Scaling Up of PMTCT through National PMTCT Behavior Change Campaign

PEPFAR aims at providing 80% of HIV+ pregnant women with ARV prophylaxis and reduce infant infection

by 40% in focus countries including Ethiopia by 2009. Of the 2.2 million pregnancies expected in 2008,

there will be up to 79,000 HIV positive women which may lead to 14,000 HIV positive infants if best

strategies to reduce mother-to-child transmission are not in place. The PMTCT coverage of Ethiopia is

estimated at 2%, which is the lowest compared to other 15 PEPFAR focus countries. According to the

Ethiopia DHS 2005, the national ANC coverage is 28% and only 6% of births are delivered by skilled

attendants.

Despite the expansion of PMTCT services to more than 50% of health facilities providing MNCH services,

the PMTCT uptake remains low at different level. In 2006-2007, of women enrolled in ANC only about 50%

were counseled and tested for HIV and of those women who were HIV positive, only 52% received ARV

prophylaxis.

The low PMTCT service utilization among pregnant women could be attributed to many factors. Low ANC

coverage, lack of access and/or poor quality of ANC/PMTCT services, services not user friendly, shortage

of man power and other resources at sites, lack of knowledge of the availability and benefits of PMTCT

services among clients, cultural barriers, misconceptions and attitude against the service, stigma and

discrimination (feared and actual) and passive involvement of men in the service utilization are some of the

factors that pull back the effort to reach as much pregnant women as intended..

Strategies for improving uptake of PMTCT services should give special emphasis to increasing awareness

of the benefits of MNCH/PMTCT services and providing quality services. In an effort to improve the PMTCT

uptake, the government of Ethiopia has started rolling out the revised PMTCT guidelines mainly focusing on

providing comprehensive PMTCT services. Although there are efforts to improve the quality, it will be

necessary to implement interventions focusing on changing behaviors of women, their partners and the

community to improve utilization of the existing services.

The need to expand PMTCT services has to be backed up with consolidated effort to improve the

knowledge, attitude and practices of women and men of reproductive age. However, though there are a

number of programmatic initiatives, the activities done in terms of improving the knowledge, attitude and

practice of pregnant mothers and women and men in the age of reproductive health are minimal.

Furthermore, existing cultural practices that undermine health service seeking behavior are playing role in

hindering pregnant women from attending ANC there by challenging PMCT initiative. The rampant harmful

traditional practices with gender inequalities are fueling to this problem.

The objectives of these activities are to scale up PMTCT in Ethiopia through implementing a National

PMTCT Behavior Change Campaign and expansion of outreach PMTCT services.

The BCC initiative will be implemented with the objective of improving PMTCT uptake among pregnant

women tested HIV-positive, by working on and changing certain behaviors that hindered utilization of ANC

and PMTCT services.

The Behavior Change Campaign will focus on attitudinal, knowledge and behavioral features of service

users, service providers and the community that contributed to low PMTCT utilization. The effort fully utilizes

BCC models and theories of BCC to the success of the initiative. This activity will carry out nation wide

Behavior Change Communication to bring about desired behavior favoring ANC, institutional delivery, HIV

testing of pregnant women and utilization of PMTCT services by HIV-positive pregnant women.

Effective PMTCT program require coordination and collaboration of the different stake holders. Pregnant

women need support from their partners, the family and health service providers. The involvement of both

men and women in PMTCT plays crucial role in attaining PMTCT initiative objectives. Hence, there is a

need to catalyze and establish mass root support among men. Considering the situation in Ethiopia, where,

men are the nuclei for the decision making process in seeking medical care, their involvement need to be

improved. They should be oriented in ways that help them adopt behavior supportive to their women partner

in accessing ANC and PMTCT services.

Stigma and discrimination is another barrier leading to low uptake of PMTCT services. Pregnant women,

on the other hand, for fear of stigma do not want to go to CT even though they are attending ANC. Male

partners share the same fear. The deep rooted stigma, that has manifestation of different forms, has

worsening the problem with pregnant women. Health service providers, due to personal behavior, some

times carry out stigmatizing actions against those tested positive pregnant women. This could be during

ANC, labor and delivery. Such behavior need to be addressed systematically in a manner that ensures

sustainability and consistency.

Taking in to account the above factors and reports from National AIDS Resource Center (NARC), it is seen

that efforts should be exerted to work on Behavior Change among men and women of reproductive age,

pregnant women, health service providers and other community members to bring about desired behavior

change that enables pregnant women access and utilize ANC/PMTCT services.

