![](media/image1.png){width="1.0263888888888888in"
height="1.5798611111111112in"}

**Module 9** PMTCT Programme Monitoring

![](media/image2.png){width="0.5597222222222222in"
height="0.5597222222222222in"} **Total Time:** 85 minutes

**SESSION 1 Introduction to the Programme Cycle**

  ----------------------------- ------------------------------ ----------
  **Activity/Method**           **Resources Needed**           **Time**

  Lecture and slide             None, other than those listed  10 minutes
  presentation                  below                          
  ----------------------------- ------------------------------ ----------

**Session 2** Global, National, and Health Facility PMTCT Indicators

  ----------------------------- ------------------------------ ----------
  **Activity/Method**           **Resources Needed**           **Time**

  Exercise 9.1 Understanding    None, other than those listed  30 minutes
  indicator requirements: small below                          
  group discussion                                             
  ----------------------------- ------------------------------ ----------

**Session 3** PMTCT Programme Monitoring at the Health Facility Level

  ----------------------------- ------------------------------ ----------
  **Activity/Method**           **Resources Needed**           **Time**

  Exercise 9.2 Using            None, other than those listed  45 minutes
  indicators: small group       below                          
  discussion                                                   

  Exercise 9.3 Completing local Paper copies of all forms for  
  PMTCT forms (optional)        all participants or a copy of  
                                each on a transparency for     
                                overhead projector             
  ----------------------------- ------------------------------ ----------

  ---------------------------------------------------- -----------------------------------------------------------
  ![](media/image3.png){width="0.7597222222222222in"   The *Pocket Guide* contains a summary of Session 3.
  height="0.6263888888888889in"}                       

  ---------------------------------------------------- -----------------------------------------------------------

**Also have available the following:**

-   Overheads or PowerPoint slides for this Module (in Presentation
    Booklet)

-   Overhead or LCD projector, extra extension cord/lead

-   Flipchart or whiteboard and markers or blackboard and chalk

-   Pencil or pen for each participant

+-----------------------------------------------------------------------+
| Relevant Policies for Inclusion in National Curriculum                |
+-----------------------------------------------------------------------+
| **Session 2**                                                         |
|                                                                       |
| -   National indicators for PMTCT programmes                          |
|                                                                       |
| -   Healthcare facility indicators for PMTCT programmes               |
|                                                                       |
|     **Appendices**                                                    |
|                                                                       |
| -   Full set of forms used in the PMTCT programmes                    |
+-----------------------------------------------------------------------+

SESSION 1 Introduction to the Programme Cycle

  ------------------------------------- ------------------------------------------------------------
  ![](media/image4.png){width="0.6in"   Advance Preparation
  height="0.9395833333333333in"}        

                                        There is no advance preparation required for this session.
  ------------------------------------- ------------------------------------------------------------

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image2.png){width="0.6263888888888889in"   **Total Session Time:** 10 minutes
  height="0.6263888888888889in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | Slides 1 and 2                                             |
| 5.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Begin by reviewing the module objectives listed below.

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

-   Describe the PMTCT programme cycle.

-   Discuss the purposes of global and national PMTCT indicators.

-   Understand the role of the healthcare worker in monitoring a PMTCT
    programme.

*Note:* This module is designed to provide introductory information on
monitoring PMTCT programmes. Some healthcare workers may benefit from
additional training in PMTCT programme monitoring and evaluation.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | Slides 3, 4, and 5                                         |
| 5.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Discuss the programme cycle, as noted in the box on the next page.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image6.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Emphasise the parallels between the five-step programme cycle and
    the five-step clinical case management process using a familiar
    clinical situation, such as an infant brought to MCH services for
    growth and developmental delay. Consider that this infant is not
    gaining weight as expected.

Programme cycle

Planning and implementation of a PMTCT programme is part of a larger
programme cycle in which healthcare workers play an important role. A
successful PMTCT programme requires implementing each step of the
programme cycle.

The *programme cycle* is the process of assessing a situation and then
designing, implementing, monitoring, and evaluating a public health
programme in response.

Note the parallels between the programme cycle and clinical case
management. The five-step process in a nationwide PMTCT programme cycle
is similar to the five-step process a healthcare worker follows when
caring for a patient. The healthcare worker:

-   Assesses the patient\'s health by taking a medical history,
    performing a physical exam, and making the diagnosis

-   Designs a patient treatment plan

-   Implements the treatment plan

-   Monitors the patient\'s progress

-   Evaluates the success of the treatment plan using lab tests,
    re-examination, and patient self-report

Assessing

The first step of the programme cycle is to analyse the problem by
conducting a needs assessment. In this case, the needs assessment would
indicate women are HIV-infected and that infants are dying of HIV/AIDS.
It might also indicate where the problem is the greatest (eg, urban or
rural areas) and the best way to begin to address the problem.

Planning

The next step is to plan the specific PMTCT treatment, care, and support
programme that will respond to the needs identified in the assessment.
Planning will involve making decisions such as which healthcare
facilities will offer PMTCT services in the first phase of the
programme; how to expand and scale-up the programme; how many and which
staff should be trained; what types of equipment, supplies, and physical
space are needed.

Planning also requires developing programme guidelines (eg, PMTCT
national guidelines), a budget and a programme management plan.

PMTCT programme goals and targets are also developed during the planning
step. For example, the programme might aim to provide pre-test
information to 100% of new ANC patients and to provide HIV testing to
95% of new patients. While these goals might not be achievable
immediately, setting targets to improve coverage rates within a specific
time frame can help the staff reach programme goals.

Implementing

The third step is the implementation of PMTCT services according to the
decisions made in the planning phase. Implementation involves training
staff, establishing standard procedures for healthcare workers, and
integrating the programme into ongoing MCH services. Often, there is a
pilot phase when a new programme is introduced at a healthcare facility.
During the pilot phase, initial problems can be identified and solved
before the programme is fully implemented.

Monitoring

The next step in the programme cycle, monitoring the PMTCT programme,
involves asking questions about the services and the implementation
process. Questions about the performance of the programme might include:
How many patients is the programme reaching? What percentage of ANC
patients receive HIV testing? What percentage of mothers, who are
HIV-infected and delivered at a PMTCT site, are receiving ARVs for
PMTCT?

Evaluating

The final step is evaluating the PMTCT programme by asking questions
about the impact of the programme. Such questions could include: What
are the barriers to full uptake of the programme? How many infants did
the programme prevent from getting HIV infection? How might the
programme be improved in order to reach its targets and goals more
quickly?

comparing outcomes to previously outlined goals is important for
measuring the programme's success.

Steps of the programme cycle occur as part of an ongoing process.
Evaluation findings should lead to new planning and implementation. This
approach provides a broad perspective on effective monitoring and
evaluation, and improves the feasibility of plans and sustainability of
projects

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image6.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   The steps of the programme cycle are part of an ongoing process.

-   Evaluation findings lead to new planning and implementation
    processes.

-   This approach improves the feasibility and sustainability of
    projects because it facilitates identification of successful
    components and procedures as well as those needing to be modified or
    phased in.

