Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa - PowerPoint PPT Presentation

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Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa


Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa – PowerPoint PPT presentation

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Title: Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa

Operational Plan for Comprehensive HIV and AIDS
Care, Management and Treatment for South Africa

Cabinet Mandate
  • On 8 August 2003 Cabinet requested the
    Ministry of Health to
  • as a matter of urgency, develop a detailed
    operational plan on an antiretroviral
    treatment programme
  • by the end of September 2003

  • Ensuring that the uninfected remain HIV negative
  • Prevention and changing lifestyles and behaviour
  • Broader context - social programmes of
    Government and the wider society that aim to
    reduce poverty through job creation and social
  • 5.3 million HIV progress as slowly as
    possible to developing AIDS
  • Appropriate treatment of AIDS-related conditions
    including the use antiretroviral therapy in
    patients presenting with low CD4 counts to
  • Improve functional health status
  • Prolong life

Guiding Principles
  • Quality of Care
  • Universal and Equitable Implementation
  • Strengthening the National Health System
  • Re-informing Prevention
  • Providing a Continuum of Care

Guiding Principles
  • Sustainability
  • Promotion of healthy lifestyles
  • Promotion of individual choice of treatments
  • Integration
  • Safety of Medicines
  • TB

  • Provide comprehensive care
  • Strengthen the National Health System

Prevention, Care and Treatment of HIV and AIDS
  • Prevention, care and treatment
  • Nutrition-related Interventions
  • Traditional Medicine

Care and Treatment Plan
  • Aim
  • prolonged and improved quality of life
  • Approach
  • Continuum of care
  • Service coordination and integration
  • Referral systems
  • HBC approach
  • Integration into current services
  • E.g. VCT, PMTCT, TB, PEP, STI management,
  • Add on ARVs for people who have progressed to
    stage 3 or 4

HIV negative
exposure to HIV
Flu like illness
  • IEC
  • Barrier Methods
  • PEP
  • Ongoing counselling

HIV positive
Symptomatic -diarrhea -Oral thrush -Weight
loss -TB -Pneumonia
  • VCT Avail.
  • Counselling
  • Support
  • Nutrition
  • Healthy Life Style

AIDS Disease
Treatment available for OIs
Year 0
Year 5
Year 10
Year 8
HIV Testing, Counselling and Clinical Staging
Regimen Drugs Test Frequency
1a d4T / 3TC / NVP CD4 VL ALT Staging, 6-monthly Baseline, 6-monthly Baseline
1b d4T / 3TC / efavirenz CD4 VL Staging, 6-monthly Baseline, 6-monthly ALT
2 AZT / DDI / Lopinavir/ritonavir CD4 FBC Fasting cholesterol Staging, 6-monthly Baseline, 1, 3, 6 mo, continue 6-monthly Baseline only
Paediatric ARV Regimens and Routine Monitoring on
Regimen Drugs Test Frequency
1a d4T/3TC Lopinavir / Ritonavir CD4 VL ALT Chol/TG Staging, 6 monthly Baseline, 6 monthly Baseline Baseline, 12 monthly
1b d4T/3TC/NVP CD4 VL ALT Staging, 6 monthly Baseline, 6 monthly Baseline, 1m, 6 monthly
1c d4T/3TC efavirenz CD4 FBC Staging, 6 monthly Baseline, 1,3,6 mo, 6 monthly
2a AZT/ddI Lopinavir / Ritonavir CD4 FBC Chol/TG Staging, 6 monthly Baseline, 1,3,6 mo, 6 monthly Baseline, q 12 monthly
2b AZT/ddI Efavirenz or NVP CD4 ALT FBC 6 monthly Baseline, 1mo, 6mo (NVP only) Baseline, 1,3,6 mo, then 6 monthly
Paediatric ARV Regimens and Routine Monitoring on
  • Notes
  • d4T syrup requires refrigeration. If no
    refrigerator at home, switch d4T to AZT.
    Clinician discretion to substitute ABC for d4T in
    infants gt 3 months of age.
  • NVP - Choice between first-line regimens is
    informed by (a) previous exposure to NVP within
    last 12 months consider lopinavir/ritonavir (b)
    children without history of NVP exposure can
    receive regimen 1b or 1c, 2b is 2nd line if
    regimen 1a was given
  • efavirenz - limited to children gt3 yrs of age and
    gt13 kg.
  • For drug failure criteria in paediatrics refer
    to Continuum of Care Building for HIV -
    Paediatric Section, developed by the national
    Department of Health
  • Staging initial testing for all
    infants/children after confirmed HIV-positive
  • Baseline for ARV eligible children at time of
    ARV initiation
  • (See Annex I.6 for paediatric ARV detailed dosing
    and drug information)