While carrying out the BCC initiative certain components of middle level advocacy works will be carried out

to influence decision makers at Regional Health Bureau level to take measures in working towards

improving the ANC/PMTCT service utilization among pregnant women.

The BCC campaign will make use of opportunities and resources to achieve its objectives. The video

production on PMTCT will be used for the same purpose in a manner that ensures efficiency and

effectiveness. The BCC issues will be drawn from JHPIEGO assessment report on knowledge, perception

and attitude of men and women of reproductive age group and health service providers towards PMTCT.

Arrangements will be made with partner universities working on similar area to avoid duplication and

overlapping of efforts.

The following are targets for the BCC campaign: women and men of reproductive age group, pregnant

women, Health service providers, religious leaders, traditional birth attendants and traditional healers. The

BCC initiative will take place in: MNCH clinics, community (idirs and other social structures, women and

youth associations), religious institutions, transport (stations) and any other relevant service outlets.

The BCC activity will develop targeted messages with indicators, identify channels of communication, Print

Materials; Brochures, booklets (Pocket size) and conduct sensitization workshops.

The main activities include:

1. Development/adaptation of IEC/BCC printed and electronic materials on PMTCT in local languages for

distribution to pregnant women and their families and the community via Health Extension Workers.

2. Development of new, improved posters and visual aids on MNCH/PMTCT services;

3. Development of series of radio and TV spots, in local languages,

4. Targeted use of national and regional mass media including MOE's educational mass media;

5. Distribution and dissemination of print and electronic materials (includes air time costs for TV and Radio)

The BCC campaign will be coordinated and implemented by CDC-Ethiopia's PMTCT and BCC units in

collaboration with PEPFAR PMTCT partners and the government.

Addition: 10/7/08

PEPFAR Ethiopia in partnership with Ethiopian Health and Nutrition Research Institute (EHNRI), a

significant progress has been made in improving the laboratory services supporting HIV/AIDS care and

treatment program and strengthening of the national laboratory system. There are still gaps in

standardization of clinical microbiology laboratory service including diagnosis of opportunistic infection,

sexually transmitted infection, tuberculosis and malaria, testing and laboratory biosafety. American Society

for Microbiology (ASM), a prime partner in many PEFAR focus countries has been providing technical

assistance in these areas. As of 2008, ASM will also provide technical assistance in improving clinical

microbiology laboratory services. ASM will assess the status of the services, provide assistance in

developing standards in simple diagnostic testing, development of training modules and mentoring, ASM

will work closely with CDC Ethiopia and Ethiopian Health and Nutrition Research Institute (EHNRI) to

establish the national clinical and public health microbiology laboratory at the national and regional labs The

support is gap filling and critical in Ethiopia and will start preliminary activity with the reprogrammed budget

and the activities will continue widely in COP09.

In COP08, the following activities will be covered by ASM

• conduct an assessment of clinical microbiology laboratories in Ethiopia, identify gaps, and develop work

plan based on the priorities

• Preparation of protocols and guidelines for improvement of Clinical Microbiology laboratory services

including, STI, Malaria and other OI diagnosis, QA, development training modules, etc

• Development training modules in clinical microbiology laboratory services (STI and malaria and OIs)

Laboratory Infrastructure

PEPFAR Ethiopia, in collaboration with the Ministry of Health (MOH), is strengthening regional, hospital,

and health center laboratories to support HIV/AIDS prevention, care, and treatment programs. CDC

Ethiopia coordinated and led all laboratory-related services implemented by PEPFAR partners, including

training, laboratory diagnosis and monitoring tests at hospital and health center levels, and referral

diagnostic services (CD4, infant diagnosis, and viral load tests).

In FY07, CDC Ethiopia supported the establishment of a national HIV referral laboratory at Ethiopian Health

and Nutrition Research Institute (EHNRI) to meet national standards. The national referral lab has been fully

networked with information technology equipment and broadband Internet connectivity. This national

laboratory is used as a model facility for training and coordinating laboratory quality assurance in the

country. All ART monitoring analyzers are installed and hence the referral lab was supporting the referral

testing for the ART program. Early infant diagnosis equipment was provided and assisted the referral

laboratory to provide referral infant diagnosis of HIV. The new rapid testing algorithms for HIV have been

made available for use, and training of trainers on rapid HIV testing using the new algorithm has been

conducted.

