No-cost tracking system for follow-up of HIV positive pregnant women and their babies till 18

months in Chandrapur district, Maharashtra. India- – A pilot by Maharashtra State AIDS Control

Society (MSACS).

Author (s) : A.S.HEGDE 1, T.M.Rane2

Institute (s): 1 Maharashtra State AIDS Control Society, Basic Services, Thane, India,

2 UNICEF, HIV/AIDS Specialist, Mumbai, India.

Maps-India Maharashtra

Chandrapur

HSS 2010• Population of Maharashtra-

112 million (Census 2011)• Estimated Pregnant

mothers- 1.91 million• 1.36 million pregnant

women were tested for HIV in 2012.

• ANC HIV prevalence is 0.42% (HSS 2010).

Maharashtra Profile

3

1

0

HIV prevalence at ANC sites <1.0

HIV prevalence at ANC sites 1.0-1.5

HIV prevalence at ANC sites 1.5 – 2.0

HIV prevalence at ANC sites 2.0-2.5

31

2003 2004 2005 2006 2007 2008-09 2010-110.00.20.40.60.81.01.2 1.1

0.8

1.0

0.8

0.5 0.5

0.3

Positivity Rate

Introduction• In the state of Maharashtra (India), the Prevention of Parent

(Mother) to Child Transmission of HIV (PPTCT) has been scaled up in the past 5 years.

• The number of Integrated Counseling and Testing Centres (ICTCs) has increased from 578 to 2965.

• The number of pregnant mothers tested has increased from 676,773 (35%) to 1,238,342 (67%) of estimated pregnant mothers.

• With the quantum of scale up, the functionaries were facing a challenge in tracking the HIV positive mothers for ARV prophylaxis during delivery and their children for Early Infant Diagnosis (EID) who were to be followed up till 18 months.

• The grass-root functionaries as well as the district level officials were unable to identify the mothers and their babies for follow up action. This resulted in 70% of the babies not being tested for 18 month testing in the ICTCs.

• PPTCT Calendar was developed in response to the challenges faced by the grass root functionaries-Piloted In Chandrapur.

Chandrapur district- profile

• Population of the district: 2,194,262 (2011 Census).

• Total mothers tested for HIV in the district during 2012: 33,923.

Material and Methods• Given the challenge faced in tracking the HIV

positive pregnant mothers and their children , the functionaries felt that a simple tool could be devised for tracking.

• Accordingly, the PPTCT team from MSACS jointly with district / ICTC from Chandrapur brainstormed on the tracking mechanism and developed a simple tool for tracking the clients (One page).

• It was felt that the tool could be piloted in One of the ICTCs in the district. The tool thus developed is in a tabular form, labeled as PPTCT Calendar.

• The alphabetic code is assigned to each of the ICTCs. Eg.: A, B, …. , AA, AB, ….

• The numeric codes are provided to the positive pregnant mothers identified in the ICTC. Eg.: A1, A2, ….

• The mothers were coded from a period which was Three years earlier to the coding.

• The fresh numbering started once the backlog was coded.

• The only prerequisite is that the information entered should be accurate

Material and Methods

Line list of the ANC includes the date of testing, testing status , delivery, NVP prophylaxis and EID an excel based individual tracking system which is

maintained at the ICTC and dynamically updated by the counselor

Dynamically updated by the counselor based on the services obtained by the Mother and child

components of PPTCT calendar

PPTCT calendar (an abstract of the Line list)

Each ICTC is pre-coded- (alphabet is assigned) in district

Every ANC in each ICTC is numbered

Ready reckoner for the District team to

monitor the ARV prophylaxis , EID,

and follow up for 18 month testing.

Ready reckoner tool for the ICTC

counselor to follow-up with the ORW

At the state level to estimate the ARV drug

stocks and review of the program staff

Outcomes

Individual tracking system in the PPTCT program

The Format - PPTCT Calendar (with e.g.)ANC Positive 2013

Jan 201

3

Feb 201

3

Mar 201

3

Apr 201

3

May 201

3

Jun 201

3

Jul 201

3

Aug 2013

Sep 201

3

Oct 2013

Nov 201

3

Dec 201

2

ANC Positive B100

ANC ART Link B100

MTP

EDD- Expected date of delivery

B100

Delivery B100

MB Pair

Only Mother

Only Baby

Still Birth

ANC LFU Institutional Delivery

Expected 6 week Follow-up B100

6 Week Test Done

6 Weeks Positive

6 Month Follow-up Expected B100

6 Month Test Done

6 Month Positive

12 Month Follow-up Expected

12 Month Test Done

12 Month Positive

18 Month Follow-up Expected

18 Month Test Done

18 Month Positive

ART Linkage of Babies

Child Death

ANC Death

Child LFU for 18 months

Once ANC registration is done and HIV test report is received, the information of the positive pregnant mother is recorded in the registers as well as the PPTCT calendar. Under the appropriate month the data is recorded using the code. The EDD is recorded for each. This is important as the ORWs from the PPTCT NGO follow-up with the positive pregnant women at the field level especially during the 8th month of pregnancy. Month of delivery is also noted.

