| 4. In which ways is the initiative creative and innovative?
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Introduction of TC system, under the Global Fund-supported project, into the existing health care system, which subsequently ensured its full state funding, programmatic and financial sustainability. At that time the trend of the donors-funded projects was establishing of separate structures with the involvement of new specialists, creation of infrastructures. However, the provided resources were used in a more optimal and creative way.
PMTCT component was included into the Standard of organization of outpatient obstetrician-gynaecological care, provision of TC and other PMTCT services were included into the ToRs of physicians dealing with perinatal care, strong linkages were established between HIV and maternal and child health care services.
Institutionalization of the advanced HIV training for medical workers through introduction of HIV Training Course into the National Institute of Health (NIH). The motivation of medical workers to undergo the free of charge Training Course was increased, since it is introduced into the credit system of advanced training. Оbstetrician-gynecologists and nurses from all antenatal clinics, laboratory doctors and assistants from all laboratories countrywide have undergone the Training Course.
Mobile TC and laboratory support teams were established for regular provision of technical assistance and methodological support for the service providers from health care institutions country-wide.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The National Centre for AIDS Prevention (NCAP) State non-profit organization, established in 2002 by the Decision of the Government, is an organization dealing with HIV prevention, treatment and monitoring under MoH system. NCAP is the principle implementer and coordinator of HIV/AIDS prevention activities in the Republic of Armenia, including this initiative. NCAP carries out HIV tests, makes final laboratory diagnosis of HIV infection, provides follow-up for HIV patients, gives them antiretroviral treatment, the treatment monitoring, provides ARV prophylaxis to prevent mother-to-child HIV transmission, makes diagnosis of opportunistic infections and HIV-associated illnesses, provides prevention and outpatient treatment of opportunistic infections, post-exposure prophylaxis, provides subspecialty consultation and referral related to HIV-associated illnesses. Follow-up includes immune status and viral load assessment, revealing HIV antiretroviral drug resistance-associated mutations, virus genotype determination, clinical examinations, and biochemistry tests. HIV patients are offered dermatovenereological, gynecological, sexopatological medical care, ultrasound and x-ray examinations are implemented, TB screening is performed. Psychosocial and legal, as well as medico-psychological counselling is provided at NCAP to HIV patients and their family members. The operation of the NCAP in the area of HIV prevention and monitoring is fixed by the Law of the Republic of Armenia on HIV/AIDS Prevention, which gives a special status to this organization in the overall AIDS response.
The initiative was implemented in close cooperation and partnership with the Institute of reproductive health, perinatology, obstetrics and gynecology, antenatal clinics, HIV testing laboratories at primary health care system countrywide under the overall oversight of the Ministry of Health.
Over the recent years, about 45,000 pregnant women (which makes more that 95% of this population) undergoing HIV testing annually benefit from the initiative.
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| 6. How was the strategy implemented and what resources were mobilized?
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Maternal and child health improvement, perinatal infections, including PMTCT, are among the major challenges to the health care system of Armenia.
• One of the goals of the NAP, approved by the Government as far back as 2002, was PMTCT.
• In 2003 Strategy on Maternal and Child Health Care for 2003-2015 was approved by the Government Decision, which included PMTCT activities.
• Implementing the NAP, the National Program for Prevention of Mother-To-Child HIV Transmission was approved and introduced by the MoH Order n 2002. The overall goal of the National Program for Prevention of Mother-To-Child HIV transmission was introduction of PMTCT. The Program envisaged provision of HIV TC at antenatal clinics, developing guidelines, on preventive treatment, training of health care workers, provision to the national and regional laboratories of test-kits required for HIV testing of pregnant women and ARVs for the preventive treatment.
• Implementing the National Program for PMTCT, the National Guidelines on HIV TC, National HIV/AIDS Treatment and Care Protocols were developed, approved and introduced in 2002.
• To support the response to the HIV epidemic in Armenia, including provision of HIV testing and ART to pregnant women, in 2003 the country project proposal was developed, submitted to the Global Fund and approved for funding.
• Procedures of HIV testing and counseling, Guidelines on PMTCT, on specificities of provision of HIV TC to pregnant women were developed, approved and introduced into the health care institutions in 2004. Training-seminars were initiated for capacity building of health care workers.
• Due to the system of HIV testing and counseling integrated into antenatal clinics in 2004, the access to HIV testing for pregnant women was enlarged. As a result, the number of HIV tests performed among pregnant increased. In recent years, almost all pregnant women (about 95%) have been tested for HIV.
• To prevent mother-to-child HIV transmission provision of ARV prophylaxis began in 2005 under the Global Fund-supported NAP.
• PMTCT has been one of the key objectives of all the subsequent National AIDS Programmes, through ensuring accessibility to HIV testing for pregnant women, providing ARV prophylaxis to HIV-positive pregnant women and infants born to them. Currently the key challenge is maintenance of the achieved status of EMTCT validation in the country.
• The National Protocols on HIV/AIDS treatment and care and on HIV testing and counseling have been periodically updated based on new WHO recommendations and guidelines.
• The Law of the Republic of Armenia on HIV/AIDS Prevention was revised in 2009, and mandatory HIV testing for pregnant women was changed into the health care provider-initiated HIV testing and counselling. Children born to HIV-positive mothers are included into the group subject to mandatory HIV testing. Accordingly, National Guidelines on HIV TC were updated and relevant mechanisms were set up.
