Scaling-up HIV Prevention Care and Antiretroviral Therapy at Primary Health Centres: A WHO/PEPFAR Collaboration

1
Scaling-up HIV PreventionCare and
Antiretroviral Therapyat Primary Health
CentresA WHO/PEPFAR Collaboration

• Stakeholder Input and Adaptation Process

2
Scaling-up HIV PreventionCare and
Antiretroviral Therapyat Primary Health
CentresA WHO/PEPFAR Collaboration

• WHO and PEPFAR coordinated
• support for a MOH-led, multi-partner collaboration

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
Why Adaptation?

• Each element of the generic Operations Manual
  was selected to be applicable to MOST country
  situations.
• Adaptation is needed to produce a manual that can
  be directly applied to a primary health centre in
  a specific country.
• For example, specific adaptations needed for
• National supply management system
• Essential lab tests for basic primary care
• Staffing requirement for basic primary care

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
Why Adaptation?

• Many countries have already adapted IMCI/IMAI
  clinical guidelines or the WHO Patient Monitoring
  Systems for HIV care/ART and TB.
• These tools may need to be re-adapted to
  reflect recent developmental work at the global
  level
• Integration of TB and PMTCT into IMAI clinical
  guidelines
• Broadening of Patient Monitoring Systems to
  include ANC/PMTCT
• HIV variables added to TB patient monitoring
  system

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National level requirements to support a
decentralized, integrated approach for scale up
at health centre level

• Key policy decisions (task shifting, lay
  counselors on clinical team, TB can be treated in
  HIV clinics, TB infection control, etc)
• Adaptation of the tools -- MOH, USG partners,
  other partners and stakeholders
• Agreements between national programmes on shared
  programme of work
• Agreements on responsibility for implementation
  support (regionalization, etc)

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"District clinicians" providing outpatient and
inpatient care at district hospital, depending on
country
Doctors, Medical officers, GPs
Health officers, Clinical officers
Nurses
Midwives, MCH nurses
TB clinic nurses
Physicians Paediatricians
IMAI task shifting for HIV care and ART clinical
management
Nursing assistants, Counsellors, Lay
counsellors PLHIV on clinical team
PLHIV (self-management)
CHWs, other community- based practitioners Communi
ty volunteers (PLHIV and others)
Family caregivers
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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
The Adaptation Process

• Initial meeting of national stakeholders convened
  by Ministry of Health, with support from WHO,
  USG, other partners
• Decision on whether adapted Operations Manual
  would help country scale-up what clinical tools
  need to be updated
• Then series of adaptation workshops focused by
  technical area

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
The Adaptation Process

• Series of adaptation workshops focused by
  technical area
• Operations Manual- several streams of work, by
  chapter
• Updated IMCI/IMAI clinical guidelines and tools
• Tanzania very up-to-date on IMAI Chronic HIV
  Care- already integrates TB-HIV co-management,
  ART in pregnancy and other PMTCT interventions,
  prevention by PLHA, psychosocial support for
  children
• IMCI 'classic' to IMCI Chart Booklet for High HIV
  Settings
• Use these to review, adapt adult, paediatric
  intervention lists (chapters 1 and 2)
• Consider additional 'new' interventions or
  changes based on new normative guidelines and/or
  data

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Operations Manual Adaptation Process

• Multiple streams of work- examples
• Patient monitoring systems for health centre
• HIV care/ART
• HIV variables into TB monitoring system
• PMTCT system
• Laboratory at health centre
• SOPs for lab tests
• System for sending out CD4 and DBS for infant
  HIV diagnosis
• Supply management
• Fit to national system and health centre
  essential drug list- stock cards, etc

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Country-adapted Operations Manual and Clinical
Tools

• National standardized guidelines, training
  materials, job aids, recording and reporting
  forms
• What services should be at health centre
• Clinical guidelines, job aids
• Laboratory support
• Supply management
• Infrastructure
• HR staffing, training, health worker protection,
  mentoring
• Patient monitoring systems
• Quality management- approach, tools, supportive
  supervision
• Operations Manual is not stand-alone. Sits next
  to clinical tools

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
Summary of PEPFAR Countries

• Adaptation of IMCI all (15/15)
• Adaptation of IMAI Uganda, South Africa (E.
  Cape, Mpumalanga..), Zambia, Ethiopia, Tanzania,
  Haiti, Botswana, Nigeria, Kenya, Guyana, Namibia,
  Mozambique (12/15)
• Adaptation of HIV care/ART Patient Monitoring
  System Uganda, South Africa, Ethiopia, Tanzania,
  Nigeria, Kenya, Guyana, Namibia (8/15)

