STATUS OF TAP IN GHANA FAMILY HEALTH INTERNATIONAL AS AN IP

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STATUS OF TAP IN GHANA-FAMILY HEALTH
INTERNATIONAL AS AN IP
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OUTLINE

• Current status of implementation
• Challenges
• Perspectives for the near future
• The role of operational research within TAP
• Clinical perspectives and challenges of PMTCT in
  Ghana

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Current status of implementation

• The Ghana TAP is being implemented by three
  partners
• Family Health International (FHI)
• National Catholic Health Services (NCHS)
• Private Enterprise Foundation (PEF)
• FHI and NCS are the main clinical implementers
  whereas PEF looks at the community arm of TAP and
  playing advocacy role

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FHIs Involvement in TAP

• June 2005, first trench of monies were deposited
  into FHIs accounts
• July 2005, Sites assessment and accreditation
  were done
• June-July 2005, doctors, nurses, pharmacist and
  adherence counsellors were trained in VCT, PMTCT,
  OIs and ART for all the four sites

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FHI Workplan

• July 2005, FHI presented a programme
  implementation plan up to December 2005 to the
  NACP. Excepts include
• Sub agreements to be ready by August 2005,
• Training of Data Entry Clerks and laboratory
  personnel to be done in September 2005
• ART to be started by September-October 2005
• Monthly meetings by sites
• Quarterly reports by FHI
• QA/QC by Noguchi Memorial Institute for Medical
  Research

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Stakeholder meetings

• Series of meetings were held between key actors
  in TAP including the NACP between September and
  October 2005
• Discussed the role of PEF, FHI, NCS
• Discussed issues of cost (30/month by employees
  and 5-6 by community people)
• FHI to support NCS with its HMIS software to make
  reporting easier and uniform
• Agreeing on regularity of meetings between IPs
  (quarterly)
• PEF and NCHS to finalize their proposals
• IPs to make request of ARVs on behalf of their
  sites from NACP
• Fixing a date for officially launching TAP in
  Ghana

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Links with sites

• FHI TAP coordinator in constant touch with sites
• addressing issues of slow pace of TAP initiation
• Agreeing on how start operationalization of TAP
  in terms of patient flow and service delivery
  points and other requirements
• Making arrangements on where specialized services
  like CD4 cell counts would be done off site

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Challenges

• Releasing of key staff to attend capacity
  building programmes for more than one week was
  very challenging for private institutions. There
  is need to always negotiate for dates
  appropriates for all sites
• Developing the sub agreements requires intensive
  imputes from the sites and this takes time as the
  document will have to travel to and fro before it
  is finalized
• Finalizing Sub agreements at FHI Head Quarters to
  meet all the technical and programme requirements
  delayed for about 3 months (August- October 2005)

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Challenges

• The final document again has to be securitized by
  site managers before they finally sign and this
  also takes some time
• The type of bank account required for the TAP was
  not what some site presented and they have to
  open separate accounts for TAP. This also took
  some time
• Procurement a per World Bank rules requires about
  three quotes from sites and some sites are slow
  on this process

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Progress so far

• Monies have been transferred into the accounts of
  sites
• Some laboratory equipments have been procured and
  installed by FHI awaiting other equipments from
  NACP
• Computers and accessories have been procured and
  HMIS has been installed
• Clinical folders to capture data have been
  adapted from other FHI sites and modified
  slightly, printed and supplied to all TAP sites

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Progress so far

• In November 2005, All the four sites in the
  Greater Accra Region and Ashanti Region, have
  been mentored at the FHI district and Teaching
  Hospital Sites involving all critical elements of
  a multidisciplinary team Doctors, Nurses,
  Pharmacist, Laboratory Technologist, Adherence
  counsellors, Data entry clerks, HIV counsellors
  etc
• The mentoring as a process will continue through
  implementation at their sites until sites are
  confident to managed their own programmes with
  FHI only playing monitoring and supervisory roles
  making sure National standards are met

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Perspectives for the near future

• Sites to successfully become fully operational
  before January ending after building a solid
  system
• TAP duly launched in Ghana in early January 2005
• FHI to use its vast experience in community
  HIV/AIDS programming to mobilize local
  communities to increase demand and patronize TAP
  services by implementing a Strategic Behaviour
  Communication to complement PEF which deals with
  advocacy for employers/companies
• Experience sharing fora by sites and IPs