In FY07, technical assistance was provided for regional rollout and decentralization of laboratory training in

HIV rapid testing, integrated laboratory training, laboratory management and lab quality system. The

trainings were successful and more than 1,000 laboratory professionals were trained. PEPFAR Ethiopia

also supported the national referral laboratory to conduct the following targeted evaluations: HIV-drug

resistance threshold survey, microscopic-observation of drug susceptibility test for TB, percentage of infant

CD4 determination, single-tube use for CD4 count, and defining the reference ranges of

hematology/chemistry profile.

All the activities started in FY07 will also continue in FY08. The activities include:

(1) Continuing to support all laboratory trainings and implementation of national quality assurance program

at all levels

(2) CDC Ethiopia will lead and coordinate all laboratory activities under PEPFAR support. Technical

assistance will be provided to EHNRI to strengthen the tiered quality laboratory services in the country and

implement the "Master Plan for National HIV/AIDS Laboratory System in Ethiopia".

(3) Support the National HIV laboratory to upgrade the facility to Biosafety Level Three to improve the

containment for some specialized tests as referral center for country

(4)Providing support, including furnishing with basic equipment, to six additional regional laboratories to

serve as regional referral hubs and providing necessary equipment for establishing DNA PCR set-ups at

sub-regional or referral hospital laboratories renovated by university partners at different regions

(5) Supporting the development and printing of laboratory guidelines and standard operating procedures

(6) Facilitating and supporting national and regional laboratory review meetings for PEPFAR-supported

programs and coordinating periodic site-level supportive supervision and mentoring

(7) Providing technical assistance in strengthening tiered laboratory services, referral networking, and

expansion of the LIS to hospital and health center facilities

(8) Supporting monitoring and evaluation of laboratory services, including: standardization of lab forms;

record keeping; and reporting support tools to include laboratory test requests, referral forms, and reporting

forms. Supporting the national and regional database system for laboratory reporting system for laboratory-

based surveillance and detection, typing, and drug susceptibility surveys

Strengthening National HIV/AIDS/STI Surveillance Systems:

CDC-Ethiopia technical staff provides direct technical assistance to the Federal Ministry of Health (MOH) of

Ethiopia, as well its component parts, the Ethiopian Health and Nutrition Research Institute (EHNRI) and the

HIV/AIDS Prevention and Control Office (HAPCO) and the nongovernmental Ethiopian Public Health

Association (EPHA) in the areas of surveillance and blood safety.

In FY07, CDC Ethiopia completed several activities within the scope of technical assistance provision to

MOH, EHNRI, HAPCO and EPHA. CDC Ethiopia's main activities were:

1) Expanding antenatal care-based HIV surveillance through training of national and regional surveillance

officers, antenatal care (ANC) clinic and laboratory staffs, and supervision of data collection at sentinel ANC

sites

2) Conducting site assessments for AIDS Mortality surveillance

3) Technical assistance for the finalization of guidelines for HIV case, tuberculosis (TB)/HIV and sexually

transmitted infections (STI) surveillance

4) Technical assistance for HIV/STI and risk-behavior surveillance among most-at-risk population (MARPs)

and survey to identify the routes of spread of HIV from "hot spots" to rural areas. Findings from these

targeted evaluations will be used to design and implement effective interventions to MARPs and rural areas.

5) Sponsorship of technical assistance visits from international subject-matter experts related to leadership

for strategic information training, TB/HIV surveillance, and HIV case surveillance

These activities have helped PEPFAR Ethiopia and the Government of Ethiopia to generate, capture,

analyze, disseminate, and use quality strategic information to guide the planning, implementation, and

monitoring and evaluation of HIV/AID prevention, care, and treatment programs.

In FY08, CDC Ethiopia will focus on the provision of technical assistance to MOH, EHNRI, Federal HAPCO,

and EPHA in the areas of:

1) Implementing of HIV case surveillance

2) Expansion of the Leadership for Strategic Information Training and its development to the Field

Epidemiology and Laboratory Training (FELTP) and further implementation based on the needs of the MOH

3) Full implementation of TB/HIV surveillance

4) Implementation of ART drug-resistance surveillance

5) Successful completion of public health evaluations (PHE) that focus on all PEPFAR-supported

interventions

6) Capture, compilation, analysis, dissemination, and use of data generated from these surveillance

activities

7) Building the capacity of EHNRI and EPHA so that they can provide adequate technical support to

regional health bureaus (RHB), laboratories, and surveillance sites

Through these activities, PEPFAR Ethiopia will strengthen the leadership, technical, and managerial

capacity of EHNRI and RHB to absorb and respond to the increasing needs for evidence-informed

surveillance information for policy- and decision-making on HIV/AIDS in particular. and public health in

general.

