When Opportunity Comes a Knockin CBD of Depo Provera in Africa

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When Opportunity Comes a Knockin CBD of Depo
Provera in Africa
September 12, 2008
Mini University Washington, DC
Victoria Graham (USAID/GH) and
John Stanback (PROGRESS Project, FHI/North
Carolina)
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SESSION OUTLINE

• What about Depo Provera?
• Victoria Graham, USAID/GH
• A brief history of the global expansion of CBD of
  Depo?
  
• John Stanback
• The situation in Malawi - the latest success
• Victoria Graham
• Where are we headed? (Scale-up Sub-Q/Uniject
  Self Injection and, social marketing, drug
  shops, and OTC
  
• John Stanback
• Discussion
• John and Victoria

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What about Depo Provera?

• Victoria Graham

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What is Depo Provera?

• Progestin-only injectable contraceptive
• Highly effective-when timely injections given 99
  effective over the first year.
  
• Administered as
• an intramuscular
• Injection (IM)
• Fertility resumes
• after 4 months
• on average

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Rising Proportion of Injectables in the
Composition of CPR
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Why do women prefer Depo Provera?

• ? Safe
• ? Private
• ? Effective
• ? Convenient
• ? Easy to use

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Challenge Expand Service Delivery of Depo Provera

• Take services to population without access to
  facility services.
  
• Take service provision of Depo Provera to a lower
  level cadre of provider
  

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A Brief History of the Global Experience

• John Stanback

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Ancient History

• 1970s - Bangladesh
• 1990s - Latin America
• Guatemala
• Bolivia
• Mexico
• Peru
• 2000s - Nepal

Modern History

• Ex Africa semper aliquid novi

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Paraprofessional Provision of DMPA Status in
Africa
2005
TUNISIA
Implementing (MOH approved)
Policies changed Interested

MOROCCO
ALGERIA
WESTERN
LIBYA
EGYPT
SAHARA
MAURITANIA
MALI
NIGER
ERITREA
SENEGAL
CHAD
SUDAN
THE
DJIBOUTI
GAMBIA
BURKINA FASO
GUINEA
GUINEA
BENIN
BISSAU
NIGERIA
ETHIOPIA
TOGO
COTE
CENTRAL
SIERRA
DTVOIRE
GHANA
AFRICAN
LEONE
REPUBLIC
LIBERIA
CAMEROON
UGANDA
SOMALIA
DEMOCRATIC
KENYA
EQUATORIAL
REP. OF
REPUBLIC
GUINEA
THE
OF THE CONGO
GABON
CONGO
RWANDA
BURUNDI
TANZANIA
ANGOLA
MALAWI
ANGOLA
ZAMBIA
MOZAMBIQUE
MADAGASCAR
ZIMBABWE
NAMIBIA
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
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Paraprofessional Provision of DMPA Status in
Africa
2008
TUNISIA
MOROCCO
Implementing (MOH approved)
Policies changed Interested

ALGERIA
WESTERN
LIBYA
EGYPT
SAHARA
MAURITANIA
MALI
NIGER
ERITREA
SENEGAL
CHAD
SUDAN
THE
DJIBOUTI
GAMBIA
BURKINA FASO
GUINEA
GUINEA
BENIN
BISSAU
NIGERIA
ETHIOPIA
TOGO
COTE
CENTRAL
SIERRA
DTVOIRE
GHANA
AFRICAN
LEONE
REPUBLIC
LIBERIA
CAMEROON
UGANDA
SOMALIA
DEMOCRATIC
KENYA
EQUATORIAL
REP. OF
REPUBLIC
GUINEA
THE
OF THE CONGO
GABON
CONGO
RWANDA
BURUNDI
TANZANIA
ANGOLA
MALAWI
ANGOLA
ZAMBIA
MOZAMBIQUE
MADAGASCAR
ZIMBABWE
NAMIBIA
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
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The USAID/Malawi Experience
Victoria Graham
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Profile of Malawi

• Population 13.9 million
• CPT 28
• TFR 6.0
• Residence 80 rural
• 20 urban
• Adult HIV 12
• MMR 984 per 100,000
• Data obtained from 2004 Demographic Health Survey
  (DHS)
  

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What is the status of CBD in Malawi?

• July 2008 MOH announced the revision of national
  policy to allow CBD of Depo Provera through HSAs
  the public sector paramedical health
  professionals
• MOH obtained consensus a challenging process
• Key to the success Madagascar Study Tour
• Lesson Learned Many pathways to policy change

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Where is CBD of Depo going?

• Scale-up of CBD of Depo
• Subcutaneous Depo and Uniject
• Self-injection of Depo
• Social Marketing of Depo

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Scale-up
SubQ
Social-Marketing
Self-Injection
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Scaling Up CBD of Depo

• 1. District/Community Level a. Demand
  creation activities b. Orientation of
  clinics/supervisors and trainers c. Adaptation
  of ME tools and supervision systems d.
  Training of CBD agents e. Ongoing ME during
  service provision2. National level a.
  Facilitation of national level leadership and
  support b. Stakeholder sensitization and
  engagement of professional associations
  and other groups c. Policy and guidelines
  review and adaptation d. Local adaptation and
  dissemination of tools/advocacy materials

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Challenges to Scaling Up CBD of Depo

• Sustainability of supplies
• Ongoing monitoring and evaluation
• Supportive supervision
• Health establishment
• National regulations
• Improving counseling

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Sustainability - depends on

• Achieving policy change enabling trained and
  supervised CHWs to provide DMPA
  
• Creating partnerships that facilitate scale up of
  CBD of DMPA to other districts
  
• Addressing challenges related to CBD programming
  
  
• Motivations for CBD agents
• Training / supervision of CBD agents
• Effective LMIS and HMIS that incorporate CBD
  needs and data

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Depo SubQ and Uniject
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Technologies

• Autodisable syringes
• Intramuscular
• Increases safety and disposal
• Prevents reuse
• US.06 each
• Uniject
• All-in one prefillable
• Prevents reuse
• Ensures dose accuracy
• Simple to use
• Cost savings with wastage rate
• Minimizes transmission of pathogens
• Opens up the possibility for self-administration

• Depo-subQ provera 104
• Subcutaneous
• Revised formulation
• Lower dose than DMPA
• Easier for health providers to administer
• Will be available in pre-filled Uniject syringe
• Cost?

Comparable Commodity Cost DMPA - 3.88 per CYP
NET-EN - 6.30 per CYP OCs - 3.00 per CY
P http//www.infoforhealth.org/injectables/progra
m_mgrs/index.shtmlEstimatingCost
http//www.infoforhealth.org/pr/k6/index.shtml
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Home Injection of Depo
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Would you prefer getting Depo

• From a clinic 34
• From a CBD agent 22
• Not sure 19
• By self-injecting at home 24

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Social Marketing of Depo

• How Social Marketing works
• Social marketing of Depo
• Drug shops

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Survey of Rural Drug Shops in Uganda 8/2007
Do you sell and inject Depo-Provera?
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Selected Results

• Keep a register 33
• Take medical history 91
• Use sharps container 45
• Ever re-use syringes 10
• Needle-stick (12 mo.) 24
• Abscess this year 16
• Know risks of unsafe injection 76
• Know irregular bleeding 60
• is side effect

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Resources and Tools

• Advocacy strategy and briefs
• The Implementation Handbook
• DMPA Screening Checklists
• Key Factors for Replication Checklist
• Rapid assessment of CBD program
• Counseling and training tools
• Available at http//www.fhi.org/en/Topics/CBDof
  DMPA.htm

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Thank You