  • Contextualised within broader nutritional
    strategies in Government
  • Criteria
  • Individual with TB and/or HIV and AIDS
  • No secure food
  • Monthly supply of nutritional supplement
  • Monthly supply of supplementary meal
  • DOH will
  • Review and set specifications of supplement meals
  • Review criteria for implementation
  • Negotiate on pricing and supply
  • Evaluate ongoing research
  • Develop appropriate training material
  • Coordinate with Social Development Agriculture

Traditional Healers
  • Role and function in the continuum of care if
    recognised (prevention, treatment, care and
  • Compliance, adherence, adverse event reporting,
    referral system
  • Ensuring safe traditional health practices
  • Support the development of QA mechanisms and
    establishing training priorities
  • Research
  • traditional medicines on immune system
  • Interaction with ARVs, TB and STI treatment

Human Resources and Facilities
  • Accreditation of Service Points
  • Human Resource Training
  • Provincial Site Assessments

Strengthening and Accreditation
  • Objectives
  • Provision of a continuum of care
  • Gold standard of care
  • Equitable manner
  • Service site
  • Single facility or grouping of facilities which
    combined meet accreditation criteria
  • Can include NGOs, private sector etc.

Strengthening and Accreditation
  • Accreditation requirements which broadly address
    capacity w.r.t. HR, labs, pharmacies, drug
    procurement distribution, referral patterns etc
  • Process
  • National defines requirements
  • Provincial assessment teams for site evaluation
    identification of gaps and developing
    strengthening plan to address gaps (with time

Context of Human Resources in Health
  • Public system is under-funded and resources not
    equitably spread across country
  • Long-standing vacancies across categories acute
    for dieticians, nutritionists and pharmacists
  • Half of hospital beds are occupied by patients
    being treated for AIDS-related illnesses
  • 15 of health care workers are HIV-positive

Short-Term Strategy
  • Recruitment strategy to attract new graduates
  • Service contracts with health professionals in
    private practice
  • Partnerships with the private sector, NGOs and
  • Incentives to support health professionals with
    scarce skills and in rural areas
  • Streamline requirements for registration of
    foreign health professionals to work in public
    and rural health services
  • Development of human resource and skills
    development plans for years 2 - 5

Short-Term Strategy
  • National Training Programme
  • Establishment of regional training centres
  • Standardised curricula for comprehensive training
    of health professionals in the identified service
  • Training of existing health professionals
  • Multi-skilling of available health professionals
  • Training of utilisation of community service
    practitioners for 2004 to address the immediate
  • Telephonic clinical consultation support at a
    provincial level for all health professionals
    providing ART treatment care
  • Development of skills development plans for years
    2- 5

Operational Issues
  • Drug procurement
  • Drug distribution
  • Laboratory services

Drug Procurement
  • Key elements
  • Reliability, security and sustainability
  • Quality
  • Sufficient volumes consistently with envisaged
  • Affordability
  • Local production

Drug Procurement
  • Approach
  • Pooled procurement
  • Flexibility
  • Compliance with regulatory standards Medicines
    Act, Patent Act, TRIPS
  • API production
  • Parallel importation
  • Activities
  • Tendering
  • Supplier pre-qualification
  • Request for proposals
  • Contracts
  • Monitoring Evaluation
  • Administrative Issues Programme Assessment