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
Inputs into the Adaptation Process

• Draws upon existing development work and
  implementation experience by partners in the
  country
• New evidence and updated global normative
  guidelines for PMTCT, PITC, infant testing, etc ?
  updated national guidelines ? tools for health
  centre
• Policy and regulatory work to expand roles of
  cadres
• Task shifting experiences from other countries
• Scale up is substantially advanced -
  modifications and new tools to support
  decentralization, expanded integration,
  accelerated prevention etc.

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
The Adaptation Process

• Includes all partners active at the health centre
  level
• USG and non-USG
• MOH, NGO, FBO
• HIV care/ART focused plus TB, maternal and child
  health, palliative care, etc
• PLHIV expert patient groups (involved in
  training, lay providers on clinical team)

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
The Adaptation Process

• Adaptation Guides are being developed to
• Standardize the adaptation process
• Evidence base for recommendations in the
  Operations Manual and IMAI clinical tools
• Guidance for selection of possible adaptations
• Substance of possible adaptations- for example,
  trigger forms for TB screening

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
Outputs of Adaptation Process

• Boxed set of field-ready tools. Country-adapted
• Operations manual
• IMCI/IMAI clinical guidelines
• Training materials
• Patient monitoring cards and registers
• QA tools
• Patient education tools (IEC materials)
• Consensus by the Ministry of Health, other
  organizations and partners to support scale-up at
  the health centre level using a single strategy.

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
Outputs of Adaptation Process

• Consistent with increased interest by Ministries
  of Health for a standard package of technical
  assistance to primary health centers
• Ethiopia
• Tanzania
• Nigeria
• Uganda, etc.

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Standardized guidelines, training, management
tools? Share training, mentors, patient
monitoring system within a district or region
MOH, other partners
Workplace HIV services
USG partners, NGO or FBO
Private providers
Military services
? Scale up toward universal access is more
feasible, sustainable
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National standardized package to support HIV
services

• For all health centres
• Government
• FBO-sponsored clinics

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Scaling-up HIV PreventionCare and
Antiretroviral Therapyat Primary Health
CentresA WHO/PEPFAR Collaboration

• The Implementation Process

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
A Powerful Combination

• Joint support for implementation by USG
  agencies/implementing partners
• WHO/Ministries of Health support for standards
  and policy changes to facilitate decentralized
  scale-up
• Other partners

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
The Implementation Process

• Opportunity to increase cooperation through
  endorsement of Ministry of Health strategy
• Between partners
• Between partners and the Ministry of Health
• Coordinated health systems strengthening
• Standardized approach to training/mentoring
• QA
• Patient monitoring

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
The Implementation Process

• Training support after training - health center
  staff
• Essential laboratory tests for health center
• Facility management
• Use of patient monitoring systems
• Etc.
• Training support after training - district
  teams
• Use of QA tools
• Patient monitoring - annual monitoring review,
  analysis, reporting to national level
• Etc.

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
Role of WHO at Country Level

• Strengthen MOH with seconded staff (NPOs)
• Work with MOH to coordinate adaptation process
• Quality assurance - minimum standards for
  IMAI/IMCI training, QA after training with
  partners
• Promote technical experts and managers within the
  MOH at central, regional and district level,
  other national institutions, NGOs/FBOs will
  also be able to support neighboring MOH (south
  to south capacity)

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres
Role of USG Partners at Country Level

• Build on relationship previously developed with
  the Ministry of Health
• Full participation in adaptation process
• Strengthen support for regional, district and
  facility management in all targeted sites
• Support implementation of adapted tools in
  assigned regions or sites- training, mentoring,
  quality assurance, supplies, lab, infrastructure
  support etc

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres

• Speed of implementation, number of primary health
  centres, patient targets, responsibility for
  regions should be a collaborative decision
  involving Ministry of Health and all stakeholders
• During implementation period, each primary health
  center will be supported using QA tools and
  evaluated on all the elements included in the
  country-adapted Operations Manual

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres Tanzania

• Strong MOH commitment to integrated models of
  care (e.g. IMCI)
• MOH already has simplified patient monitoring
  systems and IMAI guidelines, curriculum for
  health centre scale up
• Close collaboration with USG partners division
  of input by regions

