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The Plan for Elimination of Mother to Child Transmission of HIV & Syphilis in Zimbabwe

2018-2022

The Plan for Elimination of Mother to Child Transmission of HIV & Syphilis in Zimbabwe 2018-2022

CONTENTS

Abbreviations.................................................................................................................................................... 4Foreword........................................................................................................................................................... 5Acknowledgements........................................................................................................................................... 6Executive Summary............................................................................................................................................ 7

1.1 Introduction to country context and health care delivery structure........................................................... 91.2 HIV and syphilis epidemiology in Zimbabwe.......................................................................................... 101.3 Zimbabwe RMNCAH&N situation.......................................................................................................... 131.4 Rationale for dual HIV and syphilis EMTCT Plan...................................................................................... 16

2.1 Program and service delivery related bottlenecks................................................................................... 192.2 Laboratories, logistics and medical products......................................................................................... 212.3 Data systems and use for reaching the elimination targets...................................................................... 242.4 Community systems related bottlenecks................................................................................................ 252.5 Other RSSH bottlenecks......................................................................................................................... 26

3.1 Guiding principles................................................................................................................................. 283.2 EMTCT Plan vision, goal and objectives.................................................................................................. 293.3 EMTCT Theory of change....................................................................................................................... 29

SIA 1: Promoting availability of quality integrated RMNCAH&N and EMTCT services ......................................... 32SIA 2: Enhanced timely diagnosis, treatment, care and follow up of

pregnant and lactating women living with HIV, their partners and children.............................................. 34SIA 3: Strengthening laboratory and pharmacy commodities for EMTCT............................................................ 35SIA 4: Enhanced human rights, gender and community engagement for EMTCT............................................... 36SIA 5: Strengthening data and strategic evaluation for EMTCT and validation.................................................... 39SIA 6: Strengthened leadership and governance for EMTCT.............................................................................. 40

5.1 Cost of implementing the EMTCT Plan.................................................................................................... 425.2 Testing and treatment costs for HIV......................................................................................................... 435.2.1 HIV testing and treatment targets for pregnant & lactating women.......................................................... 435.2.2 HIV testing costs for pregnant and lactating women............................................................................... 445.2.3 HIV treatment costs for pregnant and lactating women........................................................................... 455.2.4 Syphilis treatment targets for pregnant and lactating women.................................................................. 455.2.5 Syphilis testing costs for pregnant and lactating women......................................................................... 455.2.6 HIV testing targets for HIV exposed infants............................................................................................. 465.2.7 HIV testing costs for infants.................................................................................................................... 46 5.2.8 HIV treatment costs for children............................................................................................................. 475.2.9 Syphilis treatment costs for children....................................................................................................... 475.3 Resource gap for Implementing the EMTCT Plan..................................................................................... 485.4 Bridging the resource gaps.................................................................................................................... 49

1.0 Background and Rationale................................................................................................................... 9

2.0 Bottlenecks to EMTCT of HIV and Syphilis............................................................................................. 19

3.0 The EMTCT Plan Framework................................................................................................................. 28

4.0 Priority Strategic intervention areas and key actions for EMTCT............................................................ 31

5.0 Financing the EMTCT Plan.................................................................................................................... 42

6.0 Monitoring and evaluation for validation of EMTCT.............................................................................. 51

LIST OF FIGURES

LIST OF TABLES

Annexes..................................................................................................................................................... 53

6.1 Monitoring and evaluation of the EMTCT Plan....................................................................................... 516.2 Setting the stage for EMTCT validation................................................................................................. 51

Figure 1: Zimbabwe administrative provinces................................................................................................ 9Figure 2: Zimbabwe health service delivery structure..................................................................................... 10Figure 3: New STI cases by year...................................................................................................................... 13Figure 4: ANC coverage by district................................................................................................................. 14Figure 5: Why dual elimination of HIV and syphilis.......................................................................................... 18Figure 6: DBS sample rejection rates by district............................................................................................... 22Figure 7: Bottlenecks along the PMTCT/EID Cascade........................................................................................... 27 Figure 8: ZEMTCT theory of change................................................................................................................ 30Figure 9: Six EMTCT strategic intervention areas aligned to the four PMTCT Prongs............................................. 31Figure 10: Total cost of EMTCT Plan............................................................................................................ 42Figure 11: Summary of HIV and syphilis testing in PMTCT.................................................................................. 44Figure 12: Treatment costs for HIV positive pregnant and lactating women........................................................ 44Figure 13: Syphilis treatment costs for pregnant women................................................................................... 45Figure 14: HIV exposed infants testing algorithm.............................................................................................. 46Figure 15: Cost of ARV prophylaxis for HIV exposed infants............................................................................... 47Figure 16: Cost of syphilis treatment for infants................................................................................................ 47Figure 17: Annual funding for EMTCT Plan....................................................................................................... 48Figure 18: Overall funding gap for EMTCT plan by economic classification......................................................... 49

Table 1: Zimbabwe PMTCT situation: A snapshot........................................................................................... 12Table 2: Strategic intervention areas............................................................................................................. 17Table 3: Costs of EMTCT Plan by strategic intervention area........................................................................... 42Table 4: Programme activity costs by economic classification excluding testing & treatment............................ 43Table 5: HIV Testing and treatment targets for pregnant & lactating women................................................... 43Table 6: Pregnant and lactating women annual HIV testing costs.................................................................. 44Table 7: Annual syphilis targets for pregnant and lactating women................................................................ 45Table 8: HIV testing and treatment targets for infants.................................................................................... 46Table 9: HIV testing costs for infants............................................................................................................. 46Table 10: Overall funding gap for EMTCT Plan by economic classification......................................................... 50

1 The EMTCT Monitoring and Evaluation Framework................................................................................. 532 Implementation framework................................................................................................................... 55

The Plan for Elimination of Mother to Child Transmission of HIV & Syphilis in Zimbabwe 2018-2022

The Plan for Elimination of Mother to Child Transmission of HIV & Syphilis in Zimbabwe 2018-2022 4

AIDS Acquired Immune Deficiency Syndrome AGYW Adolescent Girls and Young Women ANC Antenatal Care ART Antiretroviral Therapy CHAI Clinton Health Access Initiative CBOs Community Based Organisations DBS Dry Blood Spot DHIS District Health Information Systems DREAMS Determined Resilient Empowered AIDS free Mentored and Safe EHR Electronic Health Records EID Early Infant Diagnosis EPI Expanded Programme on Immunization EMTCT Elimination of Mother to Child Transmission (of HIV and syphilis) EGPAF Elizabeth Glazer Pediatric AIDS Foundation HIV Human Immunodeficiency Virus FP Family Planning MICS Multiple Indicator Cluster Survey NAT Nucleic Acid Test NatPharm National Pharmaceutical Company of Zimbabwe MoHCC Ministry of Health and Child Care OI Opportunistic Infections OPHID Organization for Public Health Interventions and Development RMNCAH&N Reproductive, Maternal, Newborn, Child and Adolescent Health& Nutrition RSSH Resilient and Sustainable Systems for Health SOPs Standard Operating Procedures STIs Sexually Transmitted Infections PBF Performance Based Financing PHC Primary Health Care PITC Provider Initiated Testing and Counselling PMTCT Prevention of Mother to Child Transmission of HIV PNC Post Natal Care POC Point of Care QI Quality Improvement UNAIDS Joint United Nations Program on HIV and AIDS UNFPA United Nations Populations Fund UNICEF United Nations Children's fund VHWs Village Health Workers WHO World Health Organisation ZAPS Zimbabwe Assisted Pull System ZEMTCT Zimbabwe Elimination of Mother to Child Transmission of HIV and syphilis ZDHS Zimbabwe Demographic Health Survey ZIMPHIA Zimbabwe Population Based HIV Impact Assessment ZNASP Zimbabwe National HIV and AIDS Strategic Plan

ABBREVIATIONS


The Government of Zimbabwe through the leadership of the Ministry of Health and Child Care has been providing services for the prevention of mother to child transmission of HIV (PMTCT) since 1999; initially only in 3 pilot sites, with national scale up in 2002. To date services for PMTCT are available in 1560 sites country-wide. In 2010, the country embraced the Global Plan to eliminate mother to child transmission of HIV (2010-2015), with the goal to reduce mother to child transmission rate to less than 5%. With recent country spectrum estimates showing a final MTCT rate of 5.78%, Zimbabwe is poised to achieve significant milestones on the path to dual elimination of HIV and syphilis among children.

