CARE

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CARE

• Caring team..

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Acknowledgements

• The people of Rwanda
• All the participants
• All the organizers and sponsors
• The team of rapporteurs
• All patients

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Outline

• Counseling Testing
• Comprehensive care
• TB/HIV
• Food and Nutrition
• OVC

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Counseling and Testing

• Dat Tran, Kathy Jacquart, Elizabeth Marum

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Innovative Approaches to HIV Testing (DeCock)

• lt20 of pregnant women get HIV Tested
• lt13 TB patients tested for HIV
• 80 of HIV infected persons do not know their HIV
  status
• Late HIV diagnosis is bad medicine
• 73 of deaths occur because CD4 cell lt100 when
  first tested
• Ambitious scale-up needed of all models
• Traditional VCT, mobile and outreach VCT
• Provider-initiated CT in health facilities
• WHO Guidelines now available
• Testing for TB patients high priority

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It's a Hard Life at WHO
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Counseling Testing in Health Care Facilities

• Opt-in testing in TB settings leads to low
  testing rates (Indonesia Abst 831)
• Successful integration in TB settings (Haiti Abst
  303, Kenya Abst 678, Uganda Abst 1062)
• Over 90 acceptance
• More testing of TB patients in PEPFAR focus
  countries compared to others (Abst 1771)
• Many programs for PITC in health facilities
  (Uganda, Tanzania, Kenya, S Africa)

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Counseling Testing in the Community

• Mobile or outreach CT in many countries (
  Rwanda, Kenya, Lesotho, Mozambique, Zambia,
  Nigeria, Cote dIvoire)
• Mobile cost effective (Kenya Abst 62)
• Home testing increasing (Uganda, India)
• Coverage from 10 to 90 in 2 years
• Door to door home testing early detection of
  HIV (Mean CD4 493 in HIV in Uganda)

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CT for High Risk Groups

• Military (mandatory for new recruits in many
  countries, VCT for soldiers and families)
• VCT for drug users in rehab (Vietnam)
• HIV as high as 60 (Abst 328)
• Prisoners (Rwanda)
• VCT for truckers in Brazil (Abst 1568)
• CT integrated in STI clinics for female CSW
  (Ghana Abst 1674), for youth (S. Africa Abst 658)
• Alcohol counseling important in VCT (Kenya)
• Adds 6 min to counseling session (Abst 1580)

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Innovative Methods Partners

• Agricultural extension workers (Cote dIvoire)
• PLWHA for family outreach (Rwanda, Abst 1490)
• Hospice program (Zambia)
• Task shifting lay counselors (Ethiopia,
  Namibia), volunteers (Lesotho)
• National Testing Week
• Malawi 97,000 in one week (Abst 956)

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Clients Tested Counseled in 2006 Impact of
National Testing Week in July
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Challenges Questions

• Disclosure to HIV infected children remains
  difficult (Abst 552, 555)
• Couple testing and identification of discordant
  couples high priority for prevention
• In mature epidemics, high incidence in married
  couples (Wilson)
• Home testing and testing of spouses of patients
  may be most effective strategy to identify
  discordant couples (Uganda)
• Policies in some countries do not yet support
  finger-prick samples, rapid tests, and same day
  results
• How long should pre-test and post-test counseling
  be?
• Stigma remains a barrier to testing in localized
  epidemics (Indonesia, Abst 831)

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Comprehensive Care

• Ana Bodipo-Memba, Tim Quick, Reson Marima

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Integration

• Provision of HIV care services within PMTCT
  clinics
• Achieved by training of staff on WHO staging and
  provision of CD4 testing at PMTCT clinic
• Resulted in more effective and earlier referrals
  to ART sites
• Abst 405

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Comprehensive Care Packages

• Components
• Prevention
• Physical -CPT, OI diagnosis and treatment, pain
  control, nutrition
• Social
• Psychological
• Spiritual
• Family centered approach
• Track all family members status and continuum of
  care
• Effective linkages and/or integration of services
• Community buy in and mobilization
• Defaulter tracing
• Remember TB

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WHO Analgesic Ladder

• Accessibility affordability
• Training/ sensitisation

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Cotrimoxazole

• CTX and ITNs in children (Abst 1031)
• CTX alone beneficial
• Combination of CTX prophylaxis and ITN associated
  with 97 reduction in malaria in HIV positive
  children
• No severe malaria cases seen in HIV infected kids
• Malawi CTX (Abst 1668)
• Among patients starting ART 40 reduction in
  mortality for patients on CTX
• CTX should be given to all symptomatic adults
• WHO guidelines issued in 2005
• All HIV exposed children until confirmed negative
• All HIV positive children

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Where are the Children ?

