Lead Consultant-Evaluation of PMTCT Retention strategies, Kampala, Uganda, 52 Days

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Background:

Globally, a dramatic progress in reduction of mother-to-child transmission (MTCT) of HIV has been recorded since the introduction of the ‘Global Plan towards the Elimination of New HIV Infections among Children, and Keeping their Mothers Alive’ (1, 2). About 160,000 new HIV infections among children under 5 years of age occurred in 2020 globally, declining from 320,000 in 2010 (a 52% decline) (3) .This was due to increased access to Prevention of Mother to Child Transmission of HIV (PMTCT) related services.

Despite this progress, the 2020 targets set by UNAIDS and partners as part of the Super-Fast-Track Framework to end AIDS have not been met (3, 4, 5). UNAIDS and the partners determined to eliminate new HIV infections among children by reducing the number of children newly infected to less than 20,000 by 2020 (6). The sub-Saharan Africa is the largest contributor and 9 in 10 of the global paediatric HIV infections in 2020 occurred in this region (3). Spectrum Estimates show that most of the Pediatric HIV infections are due to new HIV positive mothers not enrolled on ART, dropping off ante-retroviral therapy (ART) , or becoming infected during breastfeeding/pregnancy (3). Low rates of maternal retention is one of the largest contributors to mothers dropping off ART(3). Uganda was on track to achieve one of the Super-Fast-Track targets for elimination of Pediatric HIV with more than 95% of pregnant women living with HIV on lifelong ART (3). However, all this effort is marred by poor retention in care which ultimately leads to poor adherence and low viral suppression. Retention of PMTCT clients throughout the 18-month period post-delivery contributes to decreased risk of MTCT to the baby. In 2019, Uganda had a mother to child transmission rate of 5.9% by end of breastfeeding and 2.9% at 6 weeks of age.(2). Program data for 2021 and on retention indicates that 81% of mothers were alive and in care at 3months, dropping to 68% at 6 months and further dropping to 64% at 24 months.

Retention of mother-baby pairs in care is highlighted as one of the key areas that need concerted prioritization in Uganda’s PMTCT program (2). In FY 20, twelve months mother-baby pair retention was at 67%, while 18 months final-outcome retention was at 75%

Poor retention in Uganda, as elsewhere, is attributed to both health system factors and client factors including; self-stigmatization, non-disclosure of HIV status by HIV positive mothers to their spouses and lack of organized systems at clinics , transport as well access to services (7, 8).

Description of “Keeping mothers and babies in care” campaign and other retention initiatives

To address poor retention of PMTCT clients in care, a number of interventions were put in place by the Uganda Ministry of health.

In 2012, PMTCT stakeholders chose the First Lady of Uganda as the elimination of mother to child transmission of HIV (eMTCT) champion. The First Lady, together with national stakeholders, participates in setting annual PMTCT targets and monitoring progress (2).

In 2017, the Ministry of Health engaged the First lady of Uganda to champion the campaigns on the multi sectorial leadership for accelerating a Free to Shine campaign with a specific focus ‘Keeping mothers and baby in care’. Several initiatives were then developed for implementation at the facility level to improve retention of mother-baby pairs in care to complete the PMTCT-EID cascade and thus reduce MTCT.

The strategy to keep mothers and babies in care had two components:

1. The advocacy component for improved services delivery at facility level and at the community level. The advocacy component called on key leaders to promote utilization of PMTCT services through health education at several fora including media, small group meetings.
2. The patient tracking component. For the patient tracking component, the focus was on the 2015, 2016, 2017 and 2018 birth cohorts, with interest in HIV exposed infants registered in these periods and HIV positive mothers expected to have delivered in these periods that are lost to follow up.