We stand to benefit from global experiences and best practices from countries that have already been validated as having eliminated MTCT such as Cuba, Thailand, Armenia and Belarus. These countries have achieved milestones that we wish to emulate. In 2016, a successor framework to the Global Plan was launched at the UN High Level Meeting (HLM); the Start Free, Stay Free, AIDS Free framework. Zimbabwe was the first country to domesticate the framework in November 2016, and is now poised to implement a Super-fast approach to ENDING AIDS in children and adolescents.

The World Health Organization (WHO) has set process and impact indicators that countries have to attain to receive official recognition of having attained EMTCT of both HIV and syphilis, and countries are required to develop 5 year EMTCT plans outlining how these milestones will be achieved. In respect of this, this 5-year EMTCT plan (2018-2022) has been developed as further demonstration of Zimbabwe's commitment to attaining dual elimination of mother to child transmission of HIV and syphilis.

This is the first dual EMTCT plan for Zimbabwe; as integrating EMTCT of HIV and congenital syphilis is cost effective and makes programmatic sense. In addition to scaling up interventions, this plan introduces EMTCT game changers such as intensified re-testing of pregnant and lactating women who initially tested HIV negative, innovative interventions to increase partner testing such as self-testing, decentralization of early infant diagnosis services including scaling up point of care testing and piloting and scaling up of birth testing. The use of electronic health records and intensified follow up of mother baby pairs to ensure retention in the PMTCT cascade is emphasized, in addition to case investigation of all new HIV positive infants as we seek to close the tap of new HIV infections among children and eliminate congenital syphilis.

This plan was developed through a consultative process involving stakeholders at both national and sub-national levels. It is our plan towards achieving EMTCT, and I urge all stakeholders to rally behind this plan. The Ministry of Health and Child Care commits to providing an enabling environment including the necessary policy guidance to support speedy implementation.

Dr. Pagwesese David ParirenyatwaHon. Minister of Health and Child Care

FOREWORD


The Ministry of Health and Child Care acknowledges the leadership of the Director of AIDS&TB Unit Dr Owen Mugurungi; the technical input and coordination of the process for the EMTCT plan development provided by the National PMTCT and Paediatric HIV Care and Treatment Coordinator Dr Angela Mushavi, the Deputy Coordinator, Dr Solomon Mukungunugwa and the PMTCT team at national level. The Ministry of Health and Child Care greatly appreciates the role of the EMTCT Technical Working Group, which provided an institutional platform that helped in the development of the plan.

Appreciation also goes to the WHO and UNICEF for the financial support that was provided to enable recruitment of an external consultant Dr Philip Wambua; who led the process of developing the EMTCT plan, and to CHAI for availing costing experts who were instrumental in costing the 5-year EMTCT plan.

As Zimbabwe moves towards dual elimination of mother to child transmission of HIV and syphilis, it was critical that the development of this EMTCT plan be done in close collaboration with programs and departments within the MOHCC. As such, acknowledgements are extended to the Family Health Directorate, the SRH and Nutrition programs, the HTS and STI and Condom Programs, OI/ART program and key players in NAC. Appreciation is extended to key constituencies of women living with HIV and other organizations of PLHIV such as ICW and ZNNP+ who contributed to the development of the plan; their support was, and will be invaluable to the implementation of the plan.

Full implementation of this plan is dependent on the work of the Provincial Medical Directors and their teams on the ground. To them, we extend full acknowledgement including to district and facility teams on the frontline of program implementation whose experiences with regards to successes and bottlenecks helped to shape the activities outlined in this plan. To all the people who in one way or another participated in the development of this EMTCT plan, your contribution to the elimination of mother to child transmission of HIV and congenital syphilis in Zimbabwe is greatly appreciated.

The Ministry of Health and Child Care appreciates the technical and financial support from the WHO, UNICEF, PEPFAR Zimbabwe, CHAI, EGPAF, USAID, CDC, FHI360, OPHID, Kapneck Trust, ZAPP, WEI, AFRICAID, ICW, NAC, Abt, AHF, ITECH, ZNNP+ and ZACH.

This work is done as a tribute to all the women, children and fathers for whom we toil daily as we accelerate implementation towards EMTCT. To them we extend a big thank you.

ACKNOWLEDGEMENTS


Zimbabwe has made progress in the elimination of mother to child transmission (EMTCT) of both HIV and syphilis. Despite this progress, the country has significant work to do before the country can be validated as having eliminated both HIV and syphilis as public health threats as set out in the WHO Global Guidance on Criteria and Processes for Validation.

Per WHO's official guidance, the validation process is a very thorough and meticulous process. The minimum EMTCT impact targets as outlined by the WHO are:

- For HIV: less than 50 new pediatric infections per 100 000 live births and a mother to child transmission rate of either


Remaining bottlenecks to EMTCT that were identified include program and service delivery and health systems bottlenecks including those related to laboratory and commodities, data and strategic information and community systems strengthing. Weak coordination, declining funding and inadequate human resources for health to provide quality EMTCT services are also identified as slowing down achievement of EMTCT. With a vision of a Zimbabwe with zero MTCT for both HIV and syphilis the goal of this first Zimbabwe dual EMTCT plan is to contribute to accelerating elimination of mother to child transmission by 2022. In measuring progress towards this goal, the plan sets the following impact and coverage targets. By 2022:

Reduction of mother to child transmission rate of HIV to 5% or less Reduction of new peadiatric HIV cases to 250 or less per 100,000 live births Reduction of new cases of congenital syphilis to 50 cases or less per 100,000 live births

Increase ANC coverage to 95 % or more Increase coverage of HIV testing for pregnant women to 95 % or more Increase coverage of syphilis screening for pregnant women to 95% or more Increase ARV coverage for HIV positive pregnant women to 90% or more Increase treatment coverage for syphilis seropositive pregnant women to 95 % or more

Towards achievement of these EMTCT targets, Zimbabwe will implement evidence based strategies organized under six broad interlinked strategic intervention areas namely:

1. Promoting availability of quality integrated RMNCAH&N and EMTCT services2. Enhanced timely diagnosis, treatment, care and follow up of HIV positive women, their partners and

children3. Strengthening laboratory, commodity and supplies security systems for dual EMTCT of HIV and syphilis4. Enhanced Gender, human rights and community engagement in the context of dual EMTCT of HIV and

syphilis5. Strengthening data and strategic evaluation for EMTCT and validation6. Strengthened leadership and governance for EMTCT

Monitoring and evaluation of this EMTCT plan will be at two levels; level one will be to monitor the implementation of this plan while level two will be monitoring and evaluating the impact of the strategies in achieving the set EMTCT targets. A midterm review and independent end term evaluation of the plan will be conducted. A monitoring and evaluation framework to this plan is provided as an annex. The total cost for implementing the plan over the five-year period is given as $161million. With total EMTCT resource commitments in the country for the five years being $63 million, the resource gap for the plan implementation is $110 million USD. Resource mobilization strategies for bridging the resource gaps will include:

1. Increasing efficiency in implementation and resource utilization2. Integration of activities with RMNCAH&N and other programs to reduce costs3. Lobbying for increased domestic funding from the Ministry of Finance4. Targeted support for EMTCT from the NAC AIDS Levy5. GFATM6. PEPFAR 7. Advocating for funding from bilateral and multi-lateral agencies 8. Private philanthropies9. Strengthening public and private partnerships

With full scale implementation of the activities outlined in this plan, Zimbabwe is poised to achieve elimination of EMTCT in the not too distant future, and to welcome an HIV and syphilis free generation of children.

Impact targets chosen for 5 year EMTCT Plan for Zimbabwe

Coverage Targets


1.0 BACKGROUND AND RATIONALE

Zimbabwe which measures about 390,757 square kilometres has a total population of 13,061,239 people, with 6,280,539 being males and 6,780,700 females. The country has a young population with those below the age of 15 years representing 41% of the total population. It is a land-locked country in Southern Africa bordering Mozambique in the east and northeast, South Africa in the south, Botswana in the west, and Zambia in the north and northwest. With two urban (Bulawayo and Harare) and eight rural provinces, the country is divided into 10 provinces and 63 districts. The ten provinces are: Bulawayo, Harare; Manicaland, Mashonaland East, Mashonaland Central, Mashonaland West, Matabeleland North, Matabeleland South, Masvingo and Midlands.