SESSION 2 Global, National, and Health Facility PMTCT Indicators

  ------------------------------------- ------------------------------------------------------------
  ![](media/image4.png){width="0.6in"   Advance Preparation
  height="0.9395833333333333in"}        

                                        Read the scenario for Exercise 9.1 to make sure it is
                                        appropriate for your setting. If necessary, change it to
                                        reflect your local and national monitoring requirements and
                                        practices. Also, find out how all the information sought in
                                        this scenario (such as the number of women testing
                                        HIV-positive) is collected and reported to the authorities.
  ------------------------------------- ------------------------------------------------------------

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image2.png){width="0.6263888888888889in"   **Total Session Time:** 30 minutes
  height="0.6263888888888889in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | Slides 6, 7 and 8                                          |
| 5.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Discuss the importance of global, national, and health facility PMTCT
indicators, using the information below.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image6.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   PMTCT programme indicators can quickly show us how rates of MTCT are
    being reduced in a particular geographic area.

-   Funding for programmes is often dependent on outcomes.

What is an indicator?

Indicators are summary measures to describe a situation. Indicators
provide information on the status of activities related to each step of
the programme cycle. Appendix 9-A provides examples of PMTCT performance
indicators.

Indicators for PMTCT programmes

Global indicators

Global indicators generally are limited to the final step of the
programme cycle and a few key outcomes. They are based on national
indicators. Global indicators:

-   Reflect, in a few summary numbers, the current worldwide situation
    regarding PMTCT efforts

-   Provide a picture of how countries, on average, are addressing PMTCT

-   Help donors understand how to assess the results of past spending
    and prioritise future funding

*Example of a global PMTCT indicator:* Percentage of pregnant women who
are HIV-positive and received a complete course of ARV prophylaxis to
reduce the risk of MTCT

National indicators

National indicators usually address several steps of the programme
cycle. They are estimated from information provided at the local level.
National indicators:

-   Reflect the goals, objectives, and activities of the national
    HIV/AIDS programme

-   Assess the effectiveness of the national response to PMTCT

-   Include the WHO global PMTCT indicators

*Example of a national indicator:* Percentage of pregnant women in the
country making at least one ANC visit who have received an HIV test
result and post-test counselling

Healthcare facility indicators

Healthcare facility indicators---information collected at healthcare
facilities---are essential to monitoring and evaluation, and to
providing quality healthcare services to patients. National and global
indicators are reported based on healthcare facility indicators.

Healthcare facility indicators:

-   Help set targets and track progress towards reaching all women and
    infants who need PMTCT services

-   Help identify progress, problems, and challenges

-   Aid in finding solutions to the problems of increasing coverage and
    improving quality of care.

*Example of a healthcare facility indicator:* Percentage of women who
received HIV pre-test information during ANC and accepted HIV testing

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | Slide 9                                                    |
| 5.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Review the importance of PMTCT programme indicators, using the following
exercise.

+-----------+----------------------------------------------------------+
| *         |                                                          |
| *Exercise |                                                          |
| 9.1       |                                                          |
| Unde      |                                                          |
| rstanding |                                                          |
| indicator |                                                          |
| requ      |                                                          |
| irements: |                                                          |
| small     |                                                          |
| group     |                                                          |
| dis       |                                                          |
| cussion** |                                                          |
+===========+==========================================================+
| **        | To discuss the information needed to track a specific    |
| Purpose** | indicator, how to measure a specific indicator, collect, |
|           | and compile data.                                        |
|           |                                                          |
|           | To understand the importance of specific definitions of  |
|           | terms when selecting indicators and planning data        |
|           | collection.                                              |
|           |                                                          |
|           | To view monitoring from a national perspective.          |
+-----------+----------------------------------------------------------+
| **D       | 25 minutes                                               |
| uration** |                                                          |
+-----------+----------------------------------------------------------+
| **Instr   | Divide participants into four groups. Tell participants  |
| uctions** | the following:                                           |
|           |                                                          |
|           | -   You are the members of the National PMTCT Monitoring |
|           |     Team that advises the MOH on PMTCT monitoring        |
|           |     indicators. The MOH wants to know the extent to      |
|           |     which providers are following national PMTCT         |
|           |     guidelines, so that they can report to their funding |
|           |     organisations.                                       |
|           |                                                          |
|           | -   The indicator that you will be discussing today is   |
|           |     the percentage of pregnant patients who are          |
|           |     HIV-infected and received ARV prophylaxis in         |
|           |     accordance with national guidelines.                 |
+-----------+----------------------------------------------------------+
| **Act     | Ask each group to designate one member to write the      |
| ivities** | answers on a flipchart for presentation to the larger    |
|           | group. Each group will address one of the following two  |
|           | questions. Provide guidance to the groups as they work   |
|           | to answer the questions. After each question is a list   |
|           | of possible answers. Compare those responses with        |
|           | participants\' answers and offer additional answers.     |
|           |                                                          |
|           | 1\) What information do healthcare workers need to       |
|           | measure the indicator? Expect any of the following       |
|           | answers from participants:                               |
|           |                                                          |
|           | -   Number of pregnant women who are HIV-positive        |
|           |                                                          |
|           | -   Number of women who are HIV-positive and have given  |
|           |     birth to a live infant                               |
|           |                                                          |
|           | -   Number of pregnant women who are HIV-positive and    |
|           |     have received ARV prophylaxis                        |
|           |                                                          |
|           | 2\) What information do healthcare workers need to       |
|           | understand the indicator (eg, the definition of the      |
|           | terms and the relevant national guidelines)? Expect any  |
|           | of the following answers from participants:              |
|           |                                                          |
|           | -   What is the definition of a patient? For example, is |
|           |     a woman who tested HIV-positive at your clinic and   |
|           |     then moved away and was lost to follow-up considered |
|           |     a patient?                                           |
|           |                                                          |
|           | -   What does \"received ARV prophylaxis\" mean? For     |
|           |     example, if the infant received ARV but the mother   |
|           |     did not, would that be recorded as \"received ARV    |
|           |     prophylaxis\"?                                       |
|           |                                                          |
|           | -   What is does \"in line with national guidelines\"    |
|           |     mean? If the mother received ARV during false labour |
|           |     and the dose was not repeated during actual labour,  |
|           |     would that be considered \"in line with national     |
|           |     guidelines\"?                                        |
|           |                                                          |
|           | -   Invite one member of each group to present responses |
|           |     to the larger group. Compare the responses presented |
|           |     to those listed above.                               |
+-----------+----------------------------------------------------------+
| D         | Review what was learned, focusing on whether             |
| ebriefing | participants have increased understanding of what        |
|           | indicators are and how they are used in PMTCT            |
|           | programmes.                                              |
+-----------+----------------------------------------------------------+

SESSION 3 PMTCT Programme Monitoring at the Health Facility Level

+---------+------------------------------------------------------------+
| ![](med | Advance Preparation                                        |
| ia/imag |                                                            |
| e4.png) |                                                            |
| {width= |                                                            |
| "0.6in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .939583 |                                                            |
| 3333333 |                                                            |
| 333in"} |                                                            |
+---------+------------------------------------------------------------+
|         | Consider the scenario for Exercise 9.2 in light of PMTCT   |
|         | services in your area (if they are already established).   |
|         | Consider the range of reasons that a patient might refuse  |
|         | ARV prophylaxis. The reasons may be cultural (eg, fear of  |
|         | Western medicine), practical (eg, unreliable supply of     |
|         | ARVs), or service related (eg, lack of trained personnel   |
|         | to answer questions). If the data are available, change    |
|         | the percentages in the scenario to reflect the percentages |
|         | reported from local PMTCT clinics.                         |
|         |                                                            |
|         | For the optional Exercise 9.3, consider the complexity of  |
|         | the local forms and your participants' familiarity with    |
|         | completing them to decide how much time should be spent on |
|         | this exercise and the methodology (three methods for       |
|         | introducing the forms are suggested in the exercise).      |
|         | Ensure you have all materials available for presentation   |
|         | (whether it is paper copies of all forms for all           |
|         | participants or a copy of each form on a transparency for  |
|         | overhead projection).                                      |
+---------+------------------------------------------------------------+

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image2.png){width="0.6263888888888889in"   **Total Session Time:** 45 minutes
  height="0.6263888888888889in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | Slides 10, 11 and 12                                       |
| 5.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Discuss the role of monitoring and evaluation in PMTCT programmes, using
the information below.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image6.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Emphasise the importance of healthcare workers in the monitoring
    process.

