Ukraine National PMTCT Scale-up Project

With an estimated population of 46.7 million and an adult HIV prevalence rate of 1.4 percent, Ukraine is the country worst affected by the AIDS epidemic in all of Europe. If current trends are not reversed, WHO experts predict that 1.44 million people—3 percent of the total population—will be infected with HIV by 2010.

As the epidemic becomes more generalized, more women of child-bearing age are being infected and mother-to-child transmission of HIV has emerged as a significant problem. From 1998 to 2005, the number of new HIV cases reported among pregnant women rose from 686 to 2,516. According to the Ukrainian Ministry of Health, more than 1 percent of pregnant women in Odessa and Mykolayiv oblasts are registered as HIV-positive. In 2005, 2,399 children were born to HIV-positive women, representing a 300 percent increase from the 727 cases reported in 2000.

In late 2000, AIHA launched a USAID-funded pilot PMTCT project to improve quality of care in Odessa Oblast by expanding collaboration between healthcare facilities and nongovernmental organizations providing services to people living with HIV/AIDS. This pilot project adopted a comprehensive medical-social model and was replicated in eight high-prevalence regions nationwide in cooperation with Ukraine’s Ministry of Health and with support from USAID-Ukraine.

With the overarching goal of lowering the vertical transmission rate to 5-8 percent at each participating site, the project focused on:

• strengthening human resource capacity and organizational effectiveness;
• expanding high-quality PMTCT clinical and support services;
• improving collaboration among healthcare facilities and NGOs; and
• coordinating efforts of international donors and stakeholders.

Replication was launched in Cherkassy, Dnipropetrovsk, Kyiv, and Mykolayiv oblasts in June 2005. In November 2005, the project was launched in the second-phase oblasts of Chernigiv, Crimea, Kherson, and Odessa.

Clinical training to build capacity in the target regions was conducted at the Southern Ukraine AIDS Education Center (SUAEC) as well as at selected healthcare institutions in each oblast. SUAEC—which has been recognized by WHO and other international organizations as a center of PMTCT excellence in the region—was established in June 2003 at the Odessa Oblast Clinical Hospital by AIHA and various strategic partners.

During the first year of implementation, the initial scale-up strategy focused on building a strong foundation for optimization of medical-social care for HIV-positive women through targeted training of key personnel. Important steps toward reducing unplanned pregnancies and increasing adherence to preventive therapy were made, and marked improvments were made in quality of care for infants born to HIV-positive mothers. Through the project, stigma and discrimination were decreased, scarce resources were used more rationally, and monitoring and assessment processes were unified.

Final data concerning the HIV status of infants whose mothers participated in the PMTCT project was collected and analyzed in 2008, revealing that the rate of vertical transmission at the 32 target sites decreased from an average of 21 percent to 6 percent.

Through the project, AIHA provided technical assistance in the development of comprehensive community-based PMTCT operational plans that effectively organized the activities of all key stakeholders including the non-governmental sector for each project site. In addition, AIHA supported the development of model programs and methodological centers of excellence in each oblast that incorporated quality improvement processes and evidence-based practices, directly reached large numbers of women, and served as replication and training sites for staff at affiliated programs in underserved areas.

The project built human resource capacity by conducting a series of targeted training and mentoring activities that included: clinical skills-based caregiver training for targeted caregivers from each site at SUAEC using curricula developed in Odessa for region-wide replication; on-site training and mentoring utilizing the WHO/USG PMTCT Generic Training Package, which was adapted for use in Ukraine by AIHA with USAID support and the endorsement of the Ukrainian Ministry of Health; and PMTCT organizational workshops for decision-makers from each of the target oblasts. AIHA also conducted a number of Training-of-Trainers workshops using the adapted GTP to develop the capacity of local faculty thereby ensuring the sustainability of training programs in each oblast.

AIHA helped staff at the target sites develop new operational frameworks to address vertical transmission of HIV and implement effective, comprehensive, multisectoral PMTCT programs. Practitioners gained new knowledge and skills and developed a case management system to monitor and improve quality of care thanks to the project. The resulting strengthening of local capacity is serving as a foundation for ongoing improvements at the target sites, as well as other regions spanning Ukraine.

Specific achievements include:

Strengthened ability of oblast health administrations to conduct PMTCT program assessments, establish task forces, and develop strategies and annual work plans.

An expanded pool of 303 trained healthcare providers, managers, and allied staff capable of providing quality, evidence-based PMTCT-related services at project sites.

Established methodological centers of PMTCT excellence in each oblast thereby strengthening local capacity-building infrastructure.

Improved early identification and referral of HIV-infected pregnant women (45 percecnt of HIV-infected women were registered for prenatal care before the second trimester in the project PMTCT groups compared to 27 percent in baseline groups.

Improved the system of prenatal care to HIV-infected pregnant women; decreased risk of vertical transmission of HIV during labor and delivery; and improved post-natal care for infants and their HIV-infected mothers (84 percent of HIV infected women and 96 percent of their newborns received ARV prophylaxis in PMTCT groups compared to 67 percent and 50 percent respectively in baseline groups.

Increased the number of HIV-infected pregnant women receiving key non-medical services from NGOs (70 percent of HIV-infected pregnant women were referred to NGOs to receive non-medical care and support in PMTCT project groups compared to only 7 percent in baseline groups.

Wide dissemination of PMTCT results and lessons learned, coupled with greater coordination with broader maternal and child health and HIV/AIDS programs, through regular local and national meetings.