The National Health Sector Strategic Plan identifies health service providers in Zimbabwe as being: public health facilities, not-for-profit organisations, the faith-based organisations, company-operated clinics such as those owned by mining companies, the private-for-profit clinics, and the traditional medicine sector. The country has a decentralised health care delivery system with the national level (Head Office) of the Ministry of Health and Child Care being responsible for policy, regulation and administrative guidance; human resource planning; donor coordination, resource mobilisation and allocation as well as surveillance, and monitoring and evaluation. The Provincial Medical Office is responsible for management of the provincial hospital and all district health facilities within the province while the district medical officer administers the district hospital and all the rural health facilities within the district. The public health system has four tiers as described below.

The primary health care facilities (PHC) comprise of rural health centres, rural hospitals and urban clinics and form the first level of entry to the health care system. The PHC facilities provide the following basic services: Essential package of reproductive, maternal, newborn, child and adolescent health (RMNCAH&N) services comprising of antenatal care, comprehensive PMTCT services, OI/ART, normal delivery, postnatal care as well as integrated management of neonatal and childhood illnesses (IMNCI), TB and other outpatient conditions affecting children, adolescents and adults. The village health workers program provides linkage of the PHC facilities to the communities.

These comprise of government district hospitals and mission hospitals of the same designation as in districts that are not served with government hospital.

Primary Health Care Facilities

District /Mission Hospitals

1.1. INTRODUCTION TO COUNTRY CONTEXT AND HEALTH CARE DELIVERY STRUCTURE

FIGURE 1: ZIMBABWE ADMINISTRATIVE PROVINCES

MatebelelandNorth

MatebelelandSouth

Bulawayo

Midlands

Masvingo

Manicaland

MashonalandEast

MashonalandCentralMashonaland

West


Services provided at this level include those provided at the PHC level, diagnostic, surgical procedures, emergency obstetric and newborn care services (EmONC), comprehensive PMTCT services, ART, treatment of opportunistic infections, blood transfusion and inpatient and outpatient of other medical conditions affecting the population.

These are the highest referral health facilities at the provincial level and are staffed with specialists in different disciplines. The provincial hospitals are mandated to provide management of complicated newborn (pediatric), child, mother (obstetrics and gynecological) and adult medical complications as well as surgical referrals from the district hospitals, including provision of PMTCT, OI/ART and TB services.

These are the apex in the hierarchy of health care in the country and provide both the highest level of care for all referred cases as well as provide training of medical, nursing and paramedical personnel.

The figure below shows the hierarchy of the Zimbabwe Health Service Delivery Structure

Provincial Hospitals

Central Hospitals

Central Hospitals

Provincial Hospitals

District and Mission Hospitals

Primary Health Care Facilites

1.2.HIV AND SYPHILIS EPIDEMIOLOGY IN ZIMBABWE

Zimbabwe HIV and AIDS Epidemiology Although Zimbabwe has made considerable progress in the HIV and AIDS response, the country still has huge unfinished business. In terms of general HIV and AIDS epidemic, the country has an estimated 1.33 million people

1living with HIV, of these 1.2 million are aged between 15 and 64 years . HIV prevalence among adults has shown a 2

decrease over the last ten years from 18.1% in 2005 to 14.6% in 2015 . Gender disparity exists with women having a prevalence level of 16.7% compared to 10.5% among men in 2015. Prevalence among children (0-14 years) is

3estimated at 1.6% . Regional differences in HIV prevalence exist. Among adults ages 15 to 64 years, prevalence of HIV varies geographically across Zimbabwe, ranging from 11.4 % in Manicaland to 20.1 % in Matabeleland North and 22.3 % in Matabeleland South.

FIGURE 2: ZIMBABWE HEALTH SERVICE DELIVERY STRUCTURE

1Zimbabwe Population Based HIV Impact Assessment 2015-2016.2Zimbabwe Demographic Health Survey 2015.3Zimbabwe Demographic Health Survey 2015


4http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2015/june/20150630_cuba5Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive 6For Every Child, End AIDS. Seventh Stocktaking Report. UNICEF 20167Zimbabwe Start Free Stay Free AIDS Free Framework Launch and Pediatric /Adolescent HIV symposium Report8The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive Prepared for the iERG By UNAIDS May 15, 2015. Preliminary report.9Spectrum UNAIDS Estimates. 2016

Globally, each year about 1.4 million infected women including those from Zimbabwe fall pregnant. Without any intervention, these women have a 15% to 45% risk of transmitting HIV to their children, during pregnancy, labour and delivery or breastfeeding. With effective Prevention of Mother to Child Transmission of HIV (PMTCT)

4interventions, this transmission risk falls to a significant low of 1% .

Zimbabwe is one of the 22 countries (21 of which are in Africa) which account for over 90% of all pregnant women 5

living with HIV globally . Out of the total 77,000 children aged 0-14 years who were living with HIV by end of 2015 6in Zimbabwe, over 90 % of these were infected through MTCT . Despite this, the country has made significant

progress improving PMTCT indicators as well as increasing coverage of PMTCT services from three sites in 1999 to 71560 sites by end of 2013 . Significant achievements have been made across the cascade with Antenatal Care (ANC)

testing coverage being almost universal at 99%. Uptake of Antiretroviral drugs (ARVs) among HIV positive pregnant women increased from 82% in 2013 to 84% by end of 2015. Recent PMTCT program reports (2016) indicate treatment coverage for HIV positive pregnant women at 90 % indicating the country is progressing well on the path to elimination (formerly referred to as pre-elimination by the WHO). However provincial and district variations exist in terms of ARV coverage with some provinces and districts being worse off than others.

To achieve WHO validation criteria requires that targets are met even in the lowest performing districts; and interventions to accelerate ART coverage will be implemented in those districts. Although partner testing has improved from a low of 10% in 2011, it remains stubbornly low at 23%; presenting likelihood of high risk for incident infections in pregnant and lactating women. Unlike other indicators, the % of HIV exposed infants given Nevirapine prophylaxis for reduction of Mother-To-Child Transmission (MTCT) of HIV declined from 88% in 2014 to 75% 2015, which is concerning to the program. Zimbabwe has shown progress in provision of early infant diagnosis to HIV exposed infants. By February 2015, Zimbabwe was among six of the PMTCT priority countries that were providing early infant diagnosis to more than 50% of children exposed to HIV: South Africa (94%), Swaziland

8(89%), Botswana (58%), Namibia (56%), Zambia (55%) and Zimbabwe (50%). Recent reports indicate that 54.9 % of infants in the country received a virological test within 2 months.

The country is currently analyzing data from a PMTCT effectiveness survey that has been recruiting and following up mothers and HIV exposed infants over an 18 month period 2016-2017. Preliminary results indicate a mother to child transmission rate of 1,9% at 6 weeks, and a final transmission rate less than 5%, indicating the country is fast approaching the WHO validation criteria target. Given the high ANC prevalence of 14%, the country has a high case rate of 621 per 100,000, which is more than ten times the WHO validation target of 50 cases per 100,000 live

9births .


10TABLE 1: ZIMBABWE PMTCT SITUATION: A SNAPSHOT

Zimbabwe Syphilis EpidemiologyThere is paucity of data in Zimbabwe on syphilis situation especially among pregnant women and generally among women of reproductive age and their partners. Although the number of new STI cases declined from 2013 to 2015

11as per the global AIDS Response Report , the country is still far from bringing down the STI situation to a level where it is of no public health concern.

10For Every Child, End AIDS. Seventh Stocktaking Report. UNICEF 201611Zimbabwe Global AIDS Response Progress Report 2016.

Number of people living with HIV 1 334 292

Expected pregnancies 433 905

ANC coverage 418 993 (97%)

Number of pregnant women living with HIV 66 477

Number of pregnant women living with HIV who received ARVs for PMTCT 59 599 (90%)

Exposed infants started on ARVs 48 979 (74%)

Number of exposed infants who received a virological test within 2 months of birth

44 965 (68%)

Number of exposed infants started on Cotrimoxazole 42 144 (63%)

Number of children living with HIV (0 14) 72 887

Number of children receiving ART (0 14) 66 152 (93%)

Number of new infections in children (0 14) 3 845

2016 Data


Estimated syphilis prevalence (equal in women and men 15 49 years) declined from 1.9% (95% CI 1.1% to 3.4%) 12to 1.5% (1.3% to 1.8%) between 2000 and 2016 . According to Zimbabwe Population Based HIV Impact

Assessment (ZIMPHIA) 2016, 3 % of females and 2.4% of males have ever been infected with syphilis among adults ages 15 to 64 years,.