-   Explain that evaluation tells us how our programme interventions are
    working.

What is monitoring?

Monitoring is regular tracking of key programme elements.

Monitoring of the PMTCT programme will help to:

-   Assess programme performance

-   Detect and correct performance problems

-   Make more efficient use of PMTCT programme resources

Because monitoring data provide much of the information needed to track
programme performance and make programme changes, this session focuses
on monitoring data that are routinely collected through record-keeping
at the healthcare facility.

What is evaluation?

Evaluation is measuring the changes in a situation resulting from an
intervention.

A *formal evaluation* of the PMTCT programme will demonstrate to what
extent the programme contributed to changes in the indicators. Formal
evaluations should be conducted intermittently to try to examine the
ways in which the PMTCT programme is causing these changes.

What is a monitoring system?

A monitoring system is a group of components used to track programme
activities. PMTCT programme monitoring should include all activities
aimed at providing the minimum package of services for preventing
mother-to-child transmission including:

-   HIV testing and counselling for pregnant women

-   ARV treatment and prophylaxis to prevent MTCT

-   Counselling and support for safe infant-feeding practices

-   Family planning counselling or referral

Typically, data on these activities are recorded at the healthcare
facility, compiled at a district level, and forwarded to the national
level for aggregation as illustrated in Figure 9.1.

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | Slides 13 and 14                                           |
| 5.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Discuss the importance of recordkeeping and data collection.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image6.png){width="0.7597222222222222in"   Make These Points
  height="0.48680555555555555in"}                      

  ---------------------------------------------------- ------------------------------------------------------------

-   Responsible and accurate data collection help keep the important
    work of PMTCT programmes on target.

Figure 9.1 Flow of Recordkeeping Data

<table>
<colgroup>
<col style="width: 15%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 14%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 14%" />
<col style="width: 4%" />
<col style="width: 14%" />
<col style="width: 4%" />
<col style="width: 19%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12">Type of Report</td>
</tr>
<tr class="even">
<td><strong>Individual Record Form</strong></td>
<td colspan="2"></td>
<td><strong>Daily Summary Reports</strong></td>
<td colspan="2"></td>
<td><strong>Monthly Reports</strong></td>
<td></td>
<td><strong>Quarterly Reports</strong></td>
<td></td>
<td><strong>Annual Global PMTCT Reports</strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><h1 id="place-generated">Place Generated</h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Department/Facility</strong></td>
<td></td>
<td colspan="2"><strong>Department/Facility</strong></td>
<td></td>
<td><strong>Facility/ District</strong></td>
<td></td>
<td><p>District/</p>
<p><strong>National</strong></p></td>
<td></td>
<td><strong>Global</strong></td>
<td></td>
</tr>
</tbody>
</table>

Characteristics of a PMTCT programme monitoring system

A PMTCT monitoring system includes:

-   Clear definitions of indicators

-   Standard tools, data source, and methodologies

-   Clear guidelines and protocols

Examples of guidelines and protocols might address: What data quality
assurance procedures should be implemented? How often and to whom will
reports be sent? How will reports be used and disseminated?

Ideally, staff members will record the PMTCT services provided in
standard ANC and maternity ward registers as part of routine MCH data
collection. Periodic summary reports summarise register information for
local programme management and reporting.

*See Appendix 9-B for sample PMTCT columns to add to standard MCH
registers and sample PMTCT monthly summary forms*.

In every healthcare facility where PMTCT services are delivered, it is
important to designate staff and outline their responsibilities in the
monitoring process. Clear roles and responsibilities should be defined
for staff involved in:

-   Data collection

-   Analyses

-   Reporting

-   Dissemination

-   Data use

Using monitoring information for intervention-related decision-making

Monitoring information should be reviewed periodically to assess
programme performance and improve programme procedures. Monitoring
information is used for decision-making about the PMTCT programme at
local, national, and global levels.

Consider an example of decision-making based on a healthcare
facility-level indicator:

Percentage of women who deliver at a PMTCT site who know their HIV
status

If decision-makers at the healthcare facility offering PMTCT services
see that a low percentage of women know their HIV status, they should
first try to understand the causes before making recommendations to
remedy the situation. They might further investigate:

-   Of the women who do not know their HIV status at delivery, what
    percentage attended ANC?

-   Is the ANC clinic reaching its HIV testing targets?

-   Is HIV testing and counselling during labour being offered to women
    according to protocol?

Depending on the answers to these or similar questions, possible
interventions or recommendations might include:

-   Improving outreach to pregnant women to increase ANC attendance

-   Modifying ANC procedures to increase testing and counselling
    coverage

-   Increasing maternity ward staffing resources in an effort to
    increase HIV testing rates during labour

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image5.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Guide the following small group discussion of interpreting data and
developing recommendations based on the data.

+-----------+----------------------------------------------------------+
| *         |                                                          |
| *Exercise |                                                          |
| 9.2 Using |                                                          |
| in        |                                                          |
| dicators: |                                                          |
| small     |                                                          |
| group     |                                                          |
| dis       |                                                          |
| cussion** |                                                          |
+===========+==========================================================+
| **        | To interpret monitoring data from a PMTCT service and    |
| Purpose** | consider recommendations to improve performance.         |
+-----------+----------------------------------------------------------+
| **D       | 15 minutes                                               |
| uration** |                                                          |
+-----------+----------------------------------------------------------+
| **Intro   | Divide participants into four small groups. Explain that |
| duction** | this exercise will provide an opportunity to interpret   |
|           | data from a busy PMTCT clinic on the outskirts of the    |
|           | national capital.                                        |
+-----------+----------------------------------------------------------+
| **Act     | -   Ask participants to imagine that they are            |
| ivities** |     upper-level administrators and clinicians working in |
|           |     a busy PMTCT on the outskirts of the national        |
|           |     capital. The facility's Executive Director calls you |
|           |     into a meeting to help him interpret the annual      |
|           |     PMTCT monitoring data. He starts the meeting by      |
|           |     writing the following on a flipchart in the front of |
|           |     the meeting room (the trainer should do the same):   |
|           |     "Number and percentage of pregnant women receiving   |
|           |     ARV prophylaxis."                                    |
|           |                                                          |
|           | -   Then tell the groups: "The Executive Director        |
|           |     reports that the MOH has discovered that only 25% of |
|           |     pregnant women who are HIV-infected nationwide       |
|           |     received ARV prophylaxis in 2003." He writes 25% on  |
|           |     the flipchart, just to emphasise his point. The      |
|           |     Executive Director continues by saying that our      |
|           |     health facility is among the lowest, with 18% of     |
|           |     pregnant women who are HIV-positive taking ARV       |
|           |     prophylaxis, and writes 18% on the flipchart. He     |
|           |     explains to the group that he called the meeting to  |
|           |     find out from "my best and brightest clinicians and  |
|           |     administrators from the PMTCT Clinic" why the        |
|           |     numbers are so low. He waits for a response.         |
|           |                                                          |
|           | -   Ask each group to:                                   |
|           |                                                          |
|           | ```{=html}                                               |
|           | <!-- -->                                                 |
|           | ```                                                      |
|           | -   Develop possible interpretations of the data.        |
|           |                                                          |
|           | -   Identify any additional information they need to     |
|           |     better understand the data.                          |
|           |                                                          |
|           | -   Develop programme-related recommendations.           |
|           |                                                          |
|           | ```{=html}                                               |
|           | <!-- -->                                                 |
|           | ```                                                      |
|           | -   Ask one member of each group to record the answers   |
|           |     on a piece of flipchart paper for presentation to    |
|           |     the larger group.                                    |
+-----------+----------------------------------------------------------+
| **Deb     | As you review the groups' responses in the larger group, |
| riefing** | reinforce the usefulness of these data in providing      |
|           | information that may lead to ways to improve PMTCT in    |
|           | this setting.                                            |
+-----------+----------------------------------------------------------+