• Identification of children
• Need clear policy on counseling and testing, care
  and treatment for children
• Provider initiated
• Need to educate the community on the CT for
  children and adolescents, their rights
• Health care workers need to be trained in
  pediatric ART and other issues
• Youth involvement and support

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Let Us Not Forget Children
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Innovations

• Mothers2Mothers in PMTCT
• empowerment of women and increasing uptake in
  PMTCT by using existing services

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Effect of HIV Funding on Health Services (Abst
250)

• General health has benefited from HIV funding
• 21 of 22 services improved
• 16 statistically significant, 7 attributable to
  HIV service
• HIV services should be implemented within
  existing frameworks

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Mukoma Health Center Patient Waiting Area
Before HIV renovation work October 2006
After renovations May 2007
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Rutobwe Primary Health Center Lab
Before HIV renovation work October 2006
After HIV renovation work April 2007
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TB/HIV

• Amy Bloom, Anand Date

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WHO Global TB Report for 2005 (abst 1771)

• 7 TB patients tested for HIV
• lt0.5 of all PLHAs screened for TB

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National HIV testing among TB Patients Kenya
(Chakaya)
N115,000 in 2006
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Integrated TB/HIV Hospital-Based ClinicsHIV
testing among TB patients

• Uganda (abst 831)
• 96 of TB patients tested for HIV 33 were HIV
• 37 of patients started ART
• Kenya (abst 678)
• 94 of TB patients tested for HIV 45 were HIV.
  
• 100 of eligible patients started ART
• 100 started on CPT (national level 87)

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Integrated TB/HIV Hospital-Based ClinicsTB
screening in HIV patients

• In Uganda, 4835 HIV clinic patients were screened
  for TB 17 had active TB (Abst 831)
• In Haiti, 9 VCT clients had active TB (Abst 303)
• In Rwanda, a five question symptom screening tool
  was developed
• Of 8121 ART enrolled pts, 76 were screened
• 8 had active TB

Intensified case finding is key!
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Improving Diagnosis of TB Among HIV-infected
Individuals

• Improve technical capacity (training, QA/QC)
• Explore more sensitive, high volume techniques
  (FM)
• Expand access to culture and new diagnostic
  methods
• Consider CXR, other procedures as appropriate
• Expand availability use of sensitivity testing

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MDR/XDR TB

• A consequence of suboptimal TB control (service
  coverage, case detection, low cure rates, high
  rates of unfavorable outcomes)
• HIV infected individuals with their increased
  tendency to utilize health services at risk of
  acquiring TB including MDR and XDR TB in health
  care settings
• When HIV infected persons acquire XDRTB the
  outcomes are very poor
• Inadequate Infection Control Practices encourage
  the transmission of TB including MDR and XDRTB

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TB Infection control not happening!
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Five Steps to TB Infection Control in HIV Care
Setting

• Step I Screen
• early recognition of cases or suspects
• Step II Educate
• cough hygiene
• Step III Separate
• cases or suspects in OPDs wards
• Step IV Provide HIV/AIDS services
• prompt services to reduce exposure
• Step V Investigate for TB or refer
• TB diagnosis on site or prompt referral

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Caring for Carers Tiffany Hamm
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Innovations

• Botswana has developed of a comprehensive
  wellness program with HIV/AIDS mainstreamed as
  part of a holistic approach
• Training package includes Stress management,
  Team building, Death and dying and Occupational
  health
• Alternative testing approaches for HCW
• One rapid test project starting in Kenya
• Pop Service International engaged for outreach
  VCT in Zimbabwe for HCWs
• Development of a 30 minute documentary about five
  HIV health workers

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Integrating Food Nutritional Support within HIV
programs

