Universal ART Scale up: Delivering the second Wave

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Universal ART Scale up Delivering the second
Wave

• The Situation in Uganda

Peter Mugyenyi FRCPI, FRCP Edin, ScD Joint
Clinical Research Centre, Kampala, Uganda XVII
international AIDS Conference, Mexico, Wednesday
6, August 2008
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Greetings from Uganda in the heart of Africa
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Uganda ART programme of Partnerships and
collaborations

• Ministry of Health
• JCRC
• TASO
• Elizabeth Glaser Pediatric AIDS Foundation
• UWESO
• Health Alert Gulu
• World Vision
• GTZ Fort Portal
• AVSI Hoima
• AFXB
• Pentecostal, Anglican, and Catholic churches
• Mildmay
• Academic Alliance
• MU-JHU
• Walter Reed
• Mbarara University of Science and Technology
• etc

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Joint Clinical Research Centre (JCRC)Founded 1991

• Strategic Joint venture
• Ministry of Health
• Makerere University
• Health Dept Ministry of Defense
• Planned to maximize scanty resources

Goal To address the national AIDS crisis in
partnerships especially with MOH
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JCRC successful PEPFAR funded ART roll out TREAT
programme
JCRC
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JCRCs approach to ART scale up.

• Initial emergency response
• Maximize available infrastructure
• Low cost Renovations
• Improvisation where necessary
• Addressing Sustainability
• Infrastructure stepwise approach
• human resource development to go side with
  expansion of services
• Integrating ART services into improved continuum
  of care services
• Need for longer term commitment of donors as AIDS
  treatment transforms from emergency to Chronic
  illness management.

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• Community mobilization information and
  communication

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Best practices for introducing ART to the
community, aimed at breaking stigma, promoting
community ownership and IEC
Drama Children act AIDS death
Community participation
Parade by students
Spectacular community Concerts
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• JCRC -TREAT provides ART in over 75 places
  (Public and private) in diverse parts of Uganda
  regardless of the infrastructure state.

• Addressing Infrastructure

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Taking ART to Mubende where there we found no
infrastructure for a clinic..
JCRC

• Mubende

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Tent in Mubende before use
Space was cleared and a tent was put up
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Tent in use at Mubende
Functional Mubende clinic the following week .
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Mubende ART clinic Now
Modern laboratory
Lab equipment
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• Addressing human resource deficiency

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The Challenge of Human Resource

• Critical nationwide shortage of skilled manpower
  in clinical, laboratory, and counseling/adherence
• Recruitment and retention of staff
• Placing critical personnel in RCEs and high
  volume areas
• Improving working conditions and adequate
  compensation of staff

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Training

• The training offered in form of training
  workshops, placements in clinics and labs, hands
  on training, e-education and formal courses
• Training in ART provision, HIV related palliative
  care, TB treatment/ prophylaxis, strategic
  information and laboratory management.
• Training of support lay, staff and community
  volunteers and development of training syllabuses
  and manuals
• Expertise from within and outside the country
  have been utilized.

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• The
• achievements
• of the
• JCRC TREAT programme
• to-date.

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Cumulative patients on ART from JCRC supported
centers, 2004-2007
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Over 50 satellites and 25 outreaches established
by TREAT
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Geographical location of JCRC Regional Centre of
Excellence (RCE)

SUDAN
Moyo
Yumbe
Kitgum
Adjumani
Arua
Kotido
Pader
Gulu
DEMOCRATIC REPUBLIC CONGO
Moroto
Nebbi
Lira
Apac
Katakwi
Nakapiripirit
Masindi
Kaberamaido
Soroti
Kumi
Kapchorwa
Hoima
Nakasongola
Sironko
Pallisa
Kamuli
Kiboga
Kibaale
Fort Portal
Kayunga
Luwero
Iganga
Mbale
Tororo
Kabarole
Bugiri
Mubende
Jinja
Kyenjojo
Busia
Mayuge
Mukono
Waikiso
Kampala
KENYA
Kasese
Kamwenge
Mpigi
Sembabule
Masaka
Mbarara
Bushenyi
Kalangala
Rukungiri
Rakai
Kanungu
Ntungamo
Kabale
Kisoro
TANZANIA
KEY
RWANDA
Mbarara region
JCRC Site
Centre of excellence
Kabale region
Kampala region
Fort Portal region
Mbale region
Gulu region
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JCRC infrastructure - centers of excellence in
Uganda
Joint Clinical Research Centre Research ART scale
up Drug, and lab logistic management OVERALL
COORDINATION
Mbarara serving the south west
Fort Portal serving the West
MbaleEastern Uganda
Inside Fort Portal lab
Kabale Southern Uganda
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A network of JCRC RCE provide nation wide
referral laboratory services

• CD4 and Viral load available locally in at least
  one centre in each region
• DNA PCR infant diagnosis done in all RCEs
• HIV and TB Resistance testing done in main JCRC
  lab in Kampala

Photo from Botswana programme
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Other TREAT establishments

• Adherence programme
• Communications strategy
• A treatment campaign TREAT FOR LIFE has been
  rolled out countrywide
• IEC materials have been produced
• Logistics for drugs, laboratory supplies and
  equipment maintenance
• Support supervision, Monitoring and Evaluation in
  place

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Current state of epidemic in Uganda

• Prevalence rate 6.4 (Adult population 15 49
  years)
• About 1,100,000 living with HIV Adults 950,000,
  Children 150,000.
• 1,000,000 Children orphaned by AIDS
• 2007 132,500 new infections, 25,000 due to MTC,
  78,000 pregnant women with HIV
• 2008 130,000 adults on ART out of estimated
  280,000, and 10,000 Children out of estimated
  52,000.

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Challenges to address in second wave

• Theme
• From crisis management to quality,
  sustainability, and integration into an improved
  continuum of health delivery
• Without improvement in general /public
  health care services HIV/AIDS specific programme
  are ultimately futile and unsustainable.

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Challenges to address in second wave-1

• Rehabilitation of public sector infrastructure,
  sharing of facilities and establishing new
  appropriate infrastructure at all levels of
  health care delivery.
• Laboratory services providing CD4 and VL at all
  regional and high volume district hospitals
• Establishing basic laboratory services at health
  centers To include HIV Testing, TB and Malaria
  diagnosis.

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Challenges to address in second wave-2

• Programme to support and develop critical mass of
  human resource
• Improve working conditions of public sector
  workers to minimize both internal and external
  brain drain
• Strengthen training and include community
  volunteers and lay providers to support adherence
  and to undertake other low tech but high demand
  services

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Challenges to address in second wave-3

• Scale up to include hard to reach and other
  underserved areas
• Special incentives for staff to work and stay in
  rural areas
• Establish national robust logistics for drugs and
  laboratory services access to all levels
• Quality and sustainable services
• Adherence and counseling to be strengthened and
  integrated for best treatment outcome
• TB and HIV services to be at least linked for
  better management of HIV

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Conclusion

• Uganda must harness the available HIV/AIDS
  expertise, logistics and facilities for
  strengthening and eventual integration into an
  improved national general delivery of health care
  services.

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With sufficient support Uganda is ready for
Quality Universal ART access
Thank you