT sites and organisations visited and the persons interviewed. The evaluation schedule is given in Annex 2.
The data collection instruments employed were: questionnaires for VCT managers and counsellors; semi structured and open interviews with stakeholders; focus group discussions with counsellors, clients and pregnant women; and exit interviews with clients.
Questionnaires
- Questionnaires aimed at VCT managers were translated and distributed to all 10 managers to evaluate the VCT sites (VCT evaluation questionnaire tool 2 of UNAIDS)[2] All 10 managers responded.
- Questionnaires aimed at VCT counsellors were translated and distributed to all 36 counsellors to evaluate counsellor selection, training and support (evaluation tool 3, UNAIDS 2000[3]) Most counsellors responded (31).
- Questionnaires aimed local coordinators/ supervisors were developed, translated and distributed to 14 supervisors to evaluate the supervision process. Ten supervisors responded the other 4 were already on holiday.
Interviews
- Open interviews were held with several stakeholders with the aim to identify the strengths and weaknesses of the programme.
- A group meeting was held with trainers with the aim to evaluate the training component of the programme.
Focus groups discussions
Three focus group discussions (FGDs) were conducted with the counsellors (one FGD) and a selected group of clients, including pregnant women (two FGDs) in order to evaluate their counselling experiences. The FGDs guidelines can be found in annex 2. Clearly the results of these exercises are not representative yet they provide some useful insights about what both the counsellors and clients perceive as positive and negative aspects of the VCT and PMTCT programme.
Exit interviews
RAA developed a structured exit interview questionnaire for clients. The replies from 196 exit questionnaires at the 10 first established testing sites were analysed.
2BACKGROUND (обстановка)
2.1The HIV/AIDS epidemic and the National strategy
In 1989 Romania experienced a nosocomial HIV epidemic in which several thousand children contracted HIV through blood transfusion and use of unsterilised syringes, needles and medical instruments. Many of the new cases of HIV infections are still seen in patients who were born between 1987 and 1989 and were infected through unscreened blood and blood products, and repeated use of contaminated needles. Since 1994 there has been a steady increase in the HIV/AIDS incidence rate among adults mainly through sexual and injecting drug use transmission of the virus. This correlates with the growing incidence of STIs (syphilis in particular). The number of persons infected through vertical transmission in Romania has been also growing slowly in the last few years.
More than three quarters of the 7854 patients regularly followed up in the Regional AIDS Centres receive Antiretroviral (ARV) treatment (December, 2004). Romania has one of the highest HIV/AIDS treatment coverage in Central and Eastern Europe.
Romanian HIV/AIDS data31 december 2004
Total cumulative AIDS cases / 9.258
- AIDS cases in children
- AIDS cases in adults
- Total AIDS deaths
Total HIV cases / 6.213
- HIV cases in children
- HIV cases in adults
Total PLHAs / 10.735
Total patients lost from record / 505
Total number of patients under HAART[4] / 6.116
Total number of patients under medical surveillance[5] / 7.854
Source: MOH & National Commission against AIDS,
Department for Monitoring and Evaluation of HIV/AIDS, Romania, 2005
The table below shows a breakdown of the available date on the different groups tested between 2001 and 2004 (data provided incomplete). A rapid increase can be noted in the amount of HIV test performed among pregnant women. It is important to note the relative high prevalence figures among the tested CSW. There seems still to be low prevalence among IDU as opposed by the results of the research showing high HBV and HCV prevalence rates and risk behaviors in the same population - HCV (40-70%) and HBV (20-40%). [6] Comprehensive prevention activities within this group can hopefully still advert the high prevalence rates experienced among IDU in other countries in the region.
Cumulative reporting of HIV tests performed among different
Groups in Romania during 2001-2003[7]
Year / 2002 / 2003 / 2004Group tested / Total no. of tests / Positive tests / Total no. of tests / Positive tests / Total no. of tests / Positive tests
PH Directorate / 92.797 / 1.466
Hemodialyzed/trans. / 1.113 / 1.148 / 5967 / 2
Medical personnel / 2.239 / 4 / 5.612 / 4 / 5967 / 2
Prisoners / 1.043 / 2 / 310 / 2
On request / 78.915 / 1.349 / 101392 / 1926
Maternity hospital / 1.769 / 4 / 334 / 5 / 516 / 3
Pregnant women / 43.024 / 33 / 51.978 / 27 / 72.802 / 40
STI patients / 14.414 / 60 / 13.283 / 42 / 14856 / 43
TB patients / 11.946 / 55 / 11.025 / 55 / 8440 / 47
Prenuptial control / 5.272 / 2 / 6.249 / 5 / 4620 / 11
HIV contacts / 655 / 19 / 977 / 36 / 563 / 23
IDUs / 651 / 392 / 4 / 310 / 2
Female CSW / 114 / 7 / 92 / 5 / 146 / 2
Drivers / 7
Sailors / 42 / 5 / 1 / 341 / 0
MSM / 19 / 2 / 30 / 0
Travelers > 6 mnths / 165 / 43 / 22 / 0
Work abroad / 902 / 2 / 84 / 1 / 123 / 2
Blood donors / 365.455 / 15 / 235.384 / 67
TOTAL / 1.667 / 406.583 / 1.605 / 212.242 / 2.102
During the period 2000-03 there was significant progress in the following areas:
- Free ARV treatment for the majority of PLHAs (through price cuts and donations from six pharmaceutical companies).
- Increased number national campaigns addressing HIV/AIDS prevention and reduction of stigmatisation.
- Introduction of a health education programme in Romanian schools including HIV/AIDS prevention and substance abuse.
- Implementation of pilot projects among vulnerable groups such as CSW, drug users, MSM and Roma communities.
