South Africa Program Update

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South Africa Program Update
International Center for AIDS Care and Treatment
Programs Annual Meeting, March 2006 Dar Es
Salaam, Tanzania

• Doris Macharia
• Monday March 6

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Outline

• Background
• DOH provided services
• Supported Activities
• Achievements
• Challenges Strategies
• New Program Initiatives

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National Eastern Cape Provincial Data

• National
• Increase in National ANC HIV prevalence 27.9 in
  2003 to 29.5 in 2004
• PLWHAs by 2004 est. 5.7 6.2 million
• HIV infected babies est. 104,963
• Eastern Cape
• Population 6.5 Million
• Antenatal HIV prevalence of 28.03 in 2004
• Infant Mortality 61/1000
• In need of ART 50,000

National HIV and Syphilis antenatal
sero-prevalence survey in South Africa 2004
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HIV prevalence trends among Antenatal Care
Clients in Eastern Cape and South Africa
1990-2004
Eastern Cape HIV and Syphilis Antenatal
Sero-surveillance Survey in Eastern Cape, 2004
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Background

• In 2004 Columbia University begun Supporting the
  EC Comprehensive HIV AIDS Treatment and
  Management Program.
• Health Facilities Identified Holy Cross Hospital
  and St. Patricks (later Rietvlei Hospital)
• 19 Primary Health clinics identified as down
  referral sites for the 3 hospitals
• Total 21 health facilities
• 2005 more health facilities identified in East
  London
• Frere and Cecilia Makiwane Hospital and Ikhwezi
  Lokusa Wellness Center
• 5 Primary Health clinics also identified
• Total 8 health facilities

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Background

• 2005/6 Sites identified in Port Elizabeth
• Dora Nginza and Livingstone hospitals
• 7 Primary health clinics identified
• Total 9 health facilities
• To date ICAP-SA is supporting 7 public health
  hospitals, 1 NGO managed facility and 31 primary
  health clinics

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DOH provided services

• Pharmaceutical services incl. procurement and
  distribution of ARV drugs
• All HIV related laboratory monitoring (CD4, VL)
• Conditional grant availed to each accredited
  heath facility for ART services Up to R1 million
  (US170,000) per health facility
• Training
• HR
• Equipment
• Supplies

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ICAP Supported activities

• Clinical Care mentoring
• Information system management
• Adherence and social support
• Laboratory support
• Infrastructure development

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Clinical Care Mentoring

• Didactic training and on site Clinical mentoring
• 2 clinical advisors working with health staff on
  site
• Foundation for Professional Development
• Local organization part of the SA HIV clinicians
  Society subcontracted to provide didactic HIV
  training
• 3-day HIV course for nurses doctors 5 training
  courses conducted for a total of 220 providers
• 2-day Adherence course 2 for 80 providers
• Partnerships to support the recruitment of health
  care providers
• Regional Training center (Northern EC)
• University of Fort Hare (East London)
• Nelson Mandela Metropolitan Municipality (Port
  Elizabeth)
• Health staff recruited and placed
• Doctors -6(8), Professional nurses -12(19),
  pharmacist -2(3), pharmacist assistants -1(4)

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Clinical Care Mentoring (2)

• Supporting a provincial development and
  implementation of a HIV Clinical mentoring
  program
• Begun work with University of Fort Hare and
  Nursing colleges in the EC to enhance pre-service
  HIV training of Nurses
• Thru University of Fort Hare, supporting the
  implementation of an elective program (2 weeks)
  for final year nursing undergraduate students at
  the ART clinics
• Pharmaceutical issues remain a challenge
• Poor quantification of ARV medication (stock
  outs)
• General lack of pharmacists who are willing to
  work in rural areas
• Community service pharmacists available for 1 yr
• Working with pharmacists on site in proper ARV
  drug quantification and ordering

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HIV Information System Management (1)

• Monitoring the HIV treatment program has been
  challenging
• Lack of dedicated personnel to capture data
• Changing national/provincial HIV/AIDS indicators
• Existing data collection tools were not
  standardized
• Urgent need to monitor program activities -
  PEPFAR and provincial
• To ensure adherence by minimizing losses to
  follow-up
• Identify areas that need attention and/or further
  investigation
• Information officers hired to support data
  collection and reporting
• 6 data capturers thru existing partnerships
• ICAP-SA staff 6 data clerks, 2 data supervisors,
  nurse advisor, ME officer, Program manager

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HIV Care and Treatment Programs Patient Flow
Prior to ART initiation
Eligible for ARV
Drop out/Die or otherwise Lost
Selection Committee
Treatment Deferred
Clinic Baseline (Patient Demographics Start CXT
CD4 WHO Staging, Exam)
Monthly F/U Visits (Adherence to Ctx Exam every
6 months CD4 WHO Staging)
VCT PMTCT Other
Prescribe ARVs
Drop out/Die or otherwise Lost
After ART initiation
Stopped ART (Continued on other care)
Clinic Baseline (CD4, VL and other labs WHO
Staging, Exam Given Meds)
Monthly F/U Visits (Adherence exam given meds
every 6 months CD4, VL and other labs)
Lost/Transferred Out
Dead
Continue ART
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HIV Information System Management (2)