The time for 6 week, 6 month, 12 month and 18 month follow-up testing of exposed babies is noted as soon as delivery take place. This helps the programme to follow-up on time. During the monthly meeting the ICTC counsellor provides the PPTCT NGO a list of children to be followed up for testing in the month.

Scale up• Reviewing the success in the ICTC in Chandrapur

and the feedback provided by the functionaries, it was decided to scale up the tracking system in the State.

• It was easy to scale-up in the entire State of Maharashtra within a period of 3 months as it just needed ICTC counsellor to be oriented on the format, compilation of old data and resolving start-up issues.

SOP 1 – Adaptation and Scaling UpOrientation and Training

(ICTC Counsellor and PPTCT NGO Programme Manager)

Designing (Coding etc)

Pilot testing(In one select district)

Scaling-up(Across the state – 3 months

needed)

- What is the PPTCT Calendar?

- What can be achieved through it (success in

Maharashtra)?- How to use it effectively?- Coding of all ICTC Centres

alphabetically- Coding of women numerically to include

backlog- Changes to format

Feed

back

SACS

ICTC Counsello

r

SACS

3 m

on

ths

need

ed

Results

Data speaks … Testing of babies at 18

months- ICTC Chandrapur

2008 2009 2010 2011

30

3.84

8075.38

100 100

Before PPTCT CalendarBacklog covered (after introduction of PPTCT calendar)After PPTCT Calendar

With only 30% tracking in 2008 and 3.84% in 2009 for 18 months testing

of HIV exposed babies, when the format was used, the counsellor

could look at the backlog and track the LFU cases for 18 month testing. The coverage increased to 80% for

2008 and 75% for 2009.

PPTCT Calendar initiated

2008-09 2009-10 2010-11 2011-12 2012-130

10

20

30

40

50

60

70

80

90

100

60.6 60.2

77.9

60.6

70.482.2

89.8 90.7

% ART linkage before PPTCT calendar% ART linkage after PPTCT calendar

ANC ART LINKAGES (%)

Outcomes of Tracking system – Maharashtra-I

2008-09 2009-10 2010-11 2011-12 2012-130

102030405060708090

100

61.8 65.2 6677

91

Mother Baby Pair for ARV (%)

Outcomes of Tracking system – Maharashtra-II

08-09 09-10 10-11 11-12 12-130

10

20

30

40

50

60

70

80

90

0

24

58

0 0

20

43

7074 85

Before PPTCT calendar

After PPTCT calendar

Baby tested under EID (%)

Outcomes of Tracking system – Maharashtra- III

2008-09 2009-10 2010-110.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

24.0

35.0

0.0

58.055.0 60.0

Before PPTCT calendar

After PPTCT calendar

18 month testing of exposed babies (%)

Outcomes of Tracking system – Maharashtra-IV

Outcome of the PPTCT Calendar- Maharashtra

• Increase in pregnant mothers being initiated on ART from 53.4% in 2010 to 71.6% in 2013.

• Decrease in lost to follow up for HIV positive mothers for institutional delivery from 15% (2008) to 2% (2013).

• Increase in number of babies initiated on CPT prophylaxis and tested for Early Infant Diagnosis (EID) reaching the current level of 85% (2013) cumulative from 67% (2011).

• The babies tested for EID at 6 weeks increased from 30% (2010) to the current level of >70% (2013).

• Increase in babies being linked and initiated on ART from 49.7% (2010) to 93.7 % (2013).

ConclusionThe functionaries at the grass root level should be involved

in planning process. This ensures complete ownership by the system functionaries (those involved in implementation).

Since the tool is simple and robust for tracking, it was easy to operationalize.

The tool is very useful in field for the functionaries as it provide the information on the mothers and children to be followed up, at a glance.

It is easy to monitor and follow up at different levels using the same tool.

A simple, almost no cost tracking system enables scaling up in large geographical area within a small span of time as it leverage existing man power with little capacity building.

• “In the beginning I felt that this (the PPTCT calendar) was useless ....... I was already filling so many formats. But once I started using it I saw how it helped me, how I could plan, how I could meet my target.”

• – ICTC Counsellor, Chandrapur