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | Slide 15                                                   |
| 5.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Using the information below, review the tips for "good data" shown in
the slides.

How can healthcare workers ensure data collected is useful?

Ensuring optimal use of data for decision-making and effective
management of the PMTCT programme requires accurate and timely data. The
accuracy of the information is also critical to providing quality
healthcare services.

*The information from a monitoring system is only as useful as the
quality of the information collected in clinic registers or on patient
forms.*

Healthcare workers who are responsible for recording PMTCT services and
patient health information are strongly advised to adhere to the
following procedures:

-   *Understand the data to be collected.* Before you record
    information, make sure that you understand the data requested.

-   *Record the data every time.* Record on the appropriate form each
    time you perform a procedure, see an HIV-positive patient, prescribe
    an ARV drug, receive a test result, provide a referral, or engage in
    any other PMTCT activity.

-   *Record all the data.* Make sure you have provided all the
    information requested on the monitoring form. Doing so might even
    require noting when you did *not* provide a service.

-   *Record the data in the same way every time.* Use the same
    definitions, the same rules, and the same tests for reporting the
    same piece of information over time. Sometimes, however, doing so
    will not be possible, particularly when tests and definitions change
    as a result of new treatments and technologies. When it is not
    possible to record the data in the same way, make a note that
    describes the change.

Healthcare workers are responsible for knowing who is accountable for
the monitoring activities, recording data reliably and accurately, and
knowing how and when to report information and indicators.

Healthcare workers can contribute to making the overall monitoring
process as accurate and reliable as possible by providing feedback
about:

-   How the system is working

-   Useful methods for sharing information

-   Whether the monitoring tools are easy to complete accurately and
    reliably

+--------------+-------------------------------------------------------+
| **Exercise   |                                                       |
| 9.3          |                                                       |
| Completing   |                                                       |
| local PMTCT  |                                                       |
| forms        |                                                       |
| (optional)** |                                                       |
+--------------+-------------------------------------------------------+
| **Purpose**  | To understand the use of local PMTCT forms.           |
+--------------+-------------------------------------------------------+
| **Duration** | 15 minutes                                            |
+--------------+-------------------------------------------------------+
| **In         | This is an opportunity to introduce local forms to    |
| troduction** | participants and to emphasise the importance of       |
|              | completing them consistently and accurately.          |
+--------------+-------------------------------------------------------+
| **           | Present PMTCT forms in a manner appropriate to the    |
| Activities** | complexity of local forms and the learning needs of   |
|              | particpants. The following are three possible ways to |
|              | present local forms:                                  |
|              |                                                       |
|              | -   Show the forms on the LCD/overhead projector;     |
|              |     describe them one-by-one, or                      |
|              |                                                       |
|              | -   Show copies of the forms on an overhead projector |
|              |     and fill them in with information the group       |
|              |     provides about an imaginary patient, group of     |
|              |     patients, or programme (depending on the data     |
|              |     requested).                                       |
|              |                                                       |
|              | -   Make copies of local forms for participants;      |
|              |     break into pairs and practise completing them.    |
|              |                                                       |
|              |     Answer questions as they arise.                   |
+--------------+-------------------------------------------------------+
| **           | -   Acknowledge the amount of work required to        |
| Debriefing** |     accurately complete reporting forms, but          |
|              |     emphasise the importance of the data for          |
|              |     evaluating the programme and securing continued   |
|              |     funding.                                          |
+--------------+-------------------------------------------------------+

+---------+------------------------------------------------------------+
| !       | Trainer Instructions                                       |
| [](medi |                                                            |
| a/image | Slides 16 and 17                                           |
| 5.png){ |                                                            |
| width=" |                                                            |
| 0.61319 |                                                            |
| 4444444 |                                                            |
| 4445in" |                                                            |
| he      |                                                            |
| ight="0 |                                                            |
| .593055 |                                                            |
| 5555555 |                                                            |
| 556in"} |                                                            |
+---------+------------------------------------------------------------+

Summarise the module by reviewing the key points as described below.

Module 9: Key Points

-   Program cycle steps include:

```{=html}
<!-- -->
```
-   Assessing

-   Planning

-   Implementation

-   Monitoring

-   Evaluation

    -   Global, national, and facility level indicators measure progress
        toward programme goals.

    -   Monitoring is the routine tracking of programme information.

    -   Accurate facility registers and records provide essential
        information for monitoring PMTCT programmes.

Appendix 9-A Examples of PMTCT performance indicators

Global and national PMTCT indicators^1^

-   Existence of national guidelines for the prevention of HIV infection
    in infants and young children and the care of infants and young
    children in accordance with international or commonly agreed-upon
    standards

-   Percentage of public, missionary, and workplace venues offering the
    minimum package of services for preventing HIV infection in infants
    and young children in the preceding 12 months

-   Percentage of pregnant women making at least one ANC visit who have
    received an HIV test result and post-test counselling

-   Percentage of women who are HIV-infected and receiving a complete
    course of ARV prophylaxis to reduce MTCT in accordance with a
    nationally-approved treatment protocol in the preceding 12 months

-   Percentage of infants who are HIV-positive born to women who are
    HIV-infected

  ------------------------------------------------------------------------
  ^1^ Source. UNAIDS, World Health Organization, 2004. *National Guide to
  Monitoring and Evaluating Programmes for the Prevention of HIV in
  Infants and Young Children*. Retrieved 6 June 2004, from
  http://www.who.int/hiv/pub/prev_care/en/nationalguideyoungchildren.pdf

  ------------------------------------------------------------------------

Sample health facility PMTCT indicators

-   Percentage of women starting ANC who receive pre-test counselling

-   Percentage of women starting ANC who receive HIV testing

-   Percentage of women who are HIV-infected who receive their test
    results and post-test counselling

-   Percentage of women who are HIV-negative and receive their test
    results and post-test counselling