1.3 ZIMBABWE RMNCAH&N SITUATION

Family PlanningAccess to family planning among women of reproductive age and especially those living with HIV is an important intervention for a comprehensive approach to EMTCT. Additionally, access to FP provides an opportunity to offer HIV counseling and testing services as well as other primary prevention interventions. The Zimbabwe unmet need for

13family planning which was at a high of 13%, has shown a decline to 10% (ZDHS 2015/16) . Although no data is available, it is reported that unmet need for women living with HIV is higher than that of the general population. Zimbabwe has made progress in increasing use of FP. The ZDHS 2015/16 reported an increase in use of modern FP methods from 50% in 1999 to 66% in 2015. Variations in use exist by age, residence and region. Contraceptive use is highest (71%) among the 3039 years' age group, and among women in urban areas (71%) compared to those in rural areas (63%). Regionally, modern contraceptive use is highest in Bulawayo and Mashonaland West (each with 71%), and lowest in Manicaland (57%) and Matabeleland South (60%). Only 39% of the sexually active unmarried girls ages 15-19 years reported use of modern family planning methods; compared to their peers who were married (45%).

12Estimating prevalence trends in adult gonorrhoea and syphilis in low- and middle-income countries with the Spectrum-STI model: results for Zimbabwe and Morocco from 1995 to 2016. Accessed from http://sti.bmj.com/content/sextrans/early/2017/03/21/sextrans-2016-052953.full.pdf13Zimbabwe National Family Planning Strategy. 2016 to 2020

FIGURE 3: NEW STI CASES BY YEAR

Figure 3 below shows the new STI cases by year


Antenatal Care Coverage Antenatal care presents the first entry point into the EMTCT program. While Zimbabwe has high coverage for first ANC visit, this decreases with subsequent visits. The ZDHS 2015/16 reported high antenatal care attendance, with 93% having received care at least once during the pregnancy but the proportion that made at least four visits declined to 76%. Early ANC attendance is critical for EMTCT. According to ZDHS 2015/16, only 39% of the women reported making first ANC visit during the first trimester. Recent Ministry of Health and Child Care programme reports indicate variations in reported ANC coverage with some districts such as Harare, Mutare, Kwekwe,

14Masvingo, Gokwe North and Chiredzi having coverage rates lower than 90% . While these may represent actual rates, there could be cases of low reporting rates in big cities like Harare and Mutare where pregnant women attend private clinics. Figure 4 below shows ANC coverage by district.

14Zimbabwe DHIS 2 data downloaded May 17, 2017

FIGURE 4: ANC COVERAGE BY DISTRICT

Legend

95%

90%90% 94%=

-


Skilled birth attendance coverage

Postnatal Care (PNC) coverage

Adolescent Health

Institutional deliveries are important for EMTCT, firstly they serve as an opportunity for testing pregnant women missed at ANC, secondly they present opportunities for retesting of HIV negative women and thirdly, for ensuring best care for HIV positive women to reduce MTCT during labour and delivery. The ZDHS 2015/16 reported that 78% of women were delivered by a skilled birth attendant, 77% delivered within a health facility setting and 20% delivered in a home setting. Delivery by a skilled birth attendant was highest in Bulawayo province (95%) and lowest in Mashonaland West (67%), while Manicaland had the highest reported deliveries by traditional birth attendants (18%).

Postnatal care visits present an opportunity for integrating EMTCT interventions such as retesting of HIV negative women, re-emphasizing the need for early infant diagnosis and postpartum family planning services. According to ZDHS 2015/16, 68% of women received postnatal care; 57% within 2 days after delivery. Regional variations exist with Matabeleland South recording the highest PNC (82%) and Masvingo the lowest (44%).

Adolescent girls and young women (AGYW) present a significant source of new infections in Zimbabwe making them an important group to prioritise if the country is to achieve dual EMTCT. Of the 64000 estimated new

15infections in 2015, more than half of these were adolescents and young women . According to Zimbabwe's modes of transmission study (MoT), the greatest number of new infections- around 16000 infections a year occur among never married women. Gender disparities in HIV infection are common with young women (20-24 years) having an HIV prevalence 2.78 times greater than that of their male peers. Preliminary findings from the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA 2015-2016) reported an even more prominent gender disparity among the 20 24 year olds with three times higher prevalence among the females (8.5%) compared to males (2.7%).

Risk factors for HIV and syphilis infection among young women include: early child marriage, teenage pregnancy, gender based violence and risky sexual practices. The ZDHS 2015/16 reported 22% of the 15-19 year females had started child bearing, with 17% having given birth to their first baby and 5% pregnant with their first baby at the time of the survey. Teenage childbearing had only declined slightly from 19% in 2010/11 to 17% in 2015/16. Teenagers in rural areas were almost three times as likely as their urban peers to begin childbearing at 27% compared to 10%. Provincial variation in teenage pregnancy is evident; with the lowest rate (10%) in Harare and the highest (31%) in Mashonaland Central. The ZDHS 2015/16 showed that the Age-Specific Fertility Rate of young women ages 15 19 years measured in births per 1,000 women, increased from 114 in 2005-06, to 118 in 2010-11, which was followed by a decline to 112 in 2015. Of all female deaths in the age group 15-19 years, 24% are related to pregnancy, child birth and the post-natal period (maternal mortality), while the ZDHS 2015/16 reported 20.2%.

On other STIs, among the sexually active young people aged 15 24 years, 9.2% of the females and 11.1% of the males had either Sexually Transmitted Infection (STI), bad smelling or abnormal discharge.

15Zimbabwe Global AIDS Report 2016


1.4 RATIONALE FOR DUAL HIV AND SYPHILIS EMTCT PLAN

16Elimination of mother-to-child transmission of HIV and syphilis: A dual approach in the African Region to improve quality of antenatal care and integrated disease control. Accessed from http://www.sciencedirect.com/science/article/pii/S0020729215002076#bb002017High prevalence of HIV infection among patients with STI syndromes in Zimbabwe: Implications for prevention accessed from http://sti.bmj.com/content/91/Suppl_2/A156.2

Without any intervention, approximately 20-45% of pregnant women living with HIV will transmit the infection to 16their infants and half of these infants will most likely not live to see their second birthday . In addition, more than

50% of the pregnant women infected with syphilis will have maternal health complications including still births. Like in many other countries in Sub Saharan Africa, mother-to-child transmission of HIV is responsible for almost all new HIV infections among infants in Zimbabwe. Despite good progress in coverage of PMTCT interventions across the country, challenges still remain with wide variations between the different subnational levels.

This plan sets out strategies and key actions to address the remaining bottlenecks towards EMTCT. The EMTCT plan 2018 to 2022 aligns with and complements different national strategic documents including but not limited to: Zimbabwe National HIV and AIDS Strategic Plan 2014-2018 (ZNASP III), The Zimbabwe HIV Care and Treatment Strategic Plan 2013 2017; The Start Free, Stay free and AIDS Free Framework, Public Private Partnerships for TB/HIV Strategic Plan Zimbabwe: 20112016, the Zimbabwe National Guidelines on HIV testing and counselling 2014, Zimbabwe National guidelines and for HIV testing and counselling in children and adolescents May 2014, The National Adolescent and Youth Sexual Reproductive Health Strategy II: 2016-2020, the National RMNCAH&N and Nutrition plan 2017 to 2021 and The Zimbabwe National Family Planning Strategy 2016 to 2020.

This is the first dual elimination plan for Zimbabwe. Emerging experiences from other countries such as Cuba have shown that dual elimination of HIV and Syphilis is feasible and cost effective. Integrating elimination of MTCT of HIV and syphilis makes technical and programmatic sense. The two diseases have similar modes of transmission and share same high risk groups. Additionally, prevention of both MTCT of HIV and syphilis requires similar interventions. Prevention interventions for both diseases include condom promotion, adoption of safer sexual practices, early diagnosis and treatment and partner testing and treatment to avoid incident infections. Interventions for both diseases use similar platforms, that of RMNCAH & N and more specifically antenatal care. Like other sexually transmitted infections, syphilis infections can facilitate HIV transmission. It has also been shown that maternal syphilis can increase HIV transmission in utero or at delivery by two- to three fold. A study in

17Zimbabwe found high HIV prevalence among patients with STI syndromes . Early diagnosis and treatment of sexually transmitted infections including syphilis is a key component of primary prevention for EMTCT of HIV. Elimination of both MTCT of HIV and syphilis will help the country improve general RMNCAH&N indicators as well as align to and fulfill global commitments such as the Sustainable Development Goals and the UN Secretary General's Global Strategy for Women's, Children's and Adolescent's Health: 2016 to 2030.