• Starting from 2010 training and retraining of health care workers on the HIV/AIDS has been institutionalized due to introduction of HIV Training Course into the NIH which, is introduced into the credit system of advanced training for health care workers. Before introduction of the NIH HIV Training Course the capacity building of health care workers on the HIV/AIDS issues was provided through training-seminars organized for various specialists. Those training-seminars were not integrated into any system of education, neither they applied any systematic approach.
• Starting from 2016 test-kits for HIV testing for pregnant women, milk formula for infants born to HIV-positive mothers have been purchased from the State Budget allocations. ARVs are still provided by the Global Fund. However, it is envisaged to purchase also ARVs from the State Budget allocations to ensure the sustainability of the programme.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The Ministry of Health established the Working Group for developing and design of the National PMTCT Strategy under the National AIDS Programme, the Working Group core were specialists from the National Center for AIDS Prevention, MoH Department of the Maternal and Child Health Care, Institute of reproductive health, perinatology, obstetrics and gynecology.
External Funding - separate component was included into the country project proposal submitted to the Global Fund in Round2 Call for Proposals. CCM members took part in the process of the project proposal development, including interested Ministries, local and international NGOs, UN Agencies, multilateral and bilateral organizations, people living with HIV, including HIV-positive women. Technical assistance for the development was provided by UNAIDS and WHO.
Subsequently all interested stake-holders participated in the process of design and development of the initiative under National AIDS Programmes, as well as the country project proposals submitted to the Global Fund, where PMTCT component was included. They participated through their representation in the CCM, as well as by taking part in various national consultations and workshops organized as part of the development processes. Also, NGOs participated, by submitting, after discussions with their beneficiaries, solicited submissions for possible integration into the programmes and proposals, and by making relevant comments and recommendations.
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| 8. What were the most successful outputs and why was the initiative effective?
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1. About 45,000 pregnant women undergo HIV testing annually, within the framework of the package of services provided free of charge under the Care State Certificate Program.
2. Relevant laboratory infrastructure has been created in 10 country regions and in Yerevan, the capital, which is used not only for performing HIV tests for pregnant women, but also for HIV testing of blood donors, of patients with clinical indicators, representatives of key and vulnerable populations (persons who inject drugs, sex workers, men who have sex with men, prisoners, migrants). Those laboratories also perform testing for other infections for large group of population.
3. There are some cases when pregnant women with unknown HIV status attend maternity hospitals during labour and delivery. To perform HIV test for such women before labour and delivery and, if needed, to provide them immediately with PMTCT, all maternity hospitals have been provided with rapid tests in recent years.
4. System of external quality control, exercised by NCAP annually, was set up for all HIV testing laboratories, with provision of on-job technical assistance. The NCAP reference laboratory itself also is undergoing regular external quality control and constant internal quality control for HIV tests. A clear-cut reporting system is functioning, approved by the MoH and sanctioned by the National Statistical Service. Also, there is an established system of referral of blood samples from TC sites to HIV testing laboratories and of positive blood samples to the reference laboratory.
5. There are trained personnel in all the antenatal clinics the laboratories countrywide - obstetrician-gynecologists and nurses from all the antenatal clinics, as well as laboratory doctors and assistants from all the laboratories countrywide have undergone the NIH HIV Training Course or training-seminars. Mobile CT and laboratory support teams were established for regular provision of technical assistance and methodological support for all service providers from health care institutions country-wide.
6. Decreased level of stigma and discrimination, strengthened human rights protection.
The initiative was effective, due to the presence of the strong Government political commitment, MoH leadership, overall oversight, and consistent PMTCT introduction of strategy, strong management and M&E conducted by NCAP, cooperation between the Institute of reproductive health, perinatology, obstetrics and gynecology, antenatal clinics and HIV testing laboratories, as well as built capacity and high level of professionalism of the medical staff. Continuous technical assistance and methodological support for the initiative realization was provided also by NCAP.
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| 9. What were the main obstacles encountered and how were they overcome?
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1. Limited number of HIV testing laboratories.
Laboratory infrastructures, laboratory equipment, IT sets were supplied, personnel was trained, country-wide network was created.
2. Blood collection, storage and transportation from antenatal clinics to laboratories, due to lack of resources was carried out once or twice monthly, which complicated early HIV detection among pregnant women and timely services provision.
Funds were envisaged in the State Budget for blood samples collection, storage, transportation. MoH issued a circular note, specifying one week as the maximum period for sample transportation. The State allocated additional funds to the laboratories testing donated blood for HIV testing among pregnant women.
3. No system of tests procurement and supply was available.
Centralized procurement mechanism was established for procurement tests and consumables under MoH. From 2016 HIV tests for pregnant women are being procured from the State Budget.
4. There was no supply chain management.
The whole chain of forecasting, procurement, shipment and supply was established. Staff was trained, electronic system for calculating ARV needs was created.
5. Pregnant women with unknown HIV status.
All maternity hospitals were provided with rapid tests to perform HIV test for pregnant women with unknown HIV status attending maternity hospital during labour and delivery.
6. Quality of testing.
System of external and internal quality control exercised by NCAP was established with provision of on-job technical assistance. The NCAP reference laboratory is undergoing regular external and internal quality control for HIV testing.
7. Providing with milk formula.
Milk formula to HIV-positive women, who gave birth, was distributed through primary health care system. However, women did not apply for the milk formula due to fear of their HIV status disclosure, and had to purchase it ≈ USD 670.
The Government initiated a new mechanism of distribution of milk formula through general network of pharmacies.
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