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The role of operational research within TAP

• Looking private-public partnerships in the
  context of ART
• Effect of differential pricing in ART services at
  TAP sites
• Exit interviews/ surveys to measure service
  quality and also access adherence of those on ART
• Review clinical data collected to know the
  dynamics of the clients we seeing and also have
  information on how clients are responding to
  treatment in both adults and children
• VCT/PMTCT services in the private sector
• Resistance monitoring of treatment naïve and
  treatment experienced patients
• Other clinical trials of national and global
  interest

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Clinical perspectives and challenges of PMTCT in
Ghana
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AIDS in Ghana

• The first AIDS cases were reported in Ghana in
  1986.
• New cases 2004 - 14,312 (IDSR)
• Current estimates put the number of AIDS cases in
  Ghana to about 200,000.
• The median HIV prevalence was observed to be 2.4
  in 1994 and has increased through 3.6 in 2003 to
  3.1in 2004.

• Ghanas HIV prevalence depicts a generalised
  epidemic.

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Sites offering Antiretroviral therapy, Public
Health sector

• Manya Krobo -June 2003
• St Martin des Porres Hospital, Agomanya
• Atua Government Hospital
• Korle Bu Dec 2003
• Komfo Anokye Feb 2004
• Koforidua- August 2005
• TAP sites to join very soon as private sector
  contribution to ART role out

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VCT services

• 110 accredited sites in 73 districts
• GFATM, DFID,,
• Special support from Dutch Government
• All 34 sites in Ashanti region
• 17 in Eastern region

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PMTCT

• 103 sites 73 districts
• Special support from Dutch Government
• All 34 sites in Ashanti region
• 17 in Eastern region

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Voluntary Counselling and Testing
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VCT services June 2003 to June 2005
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Prevention of Mother To Child Transmission
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Key Accomplishments by the START program at Manya
and KBTH SITES

• 5,346 women have received VCT through PMTCT
  services since 2002
• 528 nurses and 46 lay people have received
  PMTCT/VCT counselor training
• 207 HIV positive women have received NVP during
  delivery at the PMTCT hospitals
• 219 babies have received NVP syrup at the
  hospitals
• These sites have become sites of excellence and
  used as learning sites for National Training
  Programmes

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Challenges

• A diminishing number of women seen at each stage
  (so few of the HIV women receiving NVP at
  delivery and one is uncertain whether or not
  their babies are not receiving NVP syrup
• Supervisory and monitoring procedures at clinic
• Service quality
• There are no full time counselors in the
  hospitals except one in Atua. Counselors share
  their time between their normal duties and VCT
  service provision.

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Challenges

• VCT services are not yet strongly linked to other
  social services e.g. social welfare and support,
  legal services, peer group support, PLHA support
  groups
• Disclosure and Partner Notification
• Payment of delivery services by HIV positive
  mothers at health institutions
• Infant feeding difficulties leading to babies
  becoming infected
• Early diagnosis of HIV infection in children
  problematic

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Influential family members input
Male partners attitudes, likely reaction
Belief about the treatment
stigma
resources
Concerns about infants future
Health beliefs, concerns
Womans Decision
stigma
stigma
Cultural norms
Trust in health services, clinic staff
Womans emotional state/makeup
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Lessons Learnedso far with pmtct

• Involvement of key stakeholders both at the
  national, regional and district levels ensure
  smooth running of the program as well as help
  promote the use of services.
• Due to shortage of staff, all cadres of health
  care workers need multi-skills to provide range
  of services.
• Training all midwives within the facility setting
  in PMTCT helps minimize disruption of program
  when staff are transferred out of the district or
  when they leave the service. This strategy is
  particularly helpful in settings where shortage
  of health personnel is a major problem.
• Frequent updates of knowledge and skills of
  health workers are necessary to ensure quality of
  care
• Health management information system has to be
  developed at the very onset of the program and
  staff trained in its use to ensure proper capture
  of data and timely reports

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Policy change in the pipeline for PMTCT in
Ghana---FHI Senior Clinical Officer Charged with
providing evidence (literature review)

• Sd Nevirapine is still the best option for
  up-scaling PMTCT services
• However, we know combination therapy is better
  than monotherapy
• ART is being up-scaled and it will be CRIMINAL
  to continue to give monotherapy in centers where
  full range ART can be or are being delivered

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THANK YOU