Drug distribution
  • Reliable supply consistently through
  • Inventory management
  • Patient prescription information
  • Secured storage facilities
  • Efficient secure transport
  • Improved packaging
  • Key Activities
  • Provincial Depot Level (Contingency stock plan)
  • Public Health Service level (Pharmacy Contingency
    stock plan)
  • Accreditation (checklist)
  • Prescription tracking

Laboratory Services
  • Key in disease staging, monitoring
  • Infrastructure
  • List of baseline tests (biochemistry, full blood
  • Diagnostic, clinical monitoring, viral resistance
  • Viral load, CD4
  • Strengthening of system
  • Facility location
  • Volumes
  • Transportation
  • Turnaround times
  • Staffing
  • Research

Social Mobilisation and Communication
  • Guiding Principles
  • Content
  • Balance prevention and care
  • Clear messages on ARVs
  • Information on the programme
  • Healthy lifestyles
  • Nutrition
  • Adherence
  • Process
  • 3 tiers of government focus on political
    leaders and key opinion-makers
  • General public
  • Health care providers, including traditional
  • Families, communities and caregivers
  • NGOs and CBOs
  • Sectors of civil society

Information, Monitoring and Research
  • Patient Information System
  • Monitoring and Evaluation
  • Pharmacovigilance
  • Research

Patient Information System
  • Aim
  • collect patient-related information to monitor
    compliance, adherence, response etc.
  • Standardised forms (integrated with ME)
  • Patient-linked through personal identifier
  • Build on existing data and IT infrastructure
  • Upgrading existing data management IT
  • Paper-based systems backup
  • Integrated with electronic patient records

  • Aimed at providing safety profiles for patients
    and determine morbidity mortality associated
    with the use of ARVs
  • Existing programme at UCT, but this initiative
    focuses on supporting the ARV rollout
  • Strong technical and training support to specific

  • Aim
  • developing a research agenda for research which
    defines most effective provision of care and
  • Primary focus operational/health systems and
    behavioural as well as resistance monitoring
  • Structures and process to build on current
    arrangements with an advisory group advising on
    priority research and support of the programme

  • Presents a national budget
  • Details all resource requirements for
  • Combined to provide a uniform estimate of the
    resources required to support the integrated HIV
    and AIDS care and treatment plan over a five-year

Prevention Component
  • Funding for prevention
  • The JHTTT report noted the fundamental importance
    of maintaining and strengthening an effective HIV
    prevention programme, and that the availability
    of resources for prevention must not be
    compromised by the expansion of the care and
    treatment response.
  • Funds allocated for Prevention through the
    existing enhanced response programme
  • R550m per year allocated

Budget Estimates
  • 2003/4 - R296 million
  • 2007/8 - R4.5 billion
  • 2007/8 includes
  • R1 billion - health professionals
  • R1.6 billion - ARVs
  • R800 million - laboratory monitoring
  • R650 million nutritional support

New cases starting ART
Strengthening and Upgrading the Health System
  • Staffing Requirements
  • Upgrading Facilities and Pharmacies
  • Upgrading Patient Information, Monitoring
    Evaluation Systems
  • Upgrading the National Health Laboratory Service
  • Maintaining Health After HIV Infection
  • Nutritional Support and Supplementation
  • Diagnostic Monitoring Following Diagnosis of HIV

Total Programme Budget Estimate (Millions of
  • Strengthening prevention programmes
  • Strengthen VCT, PMTCT synergistic effect
  • The recruitment, training and retention of
    health care professionals
  • Building strong partnerships between health
    facilities and community support structures
  • Strong communication and community mobilisation
  • Additional financial resources
  • Complex to manage integrated

  • Improving the integration of services at facility
  • Integration of traditional and complementary
    medicines with Western therapies
  • Strengthening the National Health Laboratory
    System to meet the demands of the programme
  • Coordination of human resources, training,
    laboratory services, pharmaceutical services,
    drug procurement, and information systems
  • Ensuring high quality of care in the private
  • Pharmacovigilance in the public and private
    health sectors
  • Good patient information
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