The Zimbabwe EMTCT (ZEMTCT) plan provides guidance for coordination of RMNCAH&N and HIV players to work towards EMTCT of both HIV and syphilis by 2022. The ZEMTCT plan will align development and implementing partners, MoHCC departments, service providers including public, private and other players to support one plan, with common strategies, key actions, including coverage and impact targets along the path to elimination.

It is a WHO requirement for countries to have 5-year national EMTCT plans as part of the validation process. As the country moves towards validation of EMTCT of both HIV and syphilis, this plan will help the country to fulfil this requirement. In addition, the costed EMTCT plan will be used as an advocacy and resource mobilisation tool.


The Plan for Elimination of Mother to Child Transmission of HIV and Syphilis in Zimbabwe sets out six broad strategic intervention areas which are elaborated at a granular level in the table below.

TABLE 2: STRATEGIC INTERVENTION AREAS

Activities

SIA 1: Promoting availability of quality integrated RMNCAH&Nand EMTCT services

Enhanced interventions for HIV and syphilis prevention among adolescent girls and young women

Promote HIV and syphilis testing and re-testing for pregnant and lactating women and their partners

Strengthen intervention packages for HIV and syphilis negative pregnant and lactating women including implementation of the re-testing algorithm

Strengthen interventions for prevention of unwanted pregnancies among women of reproductive age especially HIV positive women

Promote access to integrated RMNCAH&N and EMTCT services.

Strengthen quality improvement in provision of EMTCT services

SIA 2: Enhanced timely diagnosis, treatment, care and follow up of HIV positive women, their partners and children.

Sustain interventions for provision of lifelong ART and syphilis

treatment to all HIV and syphilis positive women in RMNCAH&N

settings

Promote interventions to increase access to maternal and infant and young child feeding counselling services in the context of EMTCT

Establish learning sites

and scale-up birth testing for HIV based on

findings from the pilot

Decentralize

EID services including scaling up of Point of Care Testing (POC)

technologies for

early infant diagnosis

Strengthen interventions for integrated sample transportation and return of results

Promote targeted

interventions to ensure quality DBS collection at facility level

Strengthen case reporting

and investigation

of all infants who test HIV positive in the context of EMTCT

SIA 3: Strengthening laboratory and pharmacy commodities supplies for dual EMTCT of HIVand syphilis

Strengthen laboratory health information systems

Strengthen district laboratory hubs to provide technical support to lower level facilities

Build capacity of health workers in forecasting quantification and management of commodities for

EMTCT

Support procurement and distribution of

commodities for

EMTCT

Strengthen laboratory Quality Assurance

SIA 4: Enhanced Gender, human rights and community engagement in the context of dual EMTCT of HIV and syphilis

Build capacity of village health workers to increase demand for and uptake of RMNCAH&Nand EMTCT services

Implement customised mobile based reminder application systems like MOM connect in South Africa

to support early uptake of services, adherence and retention.

Facilitate effective facility and community linkage for

uptake of ANC and Post delivery services including with village health workers, networks of women living with HIV and CBOs

Develop and implement national but context specific male involvement interventions for dual EMTCT

Strategic Intervention Areas


Advocacy, Communication and Social Mobilisation for uptake of services

SIA 5: Strengthening data and strategic evaluation for EMTCT and validation

Review, update print and distribute RMNCAH&N registers and tools

Strengthen HIS systems to support longitudinal/cohort follow up of mother baby pairs

Support interventions to promote use of EMTCT data for decision making

Support interventions to ensure data quality across all levels of health service delivery systems

Support strategic monitoring and evaluation of the EMTCT plan

Strengthen capacity for EMTCT operations research

Facilitate country EMTCT validation process

SIA 6: Strengthening leadership and governance for EMTCT

Review, update and disseminateEMTCT guidelines, SOPs and job aides

Enhanced political commitment and advocacy for EMTCT

Strengthen and establish functional RMNCAH&N

and EMTCT coordination forum at national and subnational level

Strengthen partnership and engagement with private sector

FIGURE 5: WHY DUAL ELIMINATION OF HIV AND SYPHILIS MAKES SENSE

Why dual eliminationA mother seeks antenatal care at Nyanga district hospital, accepts HIV counselling and testing, and, after testing HIV-positive, the mother is initiated on ART for her own health and for preventing transmission of HIV to the baby. Postpartum, her baby goes through EID, tests positive and is initiated on ART, receives counselling on breastfeeding and follows the instructions religiously. Is this a success story for EMTCT? No, unfortunately the baby died at one month due to congenital syphilis!

Activities

Strategic Intervention Areas


Despite the good progress, significant gaps and challenges remain for achieving EMTCT. This section of the EMTCT plan highlights remaining bottlenecks that need to be addressed for the country to achieve elimination. The bottlenecks were identified through country program document reviews, key informant interviews with stakeholders, field visits and interviews at subnational levels including with health workers and service beneficiaries in both public and private health facilities. In addition, consultative workshops with the EMTCT Technical Working Group (TWG) and other stakeholders were held and provided valuable insights. The bottlenecks are organized under five broad categories of programs and service delivery, laboratory, logistics and medical products, data and strategic evaluation, community systems, and other RSSH related bottlenecks. Human resources management to reach elimination targets bottlenecks are integrated across the other RSSH bottlenecks.

2.1.PROGRAM AND SERVICE DELIVERY RELATED BOTTLENECKS

Weak prioritization and lack of clearly defined package of interventions for prong 1

Increasing HIV prevalence among adolescents and young people

Weak integration of EMTCT and RMNCAH&N services

Prong 1 of primary prevention of HIV among women of reproductive age is important for achievement of EMTCT indicators especially the impact indicator of a case rate of 50 or less in 100,000 live births. There is weak prioritization for prong 1 interventions both in funding allocation and in technical programming. The EMTCT program has no clearly defined intervention package for prong 1 with primary prevention interventions spread across many other programs outside the PMTCT program. There is lack of a coordinated response to ensure these interventions respond to the national EMTCT program needs.

Zimbabwe is experiencing high prevalence of HIV among adolescents as well as high teenage pregnancies. Although the country is implementing a number of programs targeting adolescents including the USAID funded modified DREAMS, there is no nationally defined adolescent HIV intervention package especially in the context of PMTCT. With adolescents and young women having a high potential of contributing to the highest number of new HIV infections in ANC, it is critical for the country to define a priority minimum package of interventions for prevention of HIV infections in adolescent girls and young women in the context of EMTCT. Additionally, dropout rates for pregnant adolescents within the PMTCT cascade are higher than the general population. The inadequacy of health workers and lack of adequate skills in provision of adolescent friendly services including enhanced counselling for pregnant and lactating adolescents living with HIV contributes to high dropout rate from the PMTCT cascade. Additionally, health facilities' opening hours as well as lack of differentiated service delivery models make them unfriendly to adolescents.

RMNCAH&N and nutrition platforms are critical in providing entry points for EMTCT services. Gaps for integrating EMTCT and RMNCAH&N and nutrition including infant and young child feeding exist. Root causes are inadequate skills among health workers to provide integrated services, infrastructural challenges at facility level, high staff workload, lack of updated and disseminated guidelines and SOPs on integration as well as weak supportive supervision. In most health facilities, health workers at OI/ART are unable to provide family planning services due to lack of space within the clinic or because health care workers are not trained in provision of FP methods. In some cases, health workers at labour and delivery are not able to immediately initiate ART in women who test positive for HIV at labour and delivery as they are not able to keep ARV commodities at night when facility pharmacy is not open.

2.0 BOTTLENECKS TO EMTCT OF HIV AND SYPHILIS


Lack of clearly defined package of interventions for pregnant and lactating women who test negative for HIV and syphilis

Poor quality improvement in delivery of EMTCT and RMNCAH&N and Nutrition services

Weak inter-facility and community referrals

Weak structures for follow up and retention of women and baby pairs especially post-delivery

A defined package of interventions for maintaining HIV and syphilis negative status for pregnant and lactating women with an initial negative test at first ANC is critical for eliminating incident infections. Except for a policy on re-testing, the country does not have a minimum priority intervention package for women who test negative for HIV and syphilis. Given this gap, once women test negative at ANC and in most cases with the unknown status for their partners, health workers do not offer any prioritised interventions to maintain the negative status of the women. Additionally, existing ANC register does not provide recording for re-testing of women making it difficult to track and report on re-testing.

