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3.5 Years of Track 1.0 at the International Center for AIDS Care and Treatment Programs (ICAP)

3.5 Years of Track 1.0 at the International Center for AIDS Care and Treatment Programs (ICAP) September 24-26, 2007 Atlanta, Georgia David Hoos, MD, MPH. Enrollment, Sites, Outcomes Care and Treatment PMTCT and TB/HIV Highlighted Activities: Regionalization, Decentralization

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3.5 Years of Track 1.0 at the International Center for AIDS Care and Treatment Programs (ICAP)

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  1. 3.5 Years of Track 1.0 at the International Center for AIDS Care and Treatment Programs (ICAP) September 24-26, 2007 Atlanta, Georgia David Hoos, MD, MPH

  2. Enrollment, Sites, Outcomes Care and Treatment PMTCT and TB/HIV Highlighted Activities: Regionalization, Decentralization Task Shifting Community Testing

  3. Cumulative enrollment in HIV care (pre-ART and ART) & ART care at ICAP-supported sites, July 2004 - June 2007 HIV care (pre-ART and ART) Nigeria, Swaziland, Zambia Ethiopia Lesotho Mozambique Kenya, Rwanda, S. Africa, Tanzania ART care

  4. Cumulative pediatric enrollment in HIV care (pre-ART and ART) & ART care at ICAP-supported sites, July 2004 - June 2007 HIV care (pre-ART and ART) Nigeria, Swaziland, Zambia Ethiopia Lesotho Mozambique ART care Kenya, Rwanda, S. Africa, Tanzania

  5. Number of ICAP/CU-supported sites by activity, August 2007 Source: ICAP Site Census, August 2007

  6. Availability and comprehensiveness of on-site laboratory services at ICAP-supported care and treatment facilities (n=162) Source: P-FaCTS January 2007

  7. Number of providers per 1000 patients on ART at ICAP-supported care and treatment facilities (n=162) Source: P-FaCTS January 2007

  8. Cumulative enrollment in pre-ART vs. ART care at ICAP-supported sites by country as of June 2007(Total in care = 286,203)* n=35,593 n=36,737 n=26,827 n=9,184 n=24,716 n=4,618 n=36,377 n=14, 786 n=85,440 n=286,203 *Data not available for Swaziland

  9. Cumulative sex and age distribution of patients On ART at ICAP-supported sites as of June 2007 (Total on ART= 131,647) Children <15 9,870, 9% Male 15+ 35,307, 34% Female 15+ 60,235, 57%

  10. Cumulative pediatric (< 15) enrollment on ART by age and country at ICAP-supported facilities as of June 2007* n=1,091 n=1,290 n=169 n=2,203 n=229 n=836 n=1,627 n=1,071 n=1,867 n=10,384 *Does not include pediatric patients of unknown age group.

  11. ART regimens in adults at ICAP-supported sites by country, April-June 2007* Adults 15+ (%) *Data not available for Swaziland and Zambia

  12. ART regimens in children at ICAP-supported sites by country, April-June 2007* Children (%) * Data not available for Swaziland and Zambia ** In South Africa, d4T-3TC-LPV/r is also prescribed as a first-line regimen for pediatric patients.

  13. Average median CD4 count (cells/µL) at baseline and 6 and 12 months after ART initiation by country at ICAP-supported sites as of June 2007* *CD4 data are for subset of patients. Data not available for Swaziland and Zambia.

  14. Average median CD4 count (cells/µL) increase after 6 and12 months of ART by country at ICAP-supported sites as of June 2007* *CD4 data are for subset of patients. Data not available for Swaziland and Zambia.

  15. Reasons for ART discontinuation at ICAP-supported sites as of June 2007* LTF/Unknown 62% Dead 33% Stopped ART 4% *Does not include patients who transferred out.

  16. PMTCTNumber of ICAP-supported PMTCT facilities providing (n=148) and reporting (n=133) PMTCT indicator data, August 2007 Source: ICAP Site Census, August 2007

  17. Pregnant women counseled and tested in ANC atICAP-supported PMTCT facilities, April-June 2007 1st ANC=8,435 1st ANC=10,090 1st ANC=3,604 1st ANC=11,519 1st ANC=33,648

  18. TB/HIVICAP-supported HIV care and treatment facilities providing (n=170) and reporting (n=131) TB screening indicators, 8/07 Source: ICAP Site Census, August 2007