-   Number of male partners who are HIV-tested

-   Number of women attending ANC receiving ARVs for PMTCT

-   Percentage of women with unknown HIV status at delivery

-   Percentage of women with unknown HIV status who were tested at/after
    delivery

-   Percentage of women who are HIV-infected who took a full course of
    ARVs for PMTCT

-   Percentage of infants who were HIV-exposed and received ARVs

-   Percentage of women who are HIV-infected and intend to replacement
    feed

Appendix 9-B Sample PMTCT columns to add to standard ANC and maternity
ward registers

ANC Register

  ------------ -------- -------------- -------------- ---------- ------- ------- -------------- ------------- ------------
  \(1\)        \(2\)    \(3\)          \(4\)          \(5\)                      \(6\)          \(7\)         \(8\)

  **Date       **Reg.   **Date         **Date         **HIV Test                 **Date         **ARV Given** **Date ARV
  Started      No.**    Pre-test       HIV-Tested**   Result**                   Post-Test\                   Started**
  ANC**                 Counselled**                                             Counselled**                 

  (dd/mm/yy)            (dd/mm/yy)     (dd/mm/yy)     **P**      **N**   **U**   (dd/mm/yy)     (NVP, AZT,    (dd/mm/yy)
                                                                                                AZT+NVP,      
                                                                                                HAART )       

                                                                                                              

                                                                                                              

                                                                                                              
  ------------ -------- -------------- -------------- ---------- ------- ------- -------------- ------------- ------------

ANC Partner Register

  --------------- -------------- -------------- ---------- ------- ------- --------------
  \(1\)           \(2\)          \(3\)          \(4\)                      \(5\)

  **Reg. No.**    **Date         **Date         **HIV Test                 **Date
                  Pre-test       HIV-Tested**   Result**                   Post-Test
                  Counselled**                                             Counselled**

                  (dd/mm/yy)     (dd/mm/yy)     **P**      **N**   **U**   (dd/mm/yy)

                                                                           

                                                                           

                                                                           
  --------------- -------------- -------------- ---------- ------- ------- --------------

Maternity Register

  ----------------- -------- -------- --- --- ------------ --- ------------- ------------- ---------- ------------ ------------ ----------- --- ----------------
  \(1\)             \(2\)    \(3\)            \(4\)            \(5\)         \(6\)         \(7\)      \(8\)        \(9\)        \(10\)          

  **Date**          **Reg.   **HIV            **HIV Test       **ARV Woman   **Weeks Woman **ARV      **Date       **ARV Infant **Infant        
                    No.**    Status           Result           Took During   Took ARV      Woman Took Infant       Discharged   Feeding**       
                             from             at/after         Pregnancy**   During        in         Received     With**                       
                             ANC**            Delivery**                     Pregnancy**   Labour**   NVP**                                     

  (dd/mm/yy)                 P        N   U   P            N   (AZT,         \< 2 2-4 \>4  (NVP, AZT, (dd/mm/yy)   (AZT)        B           R   
                                                               AZT+3TC,                    AZT+NVP,                                             
                                                               HAART)                      HAART)                                               

                                                                                                                                                

                                                                                                                                                

                                                                                                                                                

  Source: CDC*.                                                                                                                                 
  Prevention of                                                                                                                                 
  Mother-to-Child                                                                                                                               
  HIV Transmission                                                                                                                              
  -- Monitoring                                                                                                                                 
  System*                                                                                                                                       
  (PMTCT-MS), Draft                                                                                                                             
  June 2004                                                                                                                                     
  ----------------- -------- -------- --- --- ------------ --- ------------- ------------- ---------- ------------ ------------ ----------- --- ----------------

P = postive, N = negative, U = unknown

Appendix 9-B Sample PMTCT columns to add to standard ANC and maternity
ward registers *(continued)*

**Sample PMTCT antenatal clinic (ANC) monthly summary form**

+-----------------------+--------------------------+----------+-------+
| Facility:\_\_         | Level of                 | Month of |       |
| \_\_\_\_\_\_\_\_\_\_\ | Fac                      | Rep      |       |
| _\_\_\_\_\_\_\_\_\_\_ | ility:\_\_\_\_\_\_\_\_\_ | ort:\_\_ |       |
|                       | \_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_ |       |
|                       |                          | \_\_\_\_ |       |
|                       |                          | \_\_\_\_ |       |
+-----------------------+--------------------------+----------+-------+
| District:\_\_         | Date Form                | Year of  |       |
| \_\_\_\_\_\_\_\_\_\_\ |                          | Repor    |       |
| _\_\_\_\_\_\_\_\_\_\_ | Completed:               | t:\_\_\_ |       |
|                       | \_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_ |       |
|                       | \_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_ |       |
|                       |                          | \_\_\_\_ |       |
+-----------------------+--------------------------+----------+-------+
| Region:\_\_           |                          |          |       |
| \_\_\_\_\_\_\_\_\_\_\ |                          |          |       |
| _\_\_\_\_\_\_\_\_\_\_ |                          |          |       |
+-----------------------+--------------------------+----------+-------+
|                       |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC Counselling and |                          |          |       |
| Testing**             |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **All women attending |                          |          | **Num |
| ANC during the month  |                          |          | ber** |
| of report.**          |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 01.** Number    |                          |          | \_    |
| starting ANC this     |                          |          | \_\_\ |
| month.                |                          |          | _\_\_ |
| ...........\......... |                          |          |       |
| ..................\.. |                          |          |       |
| .\...\...\...\...\... |                          |          |       |
| \...\...\...\...\.... |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 02.** Not       |                          |          | \_    |
| pre-test              |                          |          | \_\_\ |
| counsell              |                          |          | _\_\_ |
| ed................... |                          |          |       |
| ....................\ |                          |          |       |
| ...\...\...\...\...\. |                          |          |       |
| ..\...\...\...\...\.. |                          |          |       |
| .\...\...\...\...\... |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 03.** Pre-test  |                          |          | \_    |
| counselled..........  |                          |          | \_\_\ |
| ..................... |                          |          | _\_\_ |
| ..................... |                          |          |       |
| ........\...\...\...\ |                          |          |       |
| ...\...\............. |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC** **04.** Did   |                          |          | \_    |
| not have HIV          |                          |          | \_\_\ |
| test..........        |                          |          | _\_\_ |
| ..................... |                          |          |       |
| .................\... |                          |          |       |
| \...\...\...\...\...\ |                          |          |       |
| ...\................. |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 05.** Had HIV   |                          |          | \_    |
| test.                 |                          |          | \_\_\ |
| ..................... |                          |          | _\_\_ |
| ..................... |                          |          |       |
| ....................\ |                          |          |       |
| ...\...\...\...\...\. |                          |          |       |
| ..\...\..........\... |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 06.** Tested    |                          |          | \_    |
| HIV-negat             |                          |          | \_\_\ |
| ive.................. |                          |          | _\_\_ |
| ..................... |                          |          |       |
| .........\...\...\... |                          |          |       |
| \...\...\...\...\...\ |                          |          |       |
| ...\...\...\...\..... |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 06.1.**         |                          |          | \_    |
| Post-test             |                          |          | \_\_\ |
| counselled...         |                          |          | _\_\_ |
| \...\...\...\...\...\ |                          |          |       |
| ...\...\...\...\...\. |                          |          |       |
| ..\...\...\...\...\.. |                          |          |       |
| .\...\...\...\...\... |                          |          |       |
| \...\...\...\...\.... |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 06.2.** Not     |                          |          | \_    |
| post-test             |                          |          | \_\_\ |
| counselled....        |                          |          | _\_\_ |
| ...............\...\. |                          |          |       |
| ..\...\...\...\...\.. |                          |          |       |
| .\...\...\...\...\... |                          |          |       |
| \...\...\...\........ |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC** **07.**       |                          |          | \_    |
| Tested                |                          |          | \_\_\ |
| HIV-positive........  |                          |          | _\_\_ |
| ..................... |                          |          |       |
| ....\...\...\...\...\ |                          |          |       |
| ...\...\...\...\...\. |                          |          |       |
| ..\...\...\...\...\.. |                          |          |       |
| .\...\...\...\...\... |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 07.1.**         |                          |          | \_    |
| Post-test             |                          |          | \_\_\ |
| counselled...         |                          |          | _\_\_ |
| \...\...\...\...\...\ |                          |          |       |
| ...\...\...\...\...\. |                          |          |       |
| ..\...\...\...\...\.. |                          |          |       |
| .\...\...\...\...\... |                          |          |       |
| \...\...\...\...\.... |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 07.2.** Not     |                          |          | \_    |
| post-test             |                          |          | \_\_\ |
| counselled....        |                          |          | _\_\_ |
| ...............\...\. |                          |          |       |
| ..\...\...\...\...\.. |                          |          |       |
| .\...\...\...\...\... |                          |          |       |
| \...\...\...\........ |                          |          |       |
+-----------------------+--------------------------+----------+-------+
| **ANC 08.** Tested    |                          |          | \_    |
| but unknown/lost      |                          |          | \_\_\ |
| resul                 |                          |          | _\_\_ |
| t.................... |                          |          |       |
| .......\...\...\...\. |                          |          |       |
| ..\...\...\...\...... |                          |          |       |
| ..............\...... |                          |          |       |
+-----------------------+--------------------------+----------+-------+