Delivery of quality EMTCT and RMNCAH&N services is determined by both facility and health worker related factors. Although the country has guidelines and SOPs for provision of EMTCT and RMNCAH&N services, these are not always followed in practice, thereby impacting negatively on delivery of quality services. For instance, although the country has clear policies on re-testing of pregnant and lactating women, this is not practiced in all cases. Facility related factors including lack of adequate space for provision of integrated services and poor client flow are identified as key challenges in integrating EMTCT and RMNCAH&N services. In some facilities, despite health workers in ANC having been trained on syphilis rapid screening, pregnant women are referred to laboratory department for testing resulting in delays.

Timely and appropriate referrals and linkages are critical in ensuring retention of women, their partners and children in the PMTCT cascade. Although the country has a referral form, this does not have a robust feedback mechanism to monitor complete referral especially for PMTCT clients. Additionally, and especially for women living with HIV and initiated on ART at labour and delivery, there are no mechanisms to ensure that those women continue to receive HIV services at their nearby clinic where they were initially referred from. This weak referral system presents a risk to mother baby pairs dropping out of the EMTCT cascade.

The country has no clear structures for ensuring mother baby pairs are followed up and retained in the PMTCT cascade up to two years. As discussed earlier there are no robust referrals systems from facility to facility and from facility to community structures and vice versa. Although in some cases mentor mothers exist at facility and community level, there is weak linkage and poor coordination with village health workers. Additionally, networks of women living with HIV who would otherwise offer support to ensure retention in care and adherence for PMTCT women are weak. Structures for facility and community linkages to inbuilt clear tracing systems will need to be strengthened. The EMTCT plan will prioritise development of a robust follow up system including a referral system and effective tracking mechanisms to retain, or re-engage, mother baby pairs in treatment and care.

18Zimbabwe Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition Strategy 2017-2021


2.2 LABORATORIES, LOGISTICS AND MEDICAL PRODUCTS

In the context of EMTCT, laboratory capacity is essential for ensuring quality HIV and syphilis testing, timely early infant diagnosis (EID) as well viral load monitoring to identify treatment failure and poor adherence. The bottlenecks highlighted here relate to that context and more on EID which is identified as the priority remaining bottleneck to EMTCT. An effective EID system should have the ability to timely collect quality dry blood samples, transport them across the different points, ensure timely processing at the central or regional labs, timely return the results to the facilities and have mothers collect the results in a timely manner. The country has made progress in addressing commodities and supplies related bottlenecks but some gaps do remain. The following are the remaining laboratory and pharmacy commodities related bottlenecks.

Timely early infant diagnosis is important for ensuring infants are initiated on treatment as early as possible and also for reducing loss to follow up of HIV exposed infants. Although the country has decentralized EID services by adding two more EID sites (Mpilo and Mutare) in addition to the National Microbiology Reference Laboratory in Harare, EID services still remain very centralized resulting in long turnaround time of more than a month. The root causes of these delays are diverse across the EID cascade and include:

- Weak health workers' skills leading to poor quality DBS samples: This leads to rejection of samples which necessitates the mother to bring their baby for a repeat sample collection resulting in more delays. The weak health worker skills are a factor of poor mentorship, lack of training as the trained staff move to other departments or change stations and lack of refresher trainings.

- Challenges with DBS sample transportation from the clinic to the central collection points: The DBS samples are collected by riders usually Environmental Health Technicians who take the samples to a central collection point-in most cases a district laboratory. From here, samples are collected by FEDEX to NMRL, Mpilo and Mutare Provincial laboratory. The major source of delay is usually from the clinics to the central collection points. The environmental health technicians may not prioritise EID as this is not their primary role as per their job description. Cases of motorcycle breakdowns and lack of fuel also lead to delays in sample collection.

- Delays in return of results to the clinic and to the clients: The frontline SMS system that is used to transmit results is no longer very effective with most phones not functioning due to lack of airtime or not charged. There is also weak system to follow up whether the short messages are acted upon by the health workers. Even when the results are received on time, there are challenges tracing the mother early enough to come for the results. This situation shows the need to develop a robust process of prioritizing the EID positive results, having them reach the facility as early as possible and notifying mothers of the results.

Early infant diagnosis: Long turn-around time


FIGURE 6: EID DBS SAMPLE REJECTION RATES BY DISTRICT

0%

1%-5%

5%

Low Viral load testing

Sub-optimal laboratory quality assurance

Inadequate laboratory human resources for health

Stock-outs and interruption in the availability of commodities and supplies

The World Health Organization recommends routine monitoring of ART effectiveness using viral load testing at 6 months and every 12 months to monitor treatment adherence and minimize failure. This is even more critical for pregnant and lactating women. Viral load testing faces similar challenges to early infant diagnosis including poor transportation systems and stock out of reagents for VL testing. There is also poor prioritization of viral load testing especially for HIV positive children and pregnant and lactating women.

Due to inadequate funding, laboratory quality assurance is sub optimal with infrequent laboratory supportive supervision and mentorship. There is also lack of updated and disseminated laboratory quality assurance protocols and SOPs.

Just like all other health sectors, the laboratories have inadequate human resources for delivery of adequate laboratory services. The government is currently not providing support for the training of laboratory scientists but only laboratory technicians. Employment of all cadres of laboratory staff has also been frozen. There are reports of high attrition of laboratory staff from the public sector.

A stable supply of commodities and supplies for HIV and syphilis screening and treatment as well as for provision of RMNCAH&N services is critical if the country is to achieve EMTCT. Since the start of the Zimbabwe Assisted Pull System (ZAPS), the country has made progress in addressing stock outs of essential supplies and commodities.

Figure 6 below provides DBS sample rejection rates by district.


The supply and availability of Benzamine Penicillin, the standard treatment drug for syphilis in pregnant women was reported as being unstable. Stock-out of syphilis rapid test kits were reported, as well as HIV test kits such as Determine especially in cases where unplanned HIV testing campaigns were conducted. This was also the case for commodities and supplies for provision of essential RMNCAH&N services such as focused antenatal care and skilled birth assistance. Most facilities report stock out of long acting family planning methods as well as folic acid. Provision of commodities with short shelf life was reported to be a major cause for commodity stock outs.

Human resources challenges including low staff numbers in health facilities as well as gaps in skills are identified as contributing to stock out of essential RMNCAH&N commodities and supplies in health facilities. Health workers were reported to have inadequate skills in commodity forecasting and quantification leading to insufficient orders. Delays in ordering commodities resulting from the high staff workload were also reported. Poor stock management skills were also identified as a gap that resulted in wastage and stock out of essential EMTCT and RMNCAH&N commodities.

Family planning is a critical component under prong 2 of a comprehensive approach to EMTCT. Sustained commodity security for FP commodities is therefore important as the country moves to EMTCT. Almost all the FP commodities including both male and female condoms in Zimbabwe are supported through UNFPA. Discussions at country level indicate that the possible global defunding of UNFPA could pose an FP commodity security risk to the

19country .

Just like family planning, almost all EMTCT commodities in the country are procured by donors. This is identified as a risk to EMTCT. Additionally, NatPharm has weak capacity in procurement especially for EMTCT commodities. Although the agency has the mandate for procurement, in practice the agency does not procure EMTCT related commodities leaving it with inadequate capacity to perform this role. Over time it may be useful for donors to delegate some procurement role to the national agency as part of capacity strengthening and sustainability.

Human resources for health challenges and commodity stock outs

Possible defunding of UNFPA creates a FP commodity risk

Unsustainable commodity security

19 http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30995-9/fulltext


2.3 DATA SYSTEMS AND USE FOR REACHING THE ELIMINATION TARGETS

A robust health information system is important for generating quality data to inform programming, monitor and evaluate progress as well as provide data for EMTCT validation. The following are identified as the priority data and strategic information bottlenecks to EMTCT.