• Tim Quick

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Country Experiences

• Western Kenya ( 9.9/month)
• the Food by Prescription Program is providing
  fortified blended flour supplement (.30/d) and
  household water Tx to PLHIV patients with
  BMIlt18.5, PMTCT women OVC at clinics
• Nutritional assessment counseling by trained
  lay workers relieves medical staff
• Malawi
• RUTF- Ready to use Therapeutic Food
• 1 in 5 adult patients are eligible for RUTF at
  ART initiation, response 4-6 weeks
• Mozambique ( 10.8/month)
• PlumpyNut malnourished children and for weaning
• Exit at 45 days

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• WHO has developed and field tested Guidelines
  for an Integrated Approach to the Nutritional
  Care of HIV-Infected Children (6 months 14
  years) to be integrated within IMCI and other
  clinical guidelines for pediatric care Tx.
• Guidelines and job aids must be adapted and
  integrated within country guidelines for IMCI and
  pediatric care.
• Similar guidelines for nutritional care within
  IMAI to be developed for adults adolescents

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Comprehensive Care of Orphans Vulnerable
Children

• Teri Wingate

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Critical for understanding context of scaling up
OVC support Sub-saharan Africa is only region
with increasing numbers of orphans projected
through 2010. Intro for Session E3
Key Observations
Source Africas Orphaned and Vulnerable
Generations Children Affected by AIDS, UNICEF,
2006
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Key Observations

• Coordinating systems strengthening at different
  levels to promote awareness and strategies for
  action to assess and meet the needs of OVCs
• International and national leadership to foster
  understanding of the situation of orphans and
  vulnerable children and mobilize action
• PEPFAR-funded programs contribute to
  comprehensive National Plans for OVC care e.g.
  Uganda and Mozambique
• Strengthening government partners, coordinating
  bodies and district level implementation is
  critical in providing a platform for local
  capacity building of organizations, community
  workers and volunteers supporting OVC

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Key Observations

• Family centered programs provide synergies and
  use consistent referrals to enhance continuum of
  care
• Identify vulnerable children and provide
  psychosocial support to families. (abst 782
  Africare East Africa), Support Groups,
  Sensitization, Parenting Training, Links to IGA
  (ANCHOR Initiative)
• Volunteers need support
• RAPIDS (abst 581 Zambia) leverages significant
  public/private partnerships to provide
  transportation and working tools to help
  Volunteers deliver services.
• In CORE Uganda, Volunteers coordinate services
  for 3 vulnerable households with an average 4 OVC
  each

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Innovations New Tools

• New tools have been developed or adapted to
  assess the needs and track status and services
  for orphans and vulnerable children
• Child Status Index
• (piloted Tanzania Kenya)
• Quality Assessment and
• Improvement tools (piloted Ethiopia)
• Pictoral guides for Monitoring
• OVC services with
• non-literate people (Mozambique)
• Training modules for OVC
• Psychosocial Support (ANCHOR)
• OVC organizational capacity
• assessment tools (Uganda)
• Mapping OVC needs services

Poster Abstract 1735 on Mapping OVC Data
(Measure Evaluation, USAID, OGAC)
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Lessons Learned Scaling Up

• Extensive strengthening of communities to lead
  delivery and coordinating care for vulnerable
  children
• OVC Care Committees (782 COPE project Eastern
  Africa)
• Community Care Committees (Mozambique)
• Neighborhood Care Points, Grandmothers Houses
  and Chiefs Fields (568 Swaziland)
• Most Vulnerable Children Committees (629
  Tanzania)
• Adult mentors providing home visitation to child
  headed households (647 Rwanda)
• Cash transfers are promising family-focused
  programs for OVC (1468 726 Kenya, Malawi,
  South Africa, Zambia)
• Targeting extremely poor families also reaches
  high percentages of HIV-affected households
• No early evidence of misusing funds

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IMAI

• Easy, effective model for introducing HIV/AIDS
  treatment and care
• A clinical team approach maximizing the strengths
  of all cadre of health care providers
• Adaptation, training and roll out in Tanzania and
  Ethiopia
• Modules need evaluation

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We cannot always cure but we can always care
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