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IMCI Chart Booklet
Tanzania
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(No Transcript)
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(No Transcript)
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Logistics, management
Clinical guidelines
Complements
Operations Manual- Health Centre
Supplies, lab, infrastructure, QA, patient
monitoring, human resources, fiscal management
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Integrated approach better serves HIV clients
with other diseases (TB) or conditions
(pregnancy, IDU)

• Clinical co-management
• Co-supervision by district teams (HIV, TB, MCH)
• Co-sponsorship by national programmes-
• shared programme of work
• Efficient management for patient (single clinic
  visit)
• and clinical team
• TB-HIV co-management
• ART or ARV prophylaxis and other PMTCT
  interventions integrated in antenatal, LD,
  post-partum and newborn care

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Scaling-up HIV Prevention, Careand ART at
Primary Health Centres Tanzania

• Scale up of HIV services to district hospitals in
  2006
• Plan to scale up to 540 health centres in 2007-8
• USG partners, WHO, 1 representative MOH had
  introductory meeting in July
• Next step stakeholders meeting/ workshop for OM,
  new or updated clinical tools

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Mozambique

• Introductory meeting on the collaboration and
  Operations Manual with MOH, USG partners, WHO in
  August
• All interested in updated IMAI tools and adapting
  Operations Manual to support health centre scale
  up
• Translating current IMAI/IMCI tools into
  Portugese
• Hoping for date soon for adaptation workshop

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Operations Manual
Health centre tools for scaling up HIV
services integrated with basic health care- in
a country using IMAI
Bench Aid Malaria
plus
Other aids
District Addendum to the Operations Manual
Forms Patient Monitoring, Other
IMAI Adaptation Guide
Operations Manual and District Addendum
Adaptation Guide
IMCI Adaptation Guide Section C, updates
For national programme managers,
experts, partners
or other national primary care guidelines
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Operations Manual assumptions for the generic

• High HIV prevalence, generalized epidemic
• Resource constraints.
• Basic primary health care and prevention services
  
• HIV prevention, care and treatment services are
  integrated in their delivery and with these
  primary care services.
• For large or small health centres
• Large limited number LD beds, few inpatient
  beds for severe malaria or emergency surgery
  catchment up to 20,000
• Small 10,000.
• Management of up to 750 PLHIV in chronic HIV
  care, with 30 to 50 on ART.
• No surgical or specialized reproductive health
  services such as female sterilization, vasectomy,
  or adult male circumcision
• Limited essential lab on site with few tests sent
  out
• No refrigeration, other than vaccine cold chain
• Water supply
• Some electricity (variable source)
• Communication- at least mobile phone
• All routine health centre sites (not sentinel,
  research sites).

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Primary target audiences of tools

• Adaptation Guide (evidence base, possible
  adaptations)
• National programme managers, technical experts
  from universities, partners, NGOs/FBOs
• District addendum
• District management team
• Operations Manual
• Health centre team
• (already country-adapted, standard guidelines,
  tools)

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District addendum (use with updated district HIV
coordinators' training course)

• Supervisory checklist
• QA, routine evaluation tools
• Tools to assess site readiness and to reassess,
  examine service availability
• Case management observation
• Exit interviews
• Record audit DRAT, IMAI rapid assessment
• How to support patient monitoring system
• Annual monitoring review
• Supervision/QA/support (stains) for health centre
  laboratories
• Waste management

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Chapter 1 Assessment and Planning

• Assess services which are currently provided
• Where are we at now?
• What more can we do?
• What more is needed to support this?
• Determine HIV service needs in health centre
  catchment area
• Number need testing with PITC push
• HIV, ART
• clinical visit frequency
• ? estimates in Infrastructure, HR chapters based
  on 100, 250, 500, 750 in HIV care
• Need further input to forecast health centre
  needs to support scale up of PITC
• ? add costing (or in District addendum)

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What HIV and basic health services are available
(SAM)? Quality assessment and improvement
checklist, observation, patient
satisfaction, etc
What HIV and basic health services are available
(SAM)? Quality assessment and improvement
checklist, observation, patient
satisfaction, etc

• Assess and plan
• Where are we at now?
• What do we want to add?
• What more is needed to support this?

What HIV and basic health services are available
(SAM)? Quality assessment and improvement
checklist, observation, patient
satisfaction, etc

• Assess and plan
• Where are we at now?
• What do we want to add?
• What more is needed to support this?