  ------------------------------------------------------------------------------------ --------------
  **ANC Partner Testing**                                                              

  These numbers do not always relate directly to the numbers of women starting ANC     
  this month.                                                                          

  **ANC** **09.** Number of partners tested for                                        \_\_\_\_\_\_
  HIV...............................................................                   

  **ANC 09.1.** Tested                                                                 \_\_\_\_\_\_
  HIV-negative.....................................................................    

  **ANC 09.2.** Tested                                                                 \_\_\_\_\_\_
  HIV-positive......................................................................   

  A**NC 09.3.** Tested but unknown/lost                                                \_\_\_\_\_\_
  result.................................\.......................                      
  ------------------------------------------------------------------------------------ --------------

  --------------------------------------------------------------------------------- --------------
  **ANC Antiretroviral Coverage**                                                   

  Numerator data of women starting on drug during the month of report. These        
  numbers do not relate directly to the numbers from the Antenatal Counselling and  
  Testing section.                                                                  

  **ANC** **10.** Started on, or given                                              \_\_\_\_\_\_
  NVP............................................................................   

  **ANC 11.** Started on, or given                                                  \_\_\_\_\_\_
  AZT............................................................................   

  **ANC 12.** Started on, or already taking                                         \_\_\_\_\_\_
  HAART...........................................................                  
  --------------------------------------------------------------------------------- --------------

Source: CDC*. Prevention of Mother-to-Child HIV Transmission --
Monitoring System (PMTCT-MS),* draft 2004

Appendix 9-B Sample PMTCT columns to add to standard ANC and maternity
ward registers *(continued)*

**Sample PMTCT maternity (L&D) monthly summary form**

+----------------------+-------------------------+-------------+------+
| Facility:\_\_\_      | Level of                | Month of    |      |
| \_\_\_\_\_\_\_\_\_\_ | Facil                   | Report:\_\_ |      |
| \_\_\_\_\_\_\_\_\_\_ | ity:\_\_\_\_\_\_\_\_\_\ | \_\_\_\_\_\ |      |
|                      | _\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_ |      |
+----------------------+-------------------------+-------------+------+
| District:\_\_\_      | Date Form               | Year of     |      |
| \_\_\_\_\_\_\_\_\_\_ |                         | Re          |      |
| \_\_\_\_\_\_\_\_\_\_ | Completed:\_            | port:\_\_\_ |      |
|                      | \_\_\_\_\_\_\_\_\_\_\_\ | \_\_\_\_\_\ |      |
|                      | _\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_ |      |
+----------------------+-------------------------+-------------+------+
| Region:\_\_\_        |                         |             |      |
| \_\_\_\_\_\_\_\_\_\_ |                         |             |      |
| \_\_\_\_\_\_\_\_\_\_ |                         |             |      |
+----------------------+-------------------------+-------------+------+
|                      |                         |             | **   |
|                      |                         |             | Numb |
|                      |                         |             | er** |
+----------------------+-------------------------+-------------+------+
| **MAT 01.** Number   |                         |             | \_\_ |
| of women who         |                         |             | \_\_ |
| de                   |                         |             | \_\_ |
| livered............. |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 02.** Number   |                         |             | \_\_ |
| of women who had HIV |                         |             | \_\_ |
| test from            |                         |             | \_\_ |
| ANC...............   |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 02.1.** Number |                         |             | \_\_ |
| of women with known  |                         |             | \_\_ |
| HIV-negative test    |                         |             | \_\_ |
| from                 |                         |             |      |
| ANC......            |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT** **02.2.**    |                         |             | \_\_ |
| Number of women with |                         |             | \_\_ |
| known HIV-positive   |                         |             | \_\_ |
| test from            |                         |             |      |
| ANC.......           |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 03.** Number   |                         |             | \_\_ |
| of women with        |                         |             | \_\_ |
| unknown HIV status   |                         |             | \_\_ |
| at                   |                         |             |      |
| delivery....         |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 04.** Number   |                         |             | \_\_ |
| of women tested for  |                         |             | \_\_ |
| HIV at/after         |                         |             | \_\_ |
| delivery............ |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 04.1.** Number |                         |             | \_\_ |
| HIV-neg              |                         |             | \_\_ |
| ative............... |                         |             | \_\_ |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT** **04.2.**    |                         |             | \_\_ |
| Number               |                         |             | \_\_ |
| HIV-                 |                         |             | \_\_ |
| positive............ |                         |             |      |
| .................... |                         |             |      |
| ................\... |                         |             |      |
| \...\...\...\...\... |                         |             |      |
| \...\...\...\...\... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| *The section below   |                         |             |      |
| pertains to all      |                         |             |      |
| identified           |                         |             |      |
| HIV-positive women   |                         |             |      |
| who delivered live   |                         |             |      |
| births.*             |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 05. All        |                         |             | \_\_ |
| HIV-positive women** |                         |             | \_\_ |
| (MAT 02.2. + MAT     |                         |             | \_\_ |
| 04.2)..........      |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 06.** Number   |                         |             | \_\_ |
| who took AZT in      |                         |             | \_\_ |
| ANC................. |                         |             | \_\_ |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT** **06.1.**    |                         |             | \_\_ |
| Took AZT \<2         |                         |             | \_\_ |
| weeks.............   |                         |             | \_\_ |
| ..\...\...\...\...\. |                         |             |      |
| ..\...\...\...\...\. |                         |             |      |
| ..\...\...\...\...\. |                         |             |      |
| ..\...\...\...\...\. |                         |             |      |
| ..\...\...\...\..... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 06.2.** Took   |                         |             | \_\_ |
| AZT 2-4              |                         |             | \_\_ |
| wee                  |                         |             | \_\_ |
| ks.................. |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .....\.............. |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 06.3.** Took   |                         |             | \_\_ |
| AZT \>4              |                         |             | \_\_ |
| weeks..........      |                         |             | \_\_ |
| ...........\...\...\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\.... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 07.** Number   |                         |             | \_\_ |
| who took nevirapine  |                         |             | \_\_ |
| (NVP)                |                         |             | \_\_ |
| .........            |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 08.** Number   |                         |             | \_\_ |
| who took NVP         |                         |             | \_\_ |
| only                 |                         |             | \_\_ |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 09.** Number   |                         |             | \_\_ |
| who took highly      |                         |             | \_\_ |
| active               |                         |             | \_\_ |
| antiretroviral       |                         |             |      |
| therapy              |                         |             |      |
| HAART..........      |                         |             |      |
| ..\...\...\...\...\. |                         |             |      |
| ..\...\...\...\..... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT** **09.1.**    |                         |             | \_\_ |
| Took HAART \<2       |                         |             | \_\_ |
| weeks......\...      |                         |             | \_\_ |
| \...\...\...\...\... |                         |             |      |
| \...\...\...\...\... |                         |             |      |
| \...\...\...\...\... |                         |             |      |
| \...\...\...\...\... |                         |             |      |
| \...\...\...\....... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 09.2.** Took   |                         |             | \_\_ |
| HAART 2-4            |                         |             | \_\_ |
| weeks...........     |                         |             | \_\_ |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 09.3.** Took   |                         |             | \_\_ |
| HAART \>4            |                         |             | \_\_ |
| weeks..              |                         |             | \_\_ |
| ...................\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\.... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 10.** Number   |                         |             | \_\_ |
| whose infant(s)      |                         |             | \_\_ |
| received             |                         |             | \_\_ |
| NVP............\...\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\...\ |                         |             |      |
| ...\...\...\...\.... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 11.** Number   |                         |             | \_\_ |
| whose infants        |                         |             | \_\_ |
| discharged with      |                         |             | \_\_ |
| AR                   |                         |             |      |
| V................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 12.** Number   |                         |             | \_\_ |
| intending to         |                         |             | \_\_ |
| breas                |                         |             | \_\_ |
| tfeed............... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+
| **MAT 13.** Number   |                         |             | \_\_ |
| intending to         |                         |             | \_\_ |
| replacement          |                         |             | \_\_ |
| feed......           |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
| .................... |                         |             |      |
+----------------------+-------------------------+-------------+------+