• Register content and format have been designed in
  collaboration with health staff at facilities and
  include data elements that can be used for
• Patient tracking and management
• Program monitoring and evaluation
• Quality assurance
• Meet reporting requirements for National and
  Provincial ME systems
• Oct 2005, ECDoH adapted the paper-based HIV care
  and ART registers as the provincial patient
  monitoring system for all ART accredited
  facilities

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Pre-ART Register
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ART Register
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Adherence Social Support (1)

• Establishment of Wellness Centers
• St Patricks Holy Cross Hospitals (Northern EC)
• Co-located with ART clinics
• Managed through partnership with The Mothers
  Programmes
• Each Wellness Center
• 1 Site Coordinator overall supervision
• 10 Field Care Givers Home visits, patient
  tracking, adherence monitoring
• 5 Peer Educators - counseling, supporting
  linkages, adherence monitoring
• PLWHA, ART, pMTCT support groups
• Challenges in replicating model of WCs in other
  ICAP supported sites
• Peer Education program in East London
• For ART program (adults and children) -
• In the pMTCT services to strengthen referrals and
  retention into care
• Support an existing adult and paediatric wellness
  center in Port Elizabeth by recruitment of a
  psychologist
• Ongoing Technical assistance to the EC Integrated
  nutrition program (INP)
• WCs distribution points for DOH-supplied PLWHA
  supplements
• Eligibility HIV pregnant post-partum (lt1 yr)
  women and any other patients on ART

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Adherence Social Support (2)

• Lay Health workers trained in basic HIV/AIDS and
  adherence support
• 100 Field care givers, community health workers
  and Peer educators
• ICAP-SA directly supported staff
• Community liaison officer (East London)
• Site coordinator (Mzimkhulu)
• Social worker patient tracking and access
  services (East London)
• Psychosocial wellness coordinator (Port Elizabeth)

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ICAP- South Africa
Peer Education Training July 2005
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Laboratory Support

• Collaborating with the National Laboratory
  Services (NHLS)
• Supporting the recruitment and placement of 4
  laboratory clerks 1 medical technologist
• Facilitated the provision of basic computer
  training course for the laboratory staff
• Monthly in-service training of laboratory staff
  on HIV
• Courier service identified by NHLS and paid by
  ICAP-SA to transport laboratory specimen in
  Northern EC supported sites

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Infrastructure Development (1)
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Achievements (1)

• By Dec 05 EC provincial program enrolled 12,200
  on ART
• ICAP-SA supported 2,846 (23) on ART and 11,255
  in HIV care
• Children (lt14y) on ART 229/2,846 (8)
• Successful collaboration with DOH and local
  partners
• Diverse program implementation experiences

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Challenges Strategies (1)

• Program Implementation hospital based
• PHC inclusion will allow for integration of pMTCT
  and TB services
• Strategies
• Actively encourage the down-referral of ART
  services to PHC
• Advocate for accreditation of PHCs with ECDoH
• Poorly Integrated services
• Historically weak pMTCT TB program
• Strategies
• Participate in provincial pMTCT working group
  meeting
• ICAP-SA involved in the developing and
  implementing a TB/HIV Best Practice model in
  the EC
• TB/HIV advisor already recruited
• Clinical advisors (RNs and MDs) being recruited
  to support integration of pMTCT and TB services
  in Port Edward and East London
• Slow enrollment of HIV children into ART
• Lack of expertise and/or fear
• Strategies
• 3-day Paediatric workshop held in Jan 06
• 2 Local pediatricians facilitators and 42
  participants (nurses doctors)
• Similar workshop planned in April 06, for
  participants from East London and Port Elizabeth

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Challenges Strategies (2)

• Poor/lack of management skills
• Difficulties in meeting targets and seeing the
  bigger picture
• Strategies
• Program management training for health facility
  staff conducted in 2005
• 2006 working with the ECDoH to have ARV site
  coordinators participate in similar training
• Working with the Financial unit of the provincial
  program to support training of ARV site managers
  and finance officers on how to access and utilize
  the conditional grant
• 6 monthly program update conducted at district
  level to discuss progress and have joint planning
  and agreement on ART targets
• Poor ARV quantification and ordering
• Mthatha depot currently being privatized
• Strategies
• Hired a deport manager supervised by the
  Provincial pharmaceutical services director
• Currently looking to recruit a Pharmacist advisor
  to provide support to pharmacists on site

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Challenges Strategies (3)

• Rural Vs. Urban health facilities
• Northern EC
• Very rural health facilities with electricity
  shortage, no telephone or internet etc.
• Lots of traveling by ICAP staff
• Strategies
• Hiring of additional staff (Do you have a
  drivers license?)
• Supporting a mature Vs a New Program
• When ICAP support initiated at start of program
  easier to get systems established, program
  ownership less of a problem but slow enrollment
• Mature programs mis-perception of low hanging
  fruit
• Strategy
• Always striving to strike a balance
• Re-demarcation of provincial boundaries
• Mzimkhulu now Kwa Zulu Natal different
  implementation plan, and DoH officials (back to
  square one)
• Strategies
• Good opportunity to support activities in a new
  province
• Program introduction planned in next 2-3 months

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New Initiatives FY06

• TB/HIV
• Establishing a Best Practice model in Port
  Elizabeth (Empilweni TB hospital PHCs)
• Integration of TB/HIV activities in all supported
  sites
• Paediatric HIV treatment
• Supporting early infant diagnosis thru use of DBS
• Targeted evaluations (5 planned)

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Acknowledgments