The process started with stakeholder engagement comprising representatives from regional level, district level and Civil Society Organisations (CSOs), Members of Parliament and other political leaders, religious leaders, cultural leaders and AIDS Development Partners (ADPs). The consensus from this engagement addressed low retention in care through cross-cutting themes that included to: Call the mothers to ‘come back’, with their spouses and the babies for care, address structural, behavioural and socio-cultural barriers to access and uptake of eMTCT services and address knowledge gaps at community level especially the adolescents and young women. During the stakeholder’s engagement meeting, the First Lady appealed for commitment from all stakeholders in her communique/aide memoire.

At facility level, the following steps in service delivery were proposed:

Activity 1:

To line list HIV+ mothers and babies that were lost in the birth cohorts of previous 2 years (infants still in HEI care) and continue this with subsequent cohorts and to proactively consider HIV+ mothers that were expected to deliver at the health facility in month.

To do this, the facility team would then:

1. Review the relevant documentation tools to line list the HIV positive mother that ever-attended care
2. Review the relevant documentation tools to line list all mothers who were identified HIV+ who do not have a registered HIV exposed infant (HEI) yet their expected date of delivery (EDD) is more than 2 months from the review date
3. Line list all mother baby pairs that are lost / missed appointment in the HEI register across all the defined time periods
4. Zone and distribute the mothers on the line list among all relevant personnel at the site to track these mothers
5. Ensure that the tracking team has all the relevant tracking tools so as to update each mother’s (in care) status as they follow up
6. Update all relevant HIV care tools with follow up information (ART care cards, ART register, HEI care card, HEI register)

Other ongoing activities at the health facility include:

7. Pre-appointment giving for pregnant mothers at MBCP at the first antenatal visit for continued tracking to bring baby for care and services. The mothers are tracked as EDD cohorts and followed at the estimated time of delivery and given an appointment for the 1st PCR
8. Weekly reviews of appointment books to timely follow up pregnant women and mother-baby pairs that do not keep their appointments during the week
9. Monthly reviews of HEI birth cohorts at 12 and 24 months and review of 6- and 12-months retentions for HIV positive pregnant and breastfeeding women.

Activity 2:

Hold weekly meetings to update the facility team on progress of follow up

Activity 3:

Make a monthly report on the ‘Keeping Mother & Baby in care’ Though the district PMTCT focal person and with support from the implementing partner, these are forwarded to AIDS Control Program (ACP), Ministry of Health.

There was additional support from the implementing partners (IPs) to the health facilities in form of airtime and support to conduct home visits for follow up.

To ensure accountability and sustainability, regular national, regional and district accountability fora were conducted for the poor performing districts and/or facilities on the basis of the analysed data. This was aimed at provision of technical support to address the performance gaps.

The effectiveness of the campaign was to be evaluated from the retention reports at various time points, comparing retention rates before and retention rates during the campaign. The impact of the campaign was to also be evaluated through the HEI outcomes report.

For quality assurance, the district PMTCT focal persons and health facility in-charges in tandem with IPs were tasked with monitoring the ‘Keeping Mother & Baby in Care’ campaign. This was aimed at ensuring implementation to fidelity. On-going mentorship and supervision targeting the poorly performing districts based on the data shared was recommended.

Other initiatives implemented included

1. FamilyConnect: A USSD based digital platform that send stage-based messages to mothers on the care they are supposed to receive at each stage coupled with appointment reminders when their appointments are due
2. Use of DBS stickers to remind health workers when babies are due for testing
3. Strengthening birth cohort monitoring as well as early retention monitoring for mothers

It was expected that these activities/interventions would lead to improved quality of the PMTCT program services including maternal ART coverage, infant ARV and Septrin prophylaxis coverage, EID coverage (1st and 2nd DNA PCR), adherence to follow up schedule and reduced MTCT rate.