What HIV and basic health services are available
(SAM)? Quality assessment and improvement
checklist, observation, patient
satisfaction, etc

• Assess and plan
• Where are we at now?
• What do we want to add?
• What more is needed to support this?

• Assess and plan
• Where are we at now?
• What do we want to add?
• What more is needed to support this?

What laboratory tests? How many? Reagent
supplies adequate? Quality assure lab tests
What laboratory tests? How many? Reagent
supplies adequate? Quality assure lab tests
What laboratory tests? How many? Reagent
supplies adequate? Quality assure lab tests
What laboratory tests? How many? Reagent
supplies adequate? Quality assure lab tests
What infrastructure and equipment? Equipment
upkeep and quality check for scales, other
equipment Color-coded waste disposal, handwashing
at all care sites? TB infection control in place?
What infrastructure and equipment? Equipment
upkeep and quality check for scales, other
equipment Color-coded waste disposal, handwashing
at all care sites? TB infection control in place?
What infrastructure and equipment? Equipment
upkeep and quality check for scales, other
equipment Color-coded waste disposal, handwashing
at all care sites? TB infection control in place?
What infrastructure and equipment? Equipment
upkeep and quality check for scales, other
equipment Color-coded waste disposal, handwashing
at all care sites? TB infection control in place?
What supplies and commodities? How much? Check
stock cards Use supply checklists
What supplies and commodities? How much? Check
stock cards Use supply checklists
What supplies and commodities? How much? Check
stock cards Use supply checklists
What supplies and commodities? How much? Check
stock cards Use supply checklists
What human resources? How to protect them? Staff
positions filled? PEP, other HW safety in
place?terventions available
What human resources? How to protect them? Staff
positions filled? PEP, other HW safety in
place?terventions available
Manage and assure quality
What human resources? How to protect them? Staff
positions filled? PEP, other HW safety in
place?terventions available
Manage and assure quality
What human resources? How to protect them? Staff
positions filled? PEP, other HW safety in
place?terventions available
Manage and assure quality
Manage and assure quality
Are services well integrated and linked? Is each
type of patients efficiently co-managed?
Effective links with hospital, community,
services offered by others? E
Are services well integrated and linked? Is each
type of patients efficiently co-managed?
Effective links with hospital, community,
services offered by others? E
Are services well integrated and linked? Is each
type of patients efficiently co-managed?
Effective links with hospital, community,
services offered by others? E
Are services well integrated and linked? Is each
type of patients efficiently co-managed?
Effective links with hospital, community,
services offered by others? E
Manage implementation Assure quality Solve
problems
Manage implementation Assure quality Solve
problems
Manage implementation Assure quality Solve
problems
How are patients monitored? All forms and
registers present and used correctly? Review
patient monitoring data.
Manage implementation Assure quality Solve
problems
How are patients monitored? All forms and
registers present and used correctly? Review
patient monitoring data.
How are patients monitored? All forms and
registers present and used correctly? Review
patient monitoring data.
How are patients monitored? All forms and
registers present and used correctly? Review
patient monitoring data.
Is leadership and management sufficient?
Is leadership and management sufficient?
Is leadership and management sufficient?
Is leadership and management sufficient?
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Chapter 2 HIV services

• Lists of interventions- for country adaptation
• Basic essential (?consensus possible survey
  who/how)
• Desirable
• Intensified
• Includes basic primary care services for children
  and adults
• Cannot delivery HIV services when basic services
  are weak
• Matrix to help assess current services, what to
  add
• Then detailed planning for each new service- back
  to chapter 1
• Need to edit down, consistent level of detail.
• No "how to"
• From Chapter 3 on How to ..
• ? also define linked community interventions?

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Chapter 7 Patient monitoring

• Most data for treatment and care few variables
  go up
• 3 linked patient monitoring systems
• TB (decades old has just finalized few new HIV
  variables)
• HIV care/ART 2004- standardized minimum data
  set, illustrative forms
• PMTCT- simplified paper-based system still in
  development- urgent completion, consensus needed

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Chapter 7 Patient monitoring

• Quarterly cross-sectional reports few new
  variables being considered- PMTCT, TB-HIV
• Annual monitoring review by district/regional
  team to collect
• ART cohort data
• sample of cards for TB screening data, HIV
  care/ART and PMTCT data
• Simple tally sheet in development