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**Module 9** PMTCT Programme Monitoring

**SESSION 1** Introduction to the Programme Cycle

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

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

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

-   Describe the programme cycle.

-   Discuss the purposes of global and national PMTCT indicators.

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

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

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| **Relevant Policies for Inclusion in National Curriculum**            |
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| Session 2                                                             |
|                                                                       |
| -   National indicators for PMTCT programmes                          |
|                                                                       |
| -   Healthcare facility indicators for PMTCT programmes               |
|                                                                       |
| Appendices                                                            |
|                                                                       |
| -   Full set of forms used in the PMTCT programmes                    |
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  ---------------------------------------------------- -----------------------------------------------------------
  ![](media/image2.png){width="0.7597222222222222in"   The *Pocket Guide* contains a summary of Session 3.
  height="0.6263888888888889in"}                       

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SESSION 1 Introduction to the 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.

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.

SESSION 2 Global, National, and Healthcare Facility PMTCT Indicators

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

+--------------+-------------------------------------------------------+
| ### **Exe    |                                                       |
| rcise 9.1 Un |                                                       |
| derstanding  |                                                       |
| indicator re |                                                       |
| quirements:  |                                                       |
| small group  |                                                       |
| discussion** |                                                       |
+--------------+-------------------------------------------------------+
| **Purpose**  | To discuss the information needed to measure and      |
|              | track a specific indicator, and how to collect and    |
|              | compile data                                          |
|              |                                                       |
|              | To understand the importance of shared definitions of |
|              | terminology in data collection                        |
|              |                                                       |
|              | To view monitoring from a national level              |
+--------------+-------------------------------------------------------+
| **Duration** | 25 minutes                                            |
+--------------+-------------------------------------------------------+
| **In         | In your group, pretend to be a member of the national |
| structions** | PMTCT monitoring team that advises the MOH on PMTCT   |
|              | monitoring indicators. Focus on the percentage of     |
|              | pregnant women who were HIV-infected and received ARV |
|              | prophylaxis as recommended in the national            |
|              | guidelines, then address the following questions:     |
|              |                                                       |
|              | -   What is the definition of the indicator? (What    |
|              |     does it measure?)                                 |
|              |                                                       |
|              | -   What information is needed to fully understand    |
|              |     this indicator? (such as knowing the PMTCT        |
|              |     protocol, drug/drugs used for ARV prophylaxis,    |
|              |     etc)                                              |
|              |                                                       |
|              | -   Why is the indicator important?                   |
|              |                                                       |
|              | -   What healthcare facility information is used to   |
|              |     calculate this indicator?                         |
|              |                                                       |
|              | -   One member of the group will record the answers   |
|              |     on a flipchart and present them to the larger     |
|              |     group.                                            |
+--------------+-------------------------------------------------------+

SESSION 3 PMTCT Programme Monitoring at the Healthcare Facility Level

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.

**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: 22%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><strong>Type of Report</strong></td>
</tr>
<tr class="even">
<td>Individual Record Form</td>
<td colspan="2"></td>
<td>Daily Summary Reports</td>
<td colspan="2"></td>
<td>Monthly Reports</td>
<td></td>
<td>Quarterly Reports</td>
<td></td>
<td>Annual Global PMTCT Reports</td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Place Generated</strong></td>
</tr>
<tr class="even">
<td colspan="2">Department/Facility</td>
<td></td>
<td colspan="2">Department/Facility</td>
<td></td>
<td>Facility/ District</td>
<td></td>
<td><p>District/</p>
<p>National</p></td>
<td></td>
<td>Global</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

+--------------+-------------------------------------------------------+
| #            |                                                       |
| ## **Exercis |                                                       |
| e 9.2 Using  |                                                       |
| indicators:  |                                                       |
| small group  |                                                       |
| discussion** |                                                       |
+--------------+-------------------------------------------------------+
| **Purpose**  | To interpret monitoring data from a PMTCT service and |
|              | consider recommendations to improve performance.      |
+--------------+-------------------------------------------------------+
| **Duration** | 15 minutes                                            |
+--------------+-------------------------------------------------------+
| **In         | For this exercise, you are upper-level administrators |
| structions** | and clinicians working in a busy PMTCT on the         |
|              | outskirts of the national capital. The clinic         |
|              | 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:           |
|              |                                                       |
|              | *Number and percentage of pregnant women receiving    |
|              | ARV prophylaxis*                                      |
|              |                                                       |
|              | The executive director reports that the MOH has       |
|              | discovered that nationwide only 25% of pregnant women |
|              | who are HIV-infected received ARV prophylaxis in      |
|              | 2003. He writes 25% on the flipchart, just to         |
|              | emphasise his point. The executive director continues |
|              | by saying that your healthcare facility is among      |
|              | those administering ARV prophylaxis to the lowest     |
|              | percentage---with only 18% of pregnant women who are  |
|              | HIV-infected receiving ARV prophylaxis; he 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.                                       |
|              |                                                       |
|              | With the others in your small group, discuss the      |
|              | following topics:                                     |
|              |                                                       |
|              | -   What is your interpretation of the monitoring     |
|              |     data, ie, why do you think so few women receive   |
|              |     ARV prophylaxis?                                  |
|              |                                                       |
|              | -   Identify any additional information needed to     |
|              |     better understand the data.                       |
|              |                                                       |
|              | -   Choose the most plausible interpretation that     |
|              |     your group produced. Determine a set of           |
|              |     recommendations your staff can follow to address  |
|              |     the gap between guidelines and practice.          |
+--------------+-------------------------------------------------------+