Information Communications Technology (ICT) Support:

This is continuing activity from FY07. In FY07, PEPFAR Ethiopia has been supporting the development and

upgrade of the MOH and EHNRI comprehensive information technology (IT) network infrastructure,

including internet connectivity and human-capacity development for sustainable functioning of the system.

In FY07, PEPFAR Ethiopia conducted a system study for deploying a computer network within the RHB and

identified gaps.

In FY08, PEPFAR Ethiopia will deploy the computer network and establish the interconnection of five RHB.

PEPFAR will also continue to provide support for MOH and EHNRI on information and communications

technology to meet their new requirements, including expansion of their LAN/WAN system. With this

activity, all seven sites will be supported with the procurement of IT equipment, deployment of LAN/WAN

systems, provision of broadband connectivity, maintenance support, and advanced training for ICT staffs of

the partner organizations. This will ensure that the available communication technologies are sufficient to

enable the health sector to improve services, as well as enhancing the accuracy, quality, and timely flow of

health information (to the Health Management Information System, Human Resources, and Finance, among

others).

This is linked with PEPFAR Ethiopia-supported human capacity development activities aimed at

strengthening the implementation of the Sustainable Management Development Program (SMDP) to

improve the management and training skills of public health management professionals, health service

planners and managers in Ethiopia.

In FY07, CDC Ethiopia, with technical assistance from the SMDP program at CDC Global AIDS Program

(GAP) headquarters, conducted a needs assessment to design strategies for strengthening leadership and

management of HIV/AIDS care and treatment services at health facilities in support of the scale-up of

antiretroviral treatment (ART) in Ethiopia. The needs assessment targeted five PEPFAR-supported

hospitals in the Central and Northern Parts of Ethiopia (Debre Berhan, Dessie, Lalibela, Woldia, and

Zewditu, Hospitals), 2 Regional Health Bureaus (Addis Ababa and Oromiya), and five national

organizations: the federal Ministry of Health (FMOH) and its component HIV/AIDS Prevention and Control

Office (HAPCO), Addis Ababa HAPCO, the Ethiopian Public Health Association (EPHA), the Ethiopian

Health and Nutrition Institute (EHNRI), Addis Ababa University Medical Faculty Public Health Department,

and the Addis Continental Institute of Public Health.

The major objectives of the Needs Assessment were to investigate ways and means of:

1) Improving the planning and management capacities of health facilities, particularly ART cohort hospitals,

FMOH, national HAPCO, and local universities program managers, directors, planners and coordinators in

the implementation of HIV/AIDS and other diseases prevention, care and treatment programs in Ethiopia.

2) Strengthening collaboration with US-based universities and technical agencies through follow-up and

capacity enhancement in the implementation of SMDP trainings at health facilities, local universities, the

Ministry of Health, Regional Health Bureaus (RHB) and HAPCO offices.

The needs assessment included both policy-level and organizational collaboration and practical

organizational operations issues related to the need for leadership and management strengthening in

HIV/AIDS care and treatment facilities. As a result of the needs assessment:

1) EPHA was identified as an institutional home to implement SMDP in Ethiopia.

2) Customized SMDP training curricula for Ethiopia were developed.

3) First Round training of trainers (TOT) program was organized and conducted for trainers drawn from

EHNRI, HAPCO, and health facilities, with the support of the CDC/GAP's SMDP Team and CDC Ethiopia

SMDP graduates.

4) Core trainer teams were established at regional and local facilities level for sustained SMDP

implementation.

In FY08, further trainings will be designed and provided for 60 public health management professionals

drawn from PEPFAR-supported hospitals, RHB, and HAPCO. The CDC/GAP SMDP Team and Ethiopian

SMDP Team will continue providing technical assistance in building SMDP coordination and management

capacity for EPHA in areas of training. CDC Ethiopia will also follow up on the main SMDP components

such as process improvement/problem solving, Total Quality Management (TQM), healthy planning, and

strategic communications, all in collaboration with FMOH/HAPCO, health facilities, US-based universities

and agencies (Carter Center, Clinton Foundation), local universities, and health-related training institutions

in Ethiopia.

The SMDP approach actively involves all local stakeholders, including health facilities, local universities and

training institutions in human capacity development, planning and management of public health services,

process improvements, and quality assurance mechanisms in an integrated and innovative approach. As

such, the SMDP trainings will be sustained and institutionalized at local health facilities and training

institutions. Accordingly, 20% of the required budget will be expended on training material design and

adaptation with technical assistance from CDC/GAP SMDP, 45% on training material production, delivery

and management, and 35% on follow up of the SMDP training program application at health facilities at

central, regional and local levels.