Case Study on the Integration of HIV/AIDS Services in Trinidad and Tobago into Maternal, Newborn

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Case Study on the Integration of HIV/AIDS
Services in Trinidad and Tobago into Maternal,
Newborn Child Health Services, as well as
Sexual and Reproductive Health Services,
including Family Planning

• Edwin Bolastig, Yoko Laurence and Karen Pierre
• Centre for Health Sciences
• University of Trinidad and Tobago
• Funded by
• Pan American Health Organization/ World Health
  Organization

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OBJECTIVES OF CASE STUDY

• To contribute to the body of work on health
  services integration
• To determine how vertical programs and Global
  Health Initiatives have impacted on the health
  system, and affected segmentation/fragmentation

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• TRINIDAD AND TOBAGO
• Southernmost Caribbean country
• Independence 1962 Republic 1976
• Parliamentary democracy
• Multi-ethnic population 1.3M
• Oil and gas-based economy
• GNI per capita (09)US 17,884
• 10-year GDP growth(99-08) 7.7
• Epidemiologic shift CNCDs over 60 of deaths

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CONTEXT

• First HIV case diagnosed in 1983
• 8th leading cause of death in 2004
• STI-HIV co-infection prevalence rate 42 (60 M
  40 F) (Buensuceso, 2008)
• HIV/AIDS cause enjoys strong political support
• World Bank loan, EU grant, CARICOM PANCAP,
  government, private sector funding

• SOCIAL DRIVERS
• Poverty and unemployment
• Gender inequality/domestic violence
• High mobility Caribbean diaspora
• Stigma and discrimination
• Multiple sex partners/Early initiation
• Substance abuse/unprotected sex
• (UNAIDS , 2005)

• ECONOMIC DRIVERS
• Inequitable income distribution
• Sex work due to poverty
• Rapid urbanisation
• Limited skills and poor socialisation
• Sex-oriented tourism
• (Camara, CAREC, 2002)

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BROAD SECTORAL CONTEXT

• 1986 National AIDS Programme
• 1993 Caribbean Charter on Health Promotion
• 1996 Health Sector Reform Programme (HSRP)
• National Health Promotion Plan
• 2001 Health Promotion Council Directorate of
  Health Promotion and Public Health
• 2004 National AIDS Coordinating Committee
  (NACC)
• 2005 Vision 2020
• 2006 MOH Corporate Plan (2006-2009)

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SEGMENTATION/FRAGMENTATION

• Decentralisation of health service delivery to
  RHAs with the exception of Vertical Programmes
  and Services
• Fragmented human resource management
• Dual employment system
• Information and medical records management
  largely manual
• Unstructured referral system

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HIV INTEGRATION INITIATIVES

• Integration with Maternal and Child Health -
  PMTCT
• Integration with STI and Family Planning - VCT
• Integration with Population Programme - PITC
• Integration with Chronic Disease Care
• Tobago Health Promotion Clinic (THPC)
• Integration of Treatment with Prevention San
  Fernando General Hospital
• Integration of Information Systems for HIV/AIDS
• TERIDA Project

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EMERGING MODELS

• Three (3) Emerging Models of Integration
• Standalone outpatient HIV/AIDS clinic integrated
  with chronic disease care (Tobago Health
  Promotion Clinic)
• Hospital-based HIV/AIDS testing and treatment
  centres adult paediatric (San Fernando
  General Hospital)
• Satellite network of multi-tiered hospital based
  and outpatient health facilities

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MODEL 1 Stand Alone
ADVANTAGES/STRENGTHS GAPS/WEAKNESSES
By associating HIV/AIDS with other chronic diseases, stigma and discrimination may be minimised Unique branding strategy associating comprehensive approach with quality care Well-organised manual record-keeping transitioning to a paperless information system Multi-tasking of health workers Triaging according to purpose of visit (counselling and testing, pick-up of ARVs, consults, etc.) to avoid long queues and waiting times Community outreach activities (home visits) ensures good follow-up/ return rates Weak linkage with health centres doing counselling and testing Referrals have to be made to the Scarborough General Hospital for treatment of paediatric patients and to the OB/GYN Ward for pregnant women Inconspicuous location not all potential clients are aware of the clinic site (Conversely, could be an advantage too)
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MODEL 2 Hospital Based Testing and Treatment
ADVANTAGES/STRENGTHS GAPS/WEAKNESSES
Simulates one-stop shop for services (STI, HIV/AIDS testing, counselling and treatment, maternal and child care, etc.) in a single health facility/ compound Weak community outreach services Link to family planning services missing Hospital-based care is known to be generally more expensive than out-patient care
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MODEL 3 Multi-tiered Satellite Network
ADVANTAGES/STRENGTHS GAPS/WEAKNESSES
Hand-holding approach to referral of patients to other health facilities Assurance of a wide range of services Relatively good feedback being received from facilities where patients were referred to Patients being lost in the process of referring to another health facility Patients being lost to follow-up Longer time spent in securing appointments and attending clinics Travel and opportunity costs of attending multiple clinic schedules
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FINANCING Total TTD 253.5 million
1 USD 6.29 TTD
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BENEFITS

• Programmes institutionalisation of PMTCT
  integration of VCT with SRH free ARVs
• Resources - high levels of funding for HIV/AIDS
  also used for MCH, STIs and FP
• Processes - shift from a programme approach to
  institutionalisation of interventions
• Intermediate products build capacity of
  committed health personnel
• Outcomes increased HIV testing among mothers
  improved efficiency in some areas community
  outreach

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TWO SCHOOLS OF THOUGHT ON INTEGRATION

• Strengthening of services as pre-requisite to
  integration vs.
• Integration as means to improve services

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LESSONS LEARNT

• Facilitating factors
• Role of advocates and champions in the health
  system
• Perception of strong political support from
  government
• Health promotion (high risk groups and wider
  population)
• Service delivery decentralisation (RHAs)
• Increased resources for HIV/AIDS
• Expanded role of civil society knowledge
  broker

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LESSONS LEARNT

• Hindering Factors
• Structural and support services
• inadequate infrastructure, human resource
  shortages, weak reporting and referral systems
• Socio-cultural
• breach of confidentiality, SD,
  territorialism, lack of accountability
• Policy and legal environment
• lacks policy framework for zero tolerance to
  SD, non-adherence to protocols/SOPs

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AREAS FOR IMPROVEMENT

• Socio-cultural
• Health workforce
• Service delivery
• Systems interventions
• Policy and legal environment

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CONCLUSIONS

• Resources for HIV/AIDS supported integration of
  HIV services with other health programmes such as
  Maternal and Child Health
• GHIs did not seem to have undermined national
  planning and policy development process
• Integration process aligned with national
  priorities, along existing mechanisms for
  coordination