Source: CDC. *Prevention of Mother-to-Child HIV Transmission --
Monitoring System (PMTCT-MS)*, draft 2004

![](media/image1.png){width="1.0263888888888888in"
height="1.5798611111111112in"}

**Field Visit (optional)**

![](media/image2.png){width="0.5597222222222222in"
height="0.5597222222222222in"} **Total Time:** half day

Goal of the field visit

The goal of the field visit is to reinforce the classroom learning by
providing participants with an observation experience in a PMTCT
facility setting, such as an ANC clinic, labour and delivery facility,
or follow-up treatment centre.

Timing and objectives of field visit

The field visit can take place any time after *Module 6: HIV Testing and
Counselling for PMTCT*. If necessary, the field visit can take place the
week after the training course. The timing of the visit and the people
with whom trainees will meet is based on the learning objectives. The
objectives may include any of the following:

-   To observe an HIV information session

-   To observe an HIV counselling session

-   To observe rapid testing

-   To observe the provision of advice and support around ARV
    treatment/prophylaxis

-   To observe the provision of infant feeding counselling and support

-   To observe the use of universal precautions in the labour and
    delivery setting

-   To gain an understanding of the management of occupational exposure
    to HIV including post-exposure prophylaxis

-   To discuss PMTCT programme monitoring

-   To observe the provision of support to a patient who is HIV-infected

-   To observe referral and follow-up of patients to treatment, care,
    and support services

*Note*: additional information about the field visit and organising the
field visit can be found in the Training Programme and Course Director
Guide.

  ---------------------------------------------------- ------------------------------------------------------------
  ![](media/image5.png){width="0.6131944444444445in"   Trainer Instructions
  height="0.5930555555555556in"}                       

  ---------------------------------------------------- ------------------------------------------------------------

Debriefing following the visit: Once the field visit is completed it is
important to determine if the visit met the trainers' and participants'
expectations. Where you choose to have the debriefing will depend on the
facility and available space. Plan to allow at least 30 minutes for this
session.

The following questions may be helpful in directing group responses:

-   How did your observations compare with what you learned in a given
    area?

```{=html}
<!-- -->
```
-   What was the same?

-   What made it different?

```{=html}
<!-- -->
```
-   Did you observe any practice that you felt could be improved?

-   Was there a particular healthcare worker that made an impression on
    you---positive or negative?

-   What practices did you observe that you will take back to your own
    facility?

-   Did the visit, overall, meet your expectations?

-   Is there something that could have made the visit more beneficial?

Field Visit Planning Guide

The goal of the field visit is to provide participants with an
experience in a PMTCT setting to reinforce the classroom learning.

*Note*: this document can be found in the Training Programme and Course
Director Guide. It is not in the Participant Manual.

+------------+---------------------------------------------------------+
| **Planning |                                                         |
| and        |                                                         |
| Conducting |                                                         |
| a Field    |                                                         |
| Visit**    |                                                         |
+------------+---------------------------------------------------------+
| **1--4     |                                                         |
| weeks      |                                                         |
| before the |                                                         |
| training** |                                                         |
+------------+---------------------------------------------------------+
| **Organise | Contact one or more local health centres to gain        |
| the visit  | permission for participants to visit and meet with      |
| or visits  | several members of staff. The staff with whom           |
| to a local | participants will meet can be determined by the field   |
| PMTCT      | visit objectives. If there are a number of PMTCT        |
| site**     | services near to the training site, the participants    |
|            | may be divided into special interest groups and visit   |
|            | different sites. If necessary, the visits could be      |
|            | staggered over the course of a day.                     |
+------------+---------------------------------------------------------+
| **Write    | Once you have commitments from staff at the PMTCT       |
| and send   | facility, follow up with a letter confirming the date   |
| co         | and timing of the visit and the visit objectives. It    |
| nfirmation | may be a good idea to also include the following in the |
| letter**   | letter:                                                 |
|            |                                                         |
|            | -   Brief description of the training; you may want to  |
|            |     attach a copy of the overall PMTCT training agenda, |
|            |     goals/objectives                                    |
|            |                                                         |
|            | -   Information on length of the visit                  |
+------------+---------------------------------------------------------+

  ------------- ---------------------------------------------------------
  **1--4 weeks  
  before the    
  training**    

  **Develop     Finalise the visit guide for participants. See the sample
  Field Visit   guide on the following pages.
  Guide**       
  ------------- ---------------------------------------------------------

  ------------- ---------------------------------------------------------
  **1, 2, or 3  
  days before   
  the           
  training**    

  **Confirm the Telephone (or send another letter to) the people with
  meetings**    whom the participants will be meeting to reconfirm.
                Provide the healthcare workers with the final number of
                visitors.
  ------------- ---------------------------------------------------------

+------------+---------------------------------------------------------+
| **On the   |                                                         |
| morning of |                                                         |
| the Field  |                                                         |
| Visit**    |                                                         |
+------------+---------------------------------------------------------+
| **Team     | Ensure that at least one trainer will accompany each    |
| Leader,    | group of participants.                                  |
| name tags  |                                                         |
| and time   | Ask the participants to return to the training room at  |
| for        | the designated time for debriefing.                     |
| debrief**  |                                                         |
+------------+---------------------------------------------------------+

Field Visit Planning Guide *(continued)*

  ------------- ---------------------------------------------------------
  **At the      
  Site**        

  **The         Once participants arrive at the PMTCT service/clinic, the
  meeting**     trainer should ask for the healthcare worker scheduled
                for the first meeting.