Although the country has made some progress in data quality improvement through supportive supervision, data quality audits and mentorship, some gaps still remain. Factors contributing to the poor data quality include:

A largely paper based data collection system with multiple registers Lack of built-in validation rules in DHIS2 Inadequate health worker skills in completion of data collection tools and registers resulting from lack of

orientation on the tools High workload resulting in health workers failing to consistently document service provision, leading to

underreporting Inadequate data collection tools, in most cases health facilities are photocopying ANC cards for pregnant

women Weak supportive supervision and inadequate mentorship

To meet criteria for EMTCT validation, the country is required to account for women, children and partners receiving EMTCT services in both the private and public sectors. Through a USAID funded AIDS free project, the country is making an attempt to engage the private sector in EMTCT and make sure the data is reported to national level. However, gaps in reporting of number of women and children accessing RMNCAH&N and EMTCT services in the private sector still remain. Root causes for this include lack of reporting tools within the private sector, limited capacity and health worker skills in the completion of the tools, lack of motivation for reporting within the private sector and weak engagement by MOHCC.

Use of data for decision making is critical especially in the context of analyzing and responding to bottlenecks that result in leakages to retention of women and infants at different points of the PMTCT cascade. Although the country is implementing data review meetings and PMTCT cascade analysis, this is not yet institutionalized and is not implemented routinely due to lack of adequate funds. Both data review meetings and the PMTCT cascade analysis are weak at district and facility levels. Health workers at facility level lack skills to construct and use PMTCT and EID cascades. In almost all the cases including at national level, the response part of the analysis is weak. Action plans are not developed and there is no close follow up to address identified gaps and bottlenecks. The cascade analyses are not interactive online dashboards that are easy to access and utilize to make decisions. The existing PMTCT cascade analysis does not include syphilis, and this needs to be integrated in the spirit of dual elimination. Additionally, case reporting for MTCT which is critical in helping us to understand and address gaps resulting in MTCT infections has not been institutionalized.

Longitudinal registers are useful in helping track mother infant pairs until the end of the breastfeeding period. This helps to identify loss to follow up as well as to determine final HIV status of HIV exposed infants. Although the country is currently piloting a mother baby pair register and an electronic health record, these are in few facilities and will require national roll out to have any meaningful impact. Additionally, the current tools are not able to link EMTCT clients who access services at different service points or clinics as there are no unique identifiers. This usually leads to over reporting and exaggerated loss to follow up especially in cases where there is high mobility of clients and switching of health facilities which is common in Zimbabwe.

Poor data quality

Challenges with private sector reporting

Poor use of data for decision making

Weak longitudinal monitoring and tracking of mother baby pairs (MBPs)


2.4 COMMUNITY SYSTEMS RELATED BOTTLENECKS

The community related bottlenecks relate to challenges that impact on the access to and utilisation of EMTCT and RMNCAH&N services at both health facility and community level. Key community systems related bottlenecks include:

Although Zimbabwe has high first ANC coverage at 93%, late booking at first ANC continues to be a big challenge; and yet early ANC attendance, and early diagnosis and treatment of both HIV and syphilis are critical for the EMTCT agenda. The late ANC attendance is a factor of many causes including cultural factors that make people not to visit health facilities until the pregnancy is visible, user fees and long distance to health facilities. Knowledge gaps among women on the importance of early ANC attendance is also identified as contributing to late ANC attendance.

Male involvement is an important intervention in EMTCT for three critical reasons. First, it promotes early initiation on treatment for women who test positive as they have fewer challenges with disclosure, secondly it promotes retention and adherence in care and thirdly it helps in ensuring partner testing and preventing incident infections during pregnancy and lactating period. Some pregnant girls and young women need to seek permission from their male partners before they are initiated on ART, leading to delayed initiation of ART and increased risk of MTCT.

Low male involvement in EMTCT and other RMNCAH&N services is identified as a key bottleneck to EMTCT. Multiple factors are associated with weak male involvement in Zimbabwe including lack of adequate knowledge among men on the importance of their involvement, lack of a clear package of interventions for men at health facilities, sociocultural factors that make male visit to clinics ''not macho'', the fact that most men are at work and also their high mobility especially those who have to move to neighboring countries in search of employment including mining in South Africa.

RMNCAH&N services such as antenatal care, facility delivery, postnatal care, immunization and growth monitoring present useful entry points for provision of EMTCT services to pregnant and lactating women and their infants. Although Zimbabwe has made progress in improving RMNCAH&N indicators, still some groups face challenges in access to and uptake of these services and will possibly miss out on the EMTCT interventions. Key factors that impact on the uptake of RMNCAH&N services include:

Geographical and other physical access factors including mountainous and inaccessible roads Long distance to health facilities especially for pregnant women Religious factors for example in Manicaland where the Apostolic faith objects to modern RMNCAH&N

20services including facility based delivery .

Cultural practices like Kusungira where women have to deliver their first child at their parents' home Mobile populations especially those living in districts bordering South Africa, Botswana and Mozambique Inadequate knowledge among community members and pregnant women about the benefits of ANC/PMTCT

services, Option B+ and pediatric HIV services, EID services, HIV and STI prevention, among others Client negative perceptions about the quality of RMNCAH&N and EMTCT services Client perceived or actual supply side barriers negatively impacting on services including user fees; long

waiting periods at clinics before being attended; unavailability of medical supplies and equipment; staff shortages and increasing workload; negative health worker attitudes

Despite a lot of progress in ending HIV and AIDS related stigma and discrimination, this was reported as impacting

Late ANC booking

Low male involvement in EMTCT

Sub-optimal access to: and low uptake of RMNCAH&N and nutrition services

HIV and AIDS related stigma and discrimination

20https://www.unicef.org/zimbabwe/ZIM_resources_apastolicreligion.pdf


adherence and retention to EMTCT services especially among adolescents. Additionally, partner disclosure presents a challenge as women fear gender based violence, which results in delays to initiation of ART. Even in the context of

21test and treat guidelines , delays are reported especially when women test positive at labour and delivery as they have to first seek permission from their partners. The Zimbabwe Stigma Index does highlight that there are still

22some levels of stigma and discrimination towards people living with HIV . This will need to be addressed as the country moves towards EMTCT.

A robust community health system is important for promoting demand and uptake of facility and community based RMNCAH&N and EMTCT services and follow up of mother baby pairs to ensure retention in PMTCT cascade. There is weak coordination of community responses, with village health workers overburdened with many roles. The VHWs are demotivated as most of them are volunteers and not remunerated. In addition to VHWs there are many other community health cadres who are poorly coordinated and with roles that are not clearly defined. There is a poor linkage between village health workers and health facilities and also with other community structures such as health centre committees and networks of women living with HIV. This negatively impacts on facility and community referrals and effective follow up of mother baby pairs.

Networks of women living with HIV especially at community level can play a critical role in supporting EMTCT interventions including providing peer support to newly tested mothers, supporting disclosure and advocating for protection of rights of people living with HIV especially adolescents. These networks especially at grassroots level are not well organized, do not meet regularly and are not adequately involved in implementation and monitoring of EMTCT activities at facility and community level.

Weak community health systems

Weak community structures especially grass root networks of women living with HIV

21Guidelines for Antiretroviral Therapy for prevention and treatment of HIV in Zimbabwe, 2013.22The Zimbabwe People Living with HIV stigma index. 2014.

2.5 OTHER RSSH BOTTLENECKS

Effective leadership and governance, adequate and motivated human resources and financing are critical to achieving EMTCT. The following are some remaining bottlenecks under each of the HSS blocks that will need to be addressed as the country moves to EMTCT.

Leadership and governance Weak coordination. Although Zimbabwe has well established technical working groups for EMTCT, these

sometimes are unable to meet regularly due to funding challenges especially at the subnational levels. In the spirit of dual elimination, it is also critical to strengthen the participation of STI players in the EMTCT coordination forums. Although there is an STI Technical advisory group, this is not convening often enough due to lack of funding.

Guidelines/SOPS on EMTCT not adequately updated and disseminated. Although the country has done well in updating guidelines and SOPS to align to global EMTCT guidelines, some still require updating to align to new WHO guidance in the context of dual EMTCT.

Almost all EMTCT interventions are externally funded by donors. The STI program is underfunded and under-prioritized by most development partners presenting a risk to dual elimination.

Inadequate financing for EMTCT


Figure 7 below summarizes the priority bottlenecks along the PMTCT and EID cascade that this plan will need to address to ensure EMTCT.