- Establishment and growth of associations of PLHAs.
2.1.1National HIV/AIDS strategy 2004-2005
In September 2004 the Romanian Government approved the National Strategy for Surveillance Control and Prevention of HIV/AIDS cases which was formulated by a multisectoral commission established for this purpose (CNMS). A summary of this strategy follows.
- Prevention of HIV transmission. The main goal is to reduce the HIV incidence by 2007 at the 2002 level. Eight priorities determine the focus of the whole strategy towards prevention activities, especially the prevention of HIV transmission among young people and groups with risk behaviours associated with commercial sex or injecting drug use.
- Access to treatment, care and psychosocial support services. This second major area aims to ensure access to universal treatment, care and social support for PLHA, as well as to reinforce the health care system for sexually transmitted infections and substance abuse. This intervention area has four priorities that are focused on the promotion and respect of the rights of PLHA and vulnerable groups.
- Surveillance of HIV and associated risk factors. The third major area of the strategy aims to develop and maintain efficient surveillance systems for HIV/AIDS and associated risk factors, to provide timely information regarding the epidemic and the determinants of its evolution and to allow development of appropriate programmes and interventions, including social interventions for PLHA and vulnerable groups.
2.1.2Prevention of Mother to Child Transmission
“The prevention of the vertical transmission has been a constant concern in the Ministry of Health’s program. Minister’s Order no. 889/1998 implemented since 1999 stipulated that counselling for HIV testing in pregnant women is compulsory and approved the health care management guide for MTCT. The order didn’t produce a spectacular increase in pregnant women’s access to testing. Although, the number of tests conducted in pregnant women between 2000 and 2003 doubled (from 25,000 to 50,000). At its maximum level, this indicator represents about a quarter of the total number of living births. One reason for the low number of testing performed is the overall situation of the prenatal system of health care, a lot of pregnant women (40% in 2002) presenting themselves to the physician for the first time for child delivery”. [8]
“Almost a third part of the women who received ante-natal consultations during pregnancy (76% out of the total pregnant women received ante-natal consultations), reported that they have been recommended HIV testing, same percentage reported HIV testing. Though, less than a third of the tested women reported that they had been counselled for HIV testing.”[9]
Starting with 2003 HIV testing has been a part of the prenatal package of services covered by the health insurance. And as stated above, not only is HIV counselling for all pregnant women compulsory, but crucially any required PMTCT treatment is totally free of charge (covered by the Ministry of Health Programme).
However the counselling capacity of the medical services has been perceived as inadequate (National Strategy document 2004). In this context, Romanian Angel Appeal is now implementing a national program aimed at increasing the access of pregnant women to HIV testing during the first quarter of pregnancy. The goal of the project is that 90% of the women from the targeted 16 districts should have access to VCT.[10]
The National HIV/AIDS strategy has formulated the following PMTCT related objectives
- Reduction of vertical transmission to 1-5% by 2007.
- Increase in the number of pregnant women receiving free HIV testing and all HIV infected pregnant women should be in counselling and within a treatment protocol.
- Inclusion of the vertical transmission prevention program in the other programs for pre and post natal assistance.
- Increase the percentage of pregnant women who report to the medical services during the first quarter of their pregnancy.
2.2Voluntary HIV Counseling and Testing (VCT)
HIV/AIDS counselling is a confidential communication between a client and a care provider aimed at enabling the client to cope with stress and take personal decisions relating to HIV/AIDS. The counselling process includes evaluation of personal risk of HIV transmission, the facilitation of preventive behaviour and evaluation of coping mechanism when the client is confronted with a positive result (WHO).
Recent studies show that VCT is a cost effective intervention in preventing HIV transmission. It gives people living with HIV infection earlier access to medical care, ARV therapy, treatment of Opportunistic Infections, preventive therapies and it increases the opportunity to prevent mother to child transmission of HIV.
UNAIDS and WHO promote the effective promotion of knowledge of HIV status among any population that may have been exposed to HIV through any mode of transmission. Pretesting counselling may be provided either on an individual basis or in a group setting with individual follow-up. The use of rapid tests is very much encouraged by the UN so that results are provided in a timely fashion and can be followed up immediately with a first post test counselling session for both HIV-negative and HIV-positive individuals. See below a schematic overview of the different aspects of comprehensive VCT services.
The rationale (обосновка) for VCT can be summarized by the following three points:
- VCT is more than drawing and testing blood and offering a few counselling sessions. It is a vital point of entry to other HIV/AIDS services including prevention of mother-to-child transmission; prevention and clinical management of HIV related illnesses, tuberculosis control, and psychosocial and legal support.
- There is demand (i.e. people want to know their HIV sero-status), or demand can be created when comprehensive services are made available( на лице/пригоден)
- VCT provides benefits for those who test positive as well as for those who test negative. VCT alleviates(облекчавам) anxiety(тревога,безпокойство), increases(увеличавам) client's perception(възприемане,усещане,разбиране схващане) of their vulnerability to HIV, promotes behavioural change, facilitates early referral for care and support including access to anti-retroviral therapy and assists reduction of stigma in the community. [11]
2.3Importance of PMTCT
Governments of 189 countries set as goal
Reduction of infants infected with HIV by 50 % by 2010
In 2001 the governments of 189 countries, including Romania, adopted the UNGASS Declaration of Commitments on HIV/AIDS. One of the goals of this declaration was to reduce HIV infection among infants by ensuring that 80% of pregnant women accessing antenatal care have;
- Information, counselling and other HIV prevention services available to them;
- Treatment to reduce MTCT including VCT, ART and breast milk substitutes, and
- Continuum of care.
The UN agencies recommend the following strategic approaches to prevent transmission of HIV to infants: