Sierra Leone Health Facility Assessment March 2015 Mo

Sierra Leone Health Facility Assessment March 2015 Mo. HS Validation Workshop

OUTLINE 1. Overview of the Health Facility Assessment (HFA) – 2015 2. PHU facility characteristics • Functional Status of PHUs • EVD Effect on human resources • Status of supplies • Infection prevention and control status 3. Utilization of MCH services 4. Program Status 5. EVD Related challenges

Overview

OBJECTIVES 1. Evaluate the status of PHU infrastructure, personnel and supplies during EVD period 2. Evaluate trends in maternal and child health (MCH) service utilization during EVD period 3. Gather additional programme information to inform health system recovery plans 4. Estimate changes in MCH service coverage during the Ebola period and model mortality impact

METHODOLOGY • Site selection: All PHUs (1, 185) • Data collection: • Round 1: October 2014 • Round 2: March 2015 Northern 452 Western 93 Southern 352 Eastern 287 • 9 months of utilization data collected during the EVD epidemic (May 2014 – Jan 2015) • 4 -month (October-January) comparison periods Pre-Ebola (2013 -14) compared to same 4 months during Ebola (2014 -15)

METHODOLOGY • Interview Teams: Mo. H & Focus 1000 (3 -4 teams per district) CHC; 257; 22% MCHP; 558; 47% PHUs Surveyed by Type March 2015 CHP; 369; 31% • Interviewed PHU in-charge or other health facility staff • Reviewed facility records and PHU registers for MCH data • Direct verification of stocks and infrastructure • Hard copy + Tablets used in 2 nd survey • GPS coordinates collected for over 70% of facilities

PHU characteristics during EVD Most PHUs are open Most health workers in service despite heavy losses Improved IPC readiness though gaps remain Many PHUs lack basic amenities (water, functional latrines, electricity, and refrigeration facilities) • Drug stock out an issue • Most PHUs are severely under-staffed • •

Most PHUs are Open & Functioning (98% open) Number of PHUs closed due to Ebola in March 2015 9 • 63% (15) of these were MCHPs (typically staffed by 1 or 2 health workers) • 15 out of 24 were closed for less than 1 month • 70 (6%) of open facilities were closed for a period in the last 4 months • Only 5 found closed in Oct were still closed in March 1 Closed PHUs by facility type (March 2015) 2 MCHP 7 Only 24 out of 1, 184 (2%) facilities were closed in March 2015 (compared to 47 in October 2014) Pujehun 1 Kono 1 Kenema 2 Bo 2 Tonkolili 2 Port Lok. . . 2 Koinadu. . . Bonthe 4 Bombali 10 8 6 4 2 0 • CHP 15 CHC

Heavy Losses of PHU Personnel to EVD Greatest Losses in Bombali, Port Loko and Moyamba Number of Health Personnel Deaths from EVD by District (Oct’ 14 March’ 15) Health Personnel EVD deaths at PHUs by Facility Type National Oct'14 -March'15 [CATEGORY NAME], [VALUE], [PERCENTAG E] of deaths [CATEGO RY NAME], [VALUE], [PERCEN TAGE] of deaths Bombali; 35 [CATEGORY NAME], [VALUE], [PERCENTAGE ] of deaths 124 Total Deaths Port Loko; 26 Moyamba; 25 [CATEGORY NAME], [VALUE], [PERCENTAGE ] of deaths Bombali Port Loko Moyamba Koinadugu Kono WA Urban WA Rural Tonkolili Bo Kailahun Kenema Kambia Bonthe Pujehun

Improved IPC readiness at PHUs • No. of PHU health personnel trained in IPC increased 2. 6 -fold from October 2014 to March 2015 (4, 052 vs. 10, 596) • 98% of facilities report having a screening/triage station • 39% of PHUs have a functional incinerator & 88% have a burning pit • 99% have one or the other for safe medical waste disposal • Near universal availability of PPE items and chlorine/disinfectant Access to Water remains a Concern • Near universal availability of handwashing facilities: • 90% at triage/screening station (Biggest gap: 65% in Port Loko) • 75% overall in labour room (Biggest gap: 35% in Moyamba) • 71% of PHUs have water at all times • 14% of PHUs never have water • Biggest gaps in: Tonkolili (35%) Pujehun (27%) Kambia (26%)

PHUs are Severely Understaffed MCH aides Standard: 2 at MCHP, 3 at CHP, 6 at CHHs • 40% of MCHP have only one MCH aide • CHPs are even more understaffed, with only 6% with the required 3 MCH aides. • Less than 2% of CHC have the required 6 MCH aides Number of MCH aides by PHU 100% 15% 80% 60% 9% >=4 MCH aides 51% 34% 40% 26% 4% 4% 3% 3% 3 MCH aides 2 MCH aides 67% 42% 0% 0% CHC 1 MCH aides 40% 0% CHP 1% MCHP 0 MCH aides

PHUs are Severely Understaffed SECHN Standard: 2+ SECHN in CHP, CHC • Only 32% of CHP have 2 or more SECHN • Only 58% of CHC are staffed with 2 or more SECHN. Number of SECHN by PHU 100% 80% 60% 8% 7% 29% 17% >=4 SECHN 6% 3 SECHN 18% 71% 79% 40% 20% 3% 0 SECHN 2% 1% CHC 2 SECHN 1 SECHN 46% 0% 2% 2% CHP 8% MCHP

Most Health Workers are still in Service despite Heavy Losses 1. Using MCH Aides as a proxy, limited evidence of health staff attrition across regions 2. Nevertheless, total of 215 personnel “abandoned” posts • 156 (73%) notably among the ‘other personnel’ category • 32 (15%) among MCH aides • 22 (10%) nurses and 5 CHO/CHA (2%). Number of MCH Aides working Pre. Ebola and During Ebola National Summary (Little change over time) 2500 2000 1906 2038 1978 1500 1000 500 0 Number working - April working - Oct working 2014 March 2015

Distribution of CHWs at PHUs 97% of PHUs have CHWs • • • 97% of PHUs have CHWs compared to 85% in Oct 2014 Median number of CHW per PHU : 11 75% of total increase from Oct due to PL –roll out of CHWs programme since Oct 2014 Hard to reach population coverage of CHWs not known. Additional survey to be undertaken soon Below standard

Remaining Gaps in IPC Readiness Among PHU personnel • 15% Midwives not trained • 13% of ‘Other health personnel’ not trained • 27% of ‘Other nonhealth personnel not trained Percentage of PHU Personnel Trained in IPC by cadres of personnel National (March 2015) All PHU Personnel (%) 84% Other non health personnel Midwives 73% 85% Other health personnel 87% MCH aides 92% CHO 94% Lab techs/ assistants 94% CHA 95% SECHN 95% 0% 100%

EVD Related Challenges Reported by PHUs PPE & Training no longer major concerns But fear of Infection and Stigma High 90% 72% 87% Other major challenges reported by PHUs: • Low turn out of patients due to patient fear coming to PHUs 66% 37% 26% NA for 2014 23% Fear of being Inadequate infected by stigmatised by supply of patient community medicine 2014 16% Inadequate supply of PPE 2015 15%12% Inadequate Information 11% Inadequate training on Ebola

Majority of PHUs Lack Basic Amenities PHUs with Missing Basic Infrastructure National (March 2015) 66% No electricity No functional incinerator 61% At least 2 latrines not available 59% No refrigerator for vacccine 60% 29% Water not always available 26% No water (on-site or <50 meters) No burning pit No safe medical waste disposal (burning pit or incinerator) 12% 1% • 66% of PHUs don’t have electricity • 60% of PHUs don’t have a refrigerator to store vaccines • 59% don’t have 2 latrines • 29% don’t have water always available • Inadequate access to water and latrine for the majority of PHUs

Majority of Sites have Water but Availability is Variable Across Districts 100% 80% Percentage of PHUs where Water is Rarely or Never Available by District Water Availability at PHUs National 71% 60% 40% 20% 4% 12% 14% 0% Always Often Rarely Never available Tonkolili Kailahun Pujehun Kambia Port Loko Moyamba WA Urban Kenema Kono WA Rural Bombali Bo Koinadugu Bonthe 48% 40% 39% 35% 29% 28% 25% 23% 21% 17% 16% 11% 6% 4% • 75% of PHUs have water always or often available • 26% have water rarely or never available • Percentage of PHUs with water rarely or never available is highest (> 30%) in Tonkolili, Kailahun, Pujehun and Kambia

Availability of Water Availability of water and distance to water 100 Percentage of PHUs % 80 Total 75% 12 60 9 Water source > 50 m Water source < 50 m Water source on site 40 53 20 0 13 6 5 Always / often available Never / Rarely available 62% of PHUs have water available from a water source on the ground or within 50 meters of the facilities IMPORTANT NOTE: Water Supply may be present but Water is not necessarily available Possible Reasons: • Technical malfunction • Well is dry • If it is a piped system, the public water system is not distributing water continuously

41% of PHUs have Standard 2 Latrines Availability of Latrines at PHUs National (March 2015) 1200 100% 94% 1000 80% 800 60% 600 41% 36% 37% 400 20% 200 0 1094 480 Any latrines At least 2 latrines 418 430 Latrines for males-only females-only 0% • 41% of PHUs have at least 2 latrines (standard) • 37% have latrines separated for females

40% of PHUs have fully functional Refrigerators for Vaccines • Nearly all facilities (99%) offer child immunisation services • 38% don’t have refrigerators • Even where a refrigerator is available, 1/3 are not functional or partly so

Serious Stock Outs of Essential Medicines March 2015 Percentage of PHUs without Essential Medicines National (March 2015) Dexamethasone (Infant lung development if. . . Injectable gentamycin (Newborn sepsis) 48% 20% Amoxicilin tabs (pnemonia) Albendazole/ mebendazole (de-worming) Cotrimoxazole tabs (pnemonia) Either Amoxicillin or Cotrimoxazole (pneumonia) 34% 32% Folic acid/ multi-vitamin (Fetal neural tube. . . Diazepam (Eclampsia if Mg. SO 4 unavailable) Oxytocin (Post-partem hemorrhage) Magnesium Sulphate Mg. SO 4 (Eclampsia) Either Diazepam or Mg. SO 4 (Eclampsia) 14% 9% Ampiciline cloxacilin (Antibiotics) Injectable benzylpenicilin (Antibiotics Doxycyline/erythomycin (Antibiotics/Malaria) Metronidazole (Antibiotics) ACT Tablets (Malaria) 37% 35% 3% 0% 27% 20% 45% 40% Infant/newborn 84% Child 62% Maternal 57% 71% 84% Antibiotics & ACT 60% 80% 100%

Impact of EVD on Utilization of MCH Services • Service uptake at PHUs declined significantly from May to Sept 2014, started recovering thereafter in majority of districts • Trends coincide with both onset of rainy season and surge of Ebola and cannot be attributed to the EVD outbreak alone • Comparing levels of MCH service utilisation Oct – Jan 2014/15 (Ebola period) vs Oct – Jan 2013/14 (non-Ebola period) • Significant declines by 14% ANC, 17% Penta 3, deliveries 7% • Largest and statistically significant decline in 4 districts most affected by ebola: Port Loko, Bombali, Western Area

Two Analyses to Measure Impact of EVD on MCH Service Utilization Analysis 1: Mapped changes in Service Utilization with changes in EVD epidemiology • 4 Tracer Interventions were assessed: ANC 4, Health Facility Deliveries, Penta 3, U 5 Malaria Treatment • 9 month EVD period analysed (May 2014 – Jan 2015) Analysis 2: Health Service Utilisation Levels were compared between Pre-Ebola period and During Ebola period • Pre-Ebola Period: October 2013 –Jan 2014 • During Ebola Period: October 2014 –Jan 2015

MCH Services Utilisation Trends during Ebola ANC 4, Penta 3, and Institutional Deliveries (May 2014 -Jan 2015) Visits to PHUs for ANC, Penta 3, and deliveries: • Declined since May 2014 • Reached their lowest levels around September 2014 • Started increasing thereafter

17% Reduction in Penta 3 Service Utilization Pre-Ebola (Oct’ 13 -Jan’ 14) and During Ebola (Oct’ 14 -Jan’ 15) Comparison • 17% Decline in Penta 3 vaccination • Decline is large and statistically significant (-27%) in 3 districts most affected by Ebola: Port Loko, Bombali and Western Area • Small declines in Other Districts and not statistically significant -7%

Drop in Utilization Levels much more Significant for Highly Ebola-affected Districts ANC 4 • Declined by 14% on average • Largest and statistically significant decline by 25% in Port Loko, Bombali and WA Deliveries • Declined by 7% on average • Largest and statistically significant decline by 19% in PL, Bombali and WA

Different Trend & Significant Drop for U 5 Malaria Treatment • The number of children treated for malaria declined by 31% • Equivalent to about 27, 200 children not treated for malaria every month • Drop observed across all districts irrespective of the intensity and duration of the EVD outbreak. 120000 2500 -31% 100000 2000 80000 1500 60000 1000 40000 500 20000 0 0 May Jun Jul Aug Sep EVD cases monthly Oct Nov 2013 Dec 2014 Jan EVD cases U 5 children treated for malaria Figure 50. National: Number of U 5 treated for malaria Oct-Jan 2014/15 vs Oct – Jan 2013/14

Estimated Impact of Changes in Service Utilisation on Child and Maternal . s. . au Ot he rc ar ia al M al at Ne on ia on Pn eu m Di ar rh oe al . . . Deaths using Lives Saved Tool (Li. ST) Mathematical Model Additional (non-EVD) Child Deaths 1. Estimated Baseline Deaths with Estimated (12 month Period) no EVD Impact (2014) • 37, 284 U 5 Child deaths 7 536 +20% 60 000 6 537 +25% • 10, 851 Newborn deaths 40 000 780 +9% 2. Observed Reduction in MCH 20 000 37 284 26 433 10 851 Services Utilisation during Ebola: 0 Total U 5 <1 month 1 -59 months • ANC 4: -14% deaths • Penta 3: -17% Baseline U 5 deaths • HF Deliveries: -7% Estimated additional U 5 deaths • U 5 treated for malaria: -31% Causes of additional (non-EVD) child 3. If these trends continue for next deaths 12 months, then: • 7536 additional U 5 deaths 2628 estimated (20% increase) 1825 1483 • 780 additional newborn 998 601 deaths estimated (9% increase) • 2628 deaths due to diarrhea • 1825 due to pneumonia

Projected change in Sierra Leone’s 2014 under 5 mortality rate resulting from declines in MCH service utilisation during the EVD epidemic Sierra Leone’s U 5 Mortality Rate in 2013: 161 deaths per 1000 live births. 193 Estimated U 5 mortality Rate in 2014 based on Model: 193 deaths per 1000 live births

Maternal & Newborn Health Services • Significant declines in maternal & neonatal services in districts highly affected by EVD (PL, Bombali, Western) but not significant in other districts • Critical lack of basic amenities and supplies to support safe child birth • Large gaps also in BEm. ONC facilities

Impact of EVD on Maternal and Newborn Services at PHU level: ANC 4, HF Deliveries, Postnatal Visits, & Family Planning Highly Affected Districts by EVD: • Significant Reductions in Utilisation observed Maternal Mortality Ratio 1, 100/100, 000 • Mothers have a 1 in 21 lifetime risk of deaths when giving birth • Approximately 1, 800 Maternal Non-highly Affected Deaths in 2013 Districts: • Neonatal Deaths • Utilization levels contributes to 25% not significantly of Under-five affected Mortality

26% of PHUs had both Recommended Medicines for ANC Percentage of Facilities with ANC Essential Medicine PHUs by region (Package consists of Folic acid + Albendazole) National Only 26% of PHUs had both drugs present in Facility 26% Northern 14% Western 16% Eastern 27% 44% Southern 0% 20% 40% 60% 80% 100% Percentage of facilities with complete ANC package

44% of BEm. ONC Facilities had All 3 Essential Drugs at BEm. ONC facilities National March 2015 100% 94% 80% 48% 60% 44% 40% 20% s ug dr Al l 3 le ta b ec ici en ylp Be nz M ag ne llin siu m -i nj Su Ox lp yt ha oc te in 0% Complete BEm. ONC • Oxytocin • Mg. SO 4 • Benzylpenicillin • (Note: Calcium Gluconate is Missing from HFA Survey)

22% of PHUs had both Delivery Bed and Complete Delivery Kit Available Both Delivery Bed and complete Delivery Kit Available 100% Complete Delivery Kit 100% 80% 60% 40% 80% 54% 39% 54% 47% 42% 20% 0% 60% Northern. Eastern. Southern. Western 40% Percentage of PHUs with Standard Delivery Bed na l 36% Na tio rn W es te er n th rn 30% 29% So u st e l na Na tio rn W es te er n So u th rn st e Ea No rth er n 0% 48% 35% Ea 20% 100% 80% 60% 40% 20% 0% er n 20% 19% 18% 22% No rth 30% National

76% of PHUs can Ensure Referral within 3 hours 100% 94% 92% 80% 60% 86% 83% 81% 80% 76% 71% 68% 64% 62% 60% 76% 54% 48% 40% 20% na l io Na t M ma oy am Po ba rt Ko Lok in o ad ug Pu u je hu Bo n m b To ali nk ol Ka ili m bi a K W on o A Ur b Ka an ila h W un A Ru ra Bo l nt he Ke ne Bo 0%

Percentage of PHUs with Family Planning Commodities in Stock (March 2015) Majority (93%) Only 58% had 98% 100% 83% 87% 80% 60% 85% 66% 92% 96% 90% 91% of PHUs had male condoms 87% 65% 58% 54% 40% 93% 29% 20% 0% Northern Eastern Oral Contraception Southern Western Depoprovera contraception National Male Condom

Percentage of PHUs that Offer/Recommend Newborn Care Services 99% of PHUs recommend breastfeeding within 1 hr after birth Skin-to-skin care 99% Breastfeeding within 1 hour of birth 99% Cord care (chlorhexidine) Newborn eye care (tetracycline) Vitamin K 92% 69% 61% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%110%

Child Health Services • Critical lack of essential child health drugs • Distribution of medicines for i. CCM and Malaria treatment declined during ebola, suggesting fewer cases were treated at the community-level • Prevention of malnutrition significantly affected • 28% reduction in number of children who attended growth monitoring programmes (Oct – Jan 2014/15 vs Oct – Jan 2013/14) • Treatment of malnutrition affected by RUTF stockout despite RUTF distribution

Child health services offered by PHU Causes of Child Deaths in Sierra Leone (DHS 2013) Other 30% Pneumonia 17% diarrhoea 13% HIV/AIDS 1% Neonatal 25% Malaria 14% Child health services surveyed in Health Facility Assessment: • Treatment of childhood diseases • Routine vaccination • Prevention and treatment of malnutrition • Functionality of Integrated community case management (i. CCM)

67% of PHUs had the Child Essential Medicines Package Child Health Essential Medicine Package (Package consists of ACT + Either Amoxicillin or Cotrimoxazole for pneumonia) Facilities by region National 67% Southern 48% Northern 74% Western 77% Eastern 82% 0% 20% 40% 60% 80% Percentage of facilities with complete CH package 100%

i. CCM: CHWs received less supervision and less medicine distribution during Ebola PHUs with Supportive Supervision for CHWs Pre-Ebola and During Ebola 100% 89% 78% 96% 89% 95% 90% 88% Northern Eastern Southern Western 92% 84% 70% 50% 0% National With supportive supervision Pre Ebola (Oct'13 -Jan'14) With supportive supervision During Ebola (Oct'14 -Jan'15) i. CCM: percentage of PHUs providing medicine to CHWs 100 86 79 56 74 70 71 50 0 Northern Eastern Southern 81 78 54 Western 65 National Percentage of PHU which provided any medicine to CHWs, May '14 to Sep '14 Percentage of PHU which provided any medicine to CHWs, Oct '14 - Jan '15

Prevention of malnutrition declined during the EVD outbreak 4000 -28% 200000 3500 3000 2500 150000 2000 100000 1500 1000 500 National EVD Cases During Ebola May'14 -Jan'15 nu ar y Ja m De ce m ve be r r be No Oc to be r m pt e gu st Se Au Ju ly Ju ne 0 ay 0 M No. of Children who attended growth monitoring programme • 28% decline in the number of children attending growth monitoring programme (Oct – Jan 2014/15 vs 2013/14) 250000 Pre-Ebola Oct'13 -Jan'14 National EVD Cases • 38% of children under 5 are stunted, including • 49% among children 18 -23 months Children Attending Growth Monitoring Programme Pre-Ebola and During Ebola

Treatment of severe acute malnutrition OTP admissions Pre-Ebola and during Ebola OTP services 3500 • 36% PHUs provide OTP services • OTP admissions declined by 3% Oct- Jan 2014/15 (during Ebola) vs 2013/14 (pre. Ebola) -3% 3000 2500 2000 1500 1000 500 0 May June July Aug Sept Oct Nov Dec Jan EVD cases 2014/15 2013/14

Treatment of SAM: RUTF stock balance decline despite distribution RUTF Stock Balance, Oct 2014 - Jan 2015 October November December January 350 000 RUTF distribution in October and December 2014 300 000 250 000 200 000 150 000 100 000 50 000 October November December January Northern 309 751 180 359 252 799 176 965 Eastern 134 901 93 148 52 894 77 639 Southern 267 896 164 322 210 810 144 159 Western Area 60 309 40 599 28 725 30 972

Trends in OTP admission & RUTF stock balance (Oct ‘ 14 – Jan ‘ 15) RUTF distribution in October and December 2014 SOUTHERN PROVINCE RUTF Stock Balance 15 в- ян 14 к- де но я т-1 ок -1 4 4 0 100 000 200 50 000 0 15 100 400 в- 50 000 150 000 ян 200 600 4 100 000 300 200 000 -1 400 800 де к 150 000 250 000 14 500 1000 я- 600 300 000 но 200 000 1200 4 700 RUTF Stock (sachets) 250 000 800 350 000 т-1 900 1400 ок 300 000 RUTF stock (sachets) Number of children admitted in OTP Number of children admitted to OTP Number of children admitted in OTP 1000 No. of children admitted to OTP NORTHERN PROVINCE

Trends in OTP admission & RUTF stock balance (Oct ‘ 14 – Jan ‘ 15) RUTF distribution in October and December 2014 Urgent need to conduct supply chain mapping and analysis to identify bottlenecks and reduce stock out of RUTF at facility level WESTERN PROVINCE RUTF Stock Balance 40 000 100 20 000 15 ян в- 14 кде но я- 14 т-1 4 0 100 20 000 50 10 000 0 15 200 30 000 ян в- 60 000 4 300 40 000 150 -1 80 000 де к 100 000 400 50 000 200 14 120 000 60 000 я- 500 250 но 140 000 70 000 т-1 4 600 300 ок 160 000 RUTF stock (sachets) RUTF Stock Balance No. children admitted to OTP Number of children admitted in OTP RUTF stock (sachets) Number of children admitted in OTP 700 ок No. of children admitted in OTP EASTERN PROVINCE

HIV Services: PMTCT & Pediatric Treatment • While most PMTCT sites offer HIV testing, only 80% nationally had test kits in stock in March, only 54% offer ARVs and 42% had the recommended regimen for PMTCT in stock in January 2015 • Comparing pre-Ebola period October 2013 – January 2014 and the same four months during the Ebola epidemic: 1. No. of pregnant women tested fell by 12% 2. No. of pregnant women initiating ARVs increased by 43%. 3. No. of children who initiated paediatric ART increased by 45%

PMTCT and Child HIV Treatment in Sierra Leone • Sierra Leone has 1. 5% HIV prevalence in the adult population (15 -49) in 2013. • HIV prevalence slightly higher among women at 1. 7% and likely higher among sexually active pregnant women. • Among the PHUs surveyed in March, 633 (91%) were identified as PMTCT sites and 625 were found open at the time of the survey.

Pregnant Women Tested for HIV and Initiated on ARVs 15 000 Number of pregnant women tested for HIV in ANC during a 4 -month period before and during Ebola 11 884 13 557 10 000 4 854 Comparing Pre-Ebola and During Ebola Periods: • 12% REDUCTION in Number of Pregnant Women Tested 5 000 3 797 3 545 2 954 3 125 3 381 Eastern Southern 2 034 1 752 Northern Western Pre-Ebola Average Oct'13 - Jan'14 During Ebola Average Oct'14 - Jan'15 Number of pregnant women initiated on ARVs for PMTCT during a 4 -month period before and during Ebola 800 663 600 • 43% INCREASE in Number of Pregnant Women Initiating ARVs National 463 400 200 93 108 187 112 231 147 111137 Northern Eastern Southern Western - Pre-Ebola (Oct 2013 - Jan 2014) During Ebola (Oct 2014 - Jan 2015) National

Children Initiated on HIV Treatment (Ages 0 -14) Number of children 0 -14 years of age initiated on HIV treatment during a four-month period before and during Ebola 45% INCREASE in Children Initiated on HIV Treatment 160 140 120 100 80 60 31 40 20 - 3 3 Western 46 50 139 96 56 37 10 Southern Northern Eastern Pre-Ebola Average Oct-Jan 2013/14 During Ebola Average Oct-Jan 2014/15 National

Low Availability of HIV Testing and Test Kits at PHUs 45% of PHUs do NOT provide HIV Testing in ANC 100% 3, 6 80% 60% 4 55% 48% 52% of PHUs have 40% Stockout in HIV Test 20% Kits 0 K W on A o W Rur A al Ur ba n Po B rt o L Bo oko m Pu bali je h Bo un M nth oy e Ko am in ba ad Ke ugu ne To ma nk o Ka lili m Ka bia ila hu n Na tio na l • Highest HIV prevalence (amongst women 15 -49): 3. 6% • Low Testing Availability: 48% • Kit Stock Out: 61% 2 1 0% KONO 3 Percentage of all facilities providing HIV testing in ANC Percentage of PHUs that had HIV test kits in stock in March 2015 HIV prevlance in women 15 -49 (2013)

Not all PMTCT sites are providing ARVs for PMTCT and Option B+ regimen is not available at all PMTCT sites 100% 80% 76% 73% 64% 63% 60% 54% 53% 51% 49% 42% 41% 40% 28% 24% 20% % offering ARVs for PMTCT na l tio Na Ka m Po bia rt L M oko oy am ba Ko n Ka o ila hu n Bo n Ko the in ad ug Bo u m ba To li nk ol ili Bo ba Ke n ne m a Ur A W Pu je hu n 0% % with TDF/3 TC/NVP in stock in Jan 2015 Option B+ Regimen

Northern Eastern Southern Western % offering HTC in ANC % with HIV test kit stock in March 2015 % of PMTCT sites offering ARVs for PMTCT % with TDF/3 TC/NVP in stock in Jan 2015 54% 42% 92% 81% 89% 82% 74% 47% 60% 47% 95% 86% 91% 85% 61% 49% 38% 32% 73% 90% Functional Availability of HIV Testing and ARVs for PMTCT in PMTCT Sites by Region National

Thank you