FIGURE 7: BOTTLENECKS ALONG THE PMTCT CASCADE

a). Late ANC booking

b). ANC booking at

private not reported

Priority BottlenecksThe EMTCT CascadePriority Bottlenecks

a). Low partnertesting

b). Low retesting

c). Sub-optimaluptake of RMNCAHServices

d). Weak integration ofRMNCAH andEMTCT services

e). No definedpackage ofinterventions forHIV and Syphilisnegative pregnant women

HIV & Syph neg PregWomen

HIV & Syph tested atANC

HIV & Syph tested

HIV Tested PNC

HIV & Syph tested

HIV Tested at 24months

HIV neg at 24months

Pregnantwomen

Womenattending

ANC

Womentestedat ANC

Virally suppressedon ART, 24 months




Delivery

ART Initiation

HIV + Preg women

HEI

ARVprophylaxis

EID at 6

weeks

HIV+

ARTinitiation

VirallySuppressedon ART, 12

months

VirallySuppressedon ART, 18

months

Weak quality practices in provision of EMTCT services, Weak Health Information Systems and poor quality data, weak laboratory systems, unstable commodities and supplies, Inadequate(numbers and skills) and demotivated health workers, low financing for EMTCT interventions especially syphilis response, Weak community support structures, geographical, sociocultural and

financial barriers to accessing EMTCT and RMNCAH services, weak private sector involvement

Cross cutting and Health Systems Bottlenecks

HEI

EID, 9-12months

EID, 18months

HIV-, 18months

HIV+ pregnant & Lactatingwomen

f). Weak integration with RMNCAH

a). Delays in ART initiation

b). Weak referrals with nofeedback mechanism

c). HIV+ women iniated onARVs at private facilities notreported

d). Weak retention andadherence especiallypostnatally

HIE and HIV+ Infants

a). Weak longitudinal/cohortfollowup mechanisms

b). Long TAT resulting in delays ininitiation

c). ART initiation for children notdecentralised in some cases

d). Weak retention in EID cascade


3.1 GUIDING PRINCIPLES

The following principles guided the development of this EMTCT plan and will further be applied during its implementation.

With limited resources and the need to ensure sustainability and coordination, implementation of this EMTCT plan will be led by the Ministry of Health and Child Health Care with support from the EMTCT TWG. In countries where MTCT has been eliminated such as Cuba, effective leadership and governance is identified as a key ingredient of success.

To achieve EMTCT status and in line with other international commitments, the plan will aim at universal access to services for EMTCT. Of importance the plan outlines interventions to address financial barriers to access and utilisation of RMNCAH&N interventions that are critical entry points for provision of EMTCT services especially for vulnerable groups such as adolescents.

To achieve EMTCT, meaningful involvement of people living with HIV will be key. PLWHIV, especially women living with HIV will be actively involved in the design, implementation and monitoring of interventions proposed under this plan.

Elimination of Mother to Child Transmission (EMTCT) of HIV and Syphilis interventions are executed within the reproductive, maternal, newborn and child health (RMNCAH&N) platforms. Additionally, some RMNCAH&N interventions such as family planning are pivotal in achieving EMTCT. This EMTCT plan will be implemented through an integrated approach with RMNCAH&N services.

This plan will be aligned with and support implementation of other national and global commitments. At national level, the plan will align with the Start Free, Stay Free, AIDS Free Framework and the ZNASP111, while at global level, the plan will align with the 90-90-90 fast track targets and the UN Global Strategy for Women's, Children's and Adolescents' Health: 2016-2030.

The implementation of the EMTCT plan will ensure inclusiveness of all players including community structures, civil society organizations, networks of people living with HIV as well as private sector players. Relevant structures and systems will be established and strengthened to ensure robust community engagement and strategic partnerships.

Gender inequalities impact on access to and utilization of services for elimination of mother to child transmission of HIV and syphilis. Provision of EMTCT services must ensure protection of rights for all especially for women living with HIV. This plan will address gender barriers to access and utilisation of services as well reaffirm clients' confidentiality, privacy and promote informed consent in choice and use of services.

Country ownership and leadership

Universal access

Greater and meaningful involvement of people living with HIV

Integrated approach

Alignment to national and global strategies and commitments

Community engagement and strategic partnerships

Gender responsiveness and human rights based approach

3.0 THE EMTCT PLAN FRAMEWORK


Centred on health systems strengthening

Equity focused

Recognising the role of resilient and sustainable health systems in availability of EMTCT interventions, this plan will build on and reinforce existing health systems strengthening efforts for improved EMTCT services.

This EMTCT plan recognises that some geographical areas have higher MTCT rates and that some groups such as adolescents are at a higher risk of HIV and syphilis and hence transmission to their babies. The Plan will ensure no one is left behind by prioritising the marginalised areas and groups at higher risk.

3.2 EMTCT PLAN VISION, GOAL AND OBJECTIVES

Vision

Goal

Impact and coverage Targets

Impact targets

Process Indicators

A Zimbabwe with zero Mother To Child Transmission (MTCT) of HIV and Syphilis

To contribute to accelerating elimination of mother-to-child transmission (MTCT) of HIV and syphilis in Zimbabwe by 2022

The following impact and coverage targets will be used to monitor and evaluate the country's path to elimination of mother to child transmission of HIV and Syphilis. The targets are aligned to the WHO validation criteria.

With a high ANC prevalence rate of 14 % and at a current MTCT case rate of 621 per 100,000 live births, while committed to achieving the other two elimination targets within this five-year plan, the country will realistically not meet the WHO validation target of: Reduction of new peadiatric infections cases to 50 or less per 100,000 live births. The country however considers the target as part of her vision to eliminating MTCT. Within the five-year period of this plan, the country commits to achieving the following impact targets. By 2022:

a. Reduction of mother to child transmission rate of HIV to 5% or less b. Reduction of new peadiatric HIV cases to 250 or less per 100,000 live births c. Reduction of new cases of congenital syphilis to 50 cases or less per 100,000 live births

Towards achievement of the EMTCT goal and impact targets, the plan seeks to achieve the following coverage targets by 2022:

a. ANC coverage of 95 % or moreb. HIV testing of pregnant women of 95 % or more c. Syphilis screening of pregnant women of 95% or more d. ART coverage for HIV positive pregnant women of 95% or more e. Treatment coverage for syphilis seropositive pregnant women of 95 % or more

3.3 EMTCT THEORY OF CHANGE

National and field level consultations and review of literature identified bottlenecks to EMTCT which have been categorised under programs and service delivery, laboratories and commodities, community systems, health information systems and leadership and governance related bottlenecks as described in the bottlenecks analysis section of this plan.


To address those bottlenecks, six strategic interventions will be utilised. The six strategic interventions are:

a.Promoting availability of quality integrated EMTCT and RMNCAH&N interventionsb.Early diagnosis, treatment, care and follow up of women, their partners, and childrenc. Strengthening laboratory, commodity and supplies security systems for EMTCTd.Strengthening community systems for EMTCT e.Strengthening data for strategic evaluation for EMTCT validation and f. Strengthening leadership and governance for EMTCT

Addressing the bottlenecks is expected to result in utilization of EMTCT and RMNCAH&N services leading to achievement of the EMTCT programmatic targets of increased coverage of ANC, HIV and syphilis testing, and treatment of HIV and syphilis.

Increased coverage is expected to lead to achievement of the impact targets of the plan which are aligned to the 23

WHO validation criteria .

Figure 8 below shows the EMTCT plan theory of change.

FIGURE 8: ZEMTCT THEORY OF CHANGE

23Global guidance on criteria and processes for validation. Elimination of mother to child transmission of HIV and Syphilis. Wh0 2014

REMAINING BOTTLENECKS

Programs & Servicedelivery bottlenecks

Labs & Commoditiesbottlenecks

Community Systems

HIS bottlenecks

Leadership &Governace

STRATEGIC INTERVENTION AREAS

Promoting availability of qualityintegrated RMNCAH and EMTCT

services

Early diagnosis, treatment, care and follow up of women, their

partners and children

Strengthening laboratory, commodity and suppliers

security systems

Strengthening community system for EMTCT

Strengthening data and strategic evaluation for EMTCT validation

Strengthening leadership and governance for EMTCT

PROGRAMMATIC TARGETS

Increase ANC coverage to 95%or more

Increase coverage of HIVtesting for pregrant women to95% or more

Increase coverage of syphilisscreening for pregnant women to 95% or more

Increase ARV coverage for HIV+pregnant women to 90% or more

Increase treatment coverage for syphilis seropositivepregnant women to 95% or more

IMPACT TARGETS

Accelarate elimination of MTCT of HIV and syphilis in

Zimbabwe

IMPACT TARGETS

a). Reduction of MTCT rate ofHIV to 5% or less

b). Reduction of new paediatric HIV infection cases

to 250 or less per 100,000 live births

c). Reduction of new cases ofcongenital s

Documents

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