PURPOSE OF THE ASSIGNMENT

The purpose of this assignment is to support the Ministry of Health AIDS Control Program to conduct an evaluation of the PMTCT retention initiatives

THE KEY RESPONSIBILITIES

1. Completing the Study Protocol
2. Finalizing Data Collection Tools, SoPs and consent forms and presentation to task team for consensus
3. Presenting the finalized study protocol and data collection tools to the task team
4. Working together with MOH submit and secure the Protocol to an IRB
5. Work with MOH to identify and train data collectors
6. Supervise data Collection
7. Conduct a desk review and KII for the qualitative component of the evaluation/assessment
8. Develop the data Entry screen and supervise data entry
9. Data Cleaning, Management, and Analysis
10. Report writing and facilitation of validation meetings

To qualify as an advocate for every child you will have…

• Advanced university degree in Medicine, Public Health or other related academic fields
• At least five to eight years of relevant experience working in the areas of public health, HIV and /or development.
• Comprehensive technical knowledge and skills for HIV programming, with focus on PMTCT work
• Experience conducting operations research
• Proven ability to manage complex partnerships
• High level of initiative and ability to navigate challenges in prioritization to complete tasks and deliverables in a timely manner is essential.
• Excellent written and oral communication skills in English with strong interpersonal and presentation skills.
• Strong qualitative and quantitative analytic skills and report writing skill

Conditions:

• Under the consultancy agreements, a month is defined as 21 working days, and fees are prorated accordingly. Consultants are not paid for weekends or public holidays
• Consultants are not entitled to payment of overtime. All remuneration must be within the contract agreement
• No contract may commence unless the consultant provides a certificate of completion of a mandatory course on “Prevention of Sexual Exploitation and Abuse”. A certificate to be submitted with the signed contract should have been obtained in the last three months.
• Clearance from DHR will be required for former UNICEF staff

• Clearance from the Government required for civil servants

• The consultancy will commence after signing of the contract.

• The SSA consultancy will include the consultancy fee and DSA. The consultant will be based at the Ministry of Health – ACP, with occasional interface with the HIV team at UNICEF Country Office team.

• The consultant will use their personal computers and will be facilitated in case they have to do any printing or photocopying.
• Transport will be arranged as per approved TAs.
• A consultant will be paid upon presentation of a deliverable report (see deliverable table 1 above)
• Consultants will not have supervisory responsibilities nor authority on UNICEF budget and other resources.
• Consultants will be required to sign the Health statement for consultants/Individual contractor prior to taking up the assignment, and to document that they have appropriate health insurance, if applicable.
• The Form 'Designation, change or revocation of beneficiary' has to be completed by the consultant upon arrival, at the HR Section

Application Procedure/Call for Proposals

Interested candidates are required to submit a technical proposal on how they intend to approach the work. The proposal should include a timeline, and methodology, based on the Terms of Reference. The proposal must also include detailed CV of the consultant, as well as a financial proposal, clearly indicating daily rate for professional fees. The financial proposal must be all-inclusive of all costs (consultancy fees and where applicable air fares, airport transfers, daily living expenses). This is an international level consultancy and competitive market rates should apply.

Evaluation of Candidate:

The consultant will be competitively selected from a list of applicants based on their past experience of doing similar work (extensive experience in writing donor reports, in compiling and editing annual reports for various UNICEF offices).

For every Child, you demonstrate…

UNICEF’s core values of Commitment, Diversity and Integrity and core competencies in Communication, Working with People and Drive for Results.

The competencies required for this post are….

View our competency framework at

http://www.unicef.org/about/employ/files/UNICEF_Competencies.pdf

UNICEF is committed to diversity and inclusion within its workforce, and encourages all candidates, irrespective of gender, nationality, religious and ethnic backgrounds, including persons living with disabilities, to apply to become a part of the organization.

UNICEF has a zero-tolerance policy on conduct that is incompatible with the aims and objectives of the United Nations and UNICEF, including sexual exploitation and abuse, sexual harassment, abuse of authority and discrimination. UNICEF also adheres to strict child safeguarding principles. All selected candidates will, therefore, undergo rigorous reference and background checks, and will be expected to adhere to these standards and principles.

Remarks:

Only shortlisted candidates will be contacted and advance to the next stage of the selection process.