  **Thank the   Thank each healthcare worker upon conclusion of each
  healthcare    observation or meeting.
  workers**     
  ------------- ---------------------------------------------------------

+------------+---------------------------------------------------------+
| **After    |                                                         |
| the site   |                                                         |
| visit**    |                                                         |
+------------+---------------------------------------------------------+
| *          | -   When everyone has returned, allow approximately 30  |
| *Debrief** |     minutes for debriefing.                             |
|            |                                                         |
|            | -   The following questions may be helpful in directing |
|            |     group response:                                     |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   How did their observations compare with what they   |
|            |     had learned in a given area? What was the same?     |
|            |     What made it different?                             |
|            |                                                         |
|            | -   Did the visit meet their expectations?              |
|            |                                                         |
|            | -   Is there something that could have made the visit   |
|            |     more beneficial?                                    |
|            |                                                         |
|            | -   Did they observe any practice that they felt could  |
|            |     be improved?                                        |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   Ask each participant to summarise their experience  |
|            |     in a sentence or two.                               |
+------------+---------------------------------------------------------+

  ------------- ---------------------------------------------------------
  **Within a    
  week after    
  the Field     
  Visit**       

  **Send out    Follow up with thank you notes to the clinical facilities
  thank you     staff that took time to meet with the participants.
  notes**       
  ------------- ---------------------------------------------------------

Field visit guide

This guide was developed as a resource for a field visit to a healthcare
facility providing PMTCT services. The following questions may be
addressed to healthcare workers, site supervisors, and programme
managers but the questions should be reviewed beforehand in light of the
local context. In addition to listening, field visit participants will
also gain information by observing the layout of the facility, attitudes
of staff when they interact with patients, the volume of patients, and
the overall atmosphere.

+-----------------------------------------------------------------------+
| Antenatal care (ANC)                                                  |
+-----------------------------------------------------------------------+
| -   How many ANC patients come here per month?                        |
|                                                                       |
| -   How many new ANC patients come here per month?                    |
|                                                                       |
| -   What is the typical flow of activities during a woman's first     |
|     visit to ANC?                                                     |
|                                                                       |
| -   Whom does she see?                                                |
|                                                                       |
| -   What activities occur?                                            |
|                                                                       |
| -   Where does she go?                                                |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| HIV testing and counselling                                           |
+-----------------------------------------------------------------------+
| -   Are patients routinely offered HIV testing? Is an opt-in or       |
|     opt-out approach used?                                            |
|                                                                       |
| -   Which of the following pre-testing services are provided?         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Group education                                                   |
|                                                                       |
| -   Individual pre-test counselling                                   |
|                                                                       |
| -   Couples pre-test counselling                                      |
|                                                                       |
| -   Ongoing HIV counselling for women who refuse testing              |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   What is the HIV testing process (for adults and infants)?         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Type of test                                                      |
|                                                                       |
| -   Testing algorithm                                                 |
|                                                                       |
| -   Where tests are performed                                         |
|                                                                       |
| -   Staff who perform testing                                         |
|                                                                       |
| -   Average number of tests per week                                  |
|                                                                       |
| -   Describe the procedures for providing HIV test results            |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ARV treatment/prophylaxis for PMTCT                                   |
+-----------------------------------------------------------------------+
| -   Which regimens are provided?                                      |
|                                                                       |
| -   What are the main counselling messages and recommendations about  |
|     ARV treatment/prophylaxis for PMTCT?                              |
|                                                                       |
| -   What is the process for providing ARVs to the women who are       |
|     HIV-infected and their infants?                                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| Labour, delivery and postpartum care                                  |
+-----------------------------------------------------------------------+
| -   How many babies are delivered per month?                          |
|                                                                       |
| -   Approximately what percentage of women deliver at home?           |
|                                                                       |
| -   Approximately what percentage of women who deliver here know      |
|     their HIV status?                                                 |
+-----------------------------------------------------------------------+

Field visit guide *(continued)*

+-----------------------------------------------------------------------+
| Infant feeding                                                        |
+-----------------------------------------------------------------------+
| -   What are the main infant-feeding messages provided?               |
|                                                                       |
| -   Is infant formula provided?                                       |
|                                                                       |
| -   When is infant-feeding counselling provided?                      |
|                                                                       |
| -   How is support for women's infant-feeding choices provided?       |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| Stigma and discrimination related to MTCT                             |
+-----------------------------------------------------------------------+
| -   What are the systems or steps used to protect confidentiality?    |
|                                                                       |
| -   What are the systems or steps used to reduce stigma and           |
|     discrimination in the facility?                                   |
|                                                                       |
| -   What are common concerns about and experiences regarding stigma   |
|     and discrimination discussed by patients?                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| Linkages to treatment and support for mothers and families            |
+-----------------------------------------------------------------------+
| -   What are the linkages to other programs or community              |
|     organisations providing the following services?                   |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Home-based care                                                   |
|                                                                       |
| -   Psychosocial services to persons living with HIV/AIDS             |
|                                                                       |
| -   Family planning                                                   |
|                                                                       |
| -   ARV treatment                                                     |
|                                                                       |
| -   Infant-feeding support                                            |
|                                                                       |
| -   HIV counselling and testing                                       |
|                                                                       |
| -   What are the mechanisms used to follow-up referrals?              |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| Safety and supportive care in the work environment                    |
+-----------------------------------------------------------------------+
| -   How do counsellors receive emotional support to share experiences |
|     and alleviate burn out?                                           |
|                                                                       |
| -   How would you describe staff attitudes towards the PMTCT          |
|     programme, satisfaction, support, workload?                       |
|                                                                       |
| -   How would you describe the adequacy of supplies and equipment to  |
|     follow infection control procedures?                              |
|                                                                       |
| -   How does this facility dispose of potentially contaminated waste  |
|     and items that are not reused (eg, bandages, syringes, etc.)?     |
|                                                                       |
| -   What is the method used here to sterilise equipment?              |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| PMTCT programme monitoring                                            |
+-----------------------------------------------------------------------+
| -   What is the PMTCT data collection and reporting process?          |
|                                                                       |
| -   Can you show me the tools you use to record PMTCT services you    |
|     provide?                                                          |
|                                                                       |
| -   What are the measures used to ensure quality information is       |
|     collected and reported?                                           |
|                                                                       |
| -   Can you tell me how information collected in the PMTCT program is |
|     used to improve the programme?                                    |
+-----------------------------------------------------------------------+