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

+--------------+-------------------------------------------------------+
| #            |                                                       |
| ## **Exercis |                                                       |
| e 9.3 Comple |                                                       |
| ting local P |                                                       |
| MTCT forms** |                                                       |
+--------------+-------------------------------------------------------+
| **Purpose**  | To understand the use of local PMTCT forms.           |
+--------------+-------------------------------------------------------+
| **Duration** | 15 minutes                                            |
+--------------+-------------------------------------------------------+
| **In         | As the facilitator reviews the local PMTCT forms,     |
| structions** | participate in the discussion about the information   |
|              | needed to complete these forms and ways to obtain     |
|              | these data.                                           |
+--------------+-------------------------------------------------------+

Module 9: Key Points

-   Program cycle steps include:

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

  (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 = positive, 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 June 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

+---------------------------+-------------------------+---------+------+
| Facil                     | Level of                | Month   |      |
| ity:\_\_\_\_\_\_\_\_\_\_\ | Facil                   | of      |      |
| _\_\_\_\_\_\_\_\_\_\_\_\_ | ity:\_\_\_\_\_\_\_\_\_\ | Repor   |      |
|                           | _\_\_\_\_\_\_\_\_\_\_\_ | t:\_\_\ |      |
|                           |                         | _\_\_\_ |      |
|                           |                         | \_\_\_\ |      |
|                           |                         | _\_\_\_ |      |
+---------------------------+-------------------------+---------+------+
| Distr                     | Date Form               | Year of |      |
| ict:\_\_\_\_\_\_\_\_\_\_\ |                         | Report: |      |
| _\_\_\_\_\_\_\_\_\_\_\_\_ | Completed:\_            | \_\_\_\ |      |
|                           | \_\_\_\_\_\_\_\_\_\_\_\ | _\_\_\_ |      |
|                           | _\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\ |      |
|                           |                         | _\_\_\_ |      |
+---------------------------+-------------------------+---------+------+
| Reg                       |                         |         |      |
| ion:\_\_\_\_\_\_\_\_\_\_\ |                         |         |      |
| _\_\_\_\_\_\_\_\_\_\_\_\_ |                         |         |      |
+---------------------------+-------------------------+---------+------+
|                           |                         |         | **   |
|                           |                         |         | Numb |
|                           |                         |         | er** |
+---------------------------+-------------------------+---------+------+
| **MAT 01.** Number of     |                         |         | \_\_ |
| women who                 |                         |         | \_\_ |
| deliver                   |                         |         | \_\_ |
| ed....................... |                         |         |      |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **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                 |                         |         | \_\_ |
| de                        |                         |         |      |
| livery................... |                         |         |      |
| ......................... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **MAT 04.** Number of     |                         |         | \_\_ |
| women tested for HIV      |                         |         | \_\_ |
| at/after                  |                         |         | \_\_ |
| delivery..                |                         |         |      |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **MAT 04.1.** Number      |                         |         | \_\_ |
| HIV-negative              |                         |         | \_\_ |
| ......................... |                         |         | \_\_ |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **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                       |                         |         | \_\_ |
| weeks...                  |                         |         | \_\_ |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
| ..........\.............. |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **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                       |                         |         | \_\_ |
| w                         |                         |         | \_\_ |
| eeks..................... |                         |         |      |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **MAT 09.3.** Took HAART  |                         |         | \_\_ |
| \>4                       |                         |         | \_\_ |
| weeks..                   |                         |         | \_\_ |
| ...................\...\. |                         |         |      |
| ..\...\...\...\...\...\.. |                         |         |      |
| .\...\...\...\...\...\... |                         |         |      |
| \...\...\...\...\...\.... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **MAT 10.** Number whose  |                         |         | \_\_ |
| infant(s) received        |                         |         | \_\_ |
| NVP............\...\...\. |                         |         | \_\_ |
| ..\...\...\...\...\...\.. |                         |         |      |
| .\...\...\...\...\...\... |                         |         |      |
| \...\...\...\...\...\.... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **MAT 11.** Number whose  |                         |         | \_\_ |
| infants discharged with   |                         |         | \_\_ |
| ARV.........              |                         |         | \_\_ |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **MAT 12.** Number        |                         |         | \_\_ |
| intending to              |                         |         | \_\_ |
| breastfeed                |                         |         | \_\_ |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
+---------------------------+-------------------------+---------+------+
| **MAT 13.** Number        |                         |         | \_\_ |
| intending to replacement  |                         |         | \_\_ |
| feed................      |                         |         | \_\_ |
| ......................... |                         |         |      |
| ......................... |                         |         |      |
+---------------------------+-------------------------+---------+------+

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

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

**Field Visit (optional)**

![](media/image4.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 labor 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

[]{.mark}

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?                                                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| 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?                                    |
+-----------------------------------------------------------------------+