  19. Screening and treatment for active TB in ICAP-supported care and treatment facilities (cascade), April-June 2007 New HIV patients=2238 New HIV patients=4401 New HIV patients=2410 New HIV patients=2290 New HIV patients=11,339

  20. HIV testing and linkages with care and treatment in ICAP-supported TB facilities (cascade), April-June 2007 New TB patients=4866 New HIV patients=84 New HIV patients=443 New HIV patients=565 New HIV patients=5,958

  21. Human Capacity Building in Eastern Cape, South Africa • With 10% of population HIV infected, there are 102 and 16 nurses and doctors per 100,000 inhabitants respectively and only 5 doctors per 100,000 inhabitants in the rural areas • The Registered Nurses (RNs) provide the majority of care and treatment services in the Primary Health Care Facilities • Training on HIV care and treatment services is limited for the PNs • The hospital based doctors do not routinely provide clinical mentoring at the PHC level • There are few qualified mid-level cadre of pharmacy staff such as pharmacist assistants.

  22. Strengthening and Training of Health Care WorkersICAP SA Initiatives • Training and Mentoring of Nurses • Post Basic Certificate Course in Clinical Management of HIV • Nurse Mentorship Initiative (NMI) • Training of Pharmacy Assistants • Picture above:Sister Nyakata of Qobo clinic. • One of the first Registered Nurse to work with ICAP Clinical nurse mentors

  23. Post Basic Certificate Course in Clinical Management of HIV • ICAP in partnership with the Universities of Fort Hare and Stellenbosch pioneered the introduction of a Post-basic Certificate Course in Clinical Management of HIV/AIDS in Adults and Children • Program is being implemented between April 2007 – February 2008 • Course is designed to provide seven 3 to 4-day contact sessions in East London and one 5-day clinical practicum at Tygerberg Hospital, Cape Town • 26 Registered nurse midwifes have enrolled into the course • Current plan is to update this course into a masters program in collaboration with South African Academic and professional Institutions • Stellenbosch University’s newly created Centre for Infectious Diseases is an implementing partner and has been involved in the design and facilitation of the course

  24. Nurse Mentorship Initiative (NMI) • In November 2006 a pilot NMI was initiated in Qaukeni Local service area of Eastern Cape • Three registered nurses with extensive experience in HIV care and treatment started mentoring and working with the DOH Nurses at the Primary health clinics (PHC) • In February 2007 ICAP in partnership with the EC nursing schools and the DOH, the NMI was launched to improve quality of HIV service delivery for the local population • 10 Clinical Nurse Mentors (CNM) were hired by ICAP to facilitate the NMI • The program focuses on advanced clinical skills for the management of HIV and AIDS

  25. NMI Strategy • One year program divided into 2-components: • On-site program • Initial 2-week training program • Three workshops spread out through the year • Off-site program • The CNMs participating in the NMI are mentored by an ICAP nurse practitioner within the PHCs • These CNMs in turn mentor DOH registered nurses at these same facilities • The registered nurses at site level then mentor the current staff and any newly deployed nurses

  26. Role of the Clinical Nurse Mentors (CNMs) • Review HIV care and treatment guidelines with the ‘Mentees’ • Help the mentees obtain clinical care competencies • Conduct comprehensive patients assessments for care and treatment in collaboration with the clinician at the PHC • Help the Mentees establish a medical diagnosis, including psychosocial and cognitive problems. • Advises on prescribing medication according to standard treatment guidelines and in consultation with supervising doctors or nurses. • Collaborates with DOH on continuing education programs to ensure current knowledge of procedures, protocols, and clinical care issues • Provides feedback on quality improvement and participates in implementing clinic-wide performance improvement measures

  27. Training of Pharmacist Assistants • The South Africa National Department of Health’s Human Resource plan for Health (HRH) underscores the need for continued training and skill development as a staff retention strategy • In Port Elizabeth, ICAP is supporting a total of 9 primary health clinics (PHCs) managed by the Eastern Cape Department of Health and the Nelson Mandela Metropolitan Municipality • These 9 PHCs share the services of one registered pharmacist, with very few qualified mid-level cadre of pharmacy staff such as pharmacist assistants • ICAP in July-August 2007 begun supporting a ‘Task-Shifting’ strategy that will result in the increase in the number of qualified pharmacists assistants

  28. Pharmacist Assistants Training Program • A basic pharmacist assistant 12 month apprenticeship course was designed for ICAP by the Frais Health Management Training and the Nelson Mandela Metropolitan University • Learning process entails 6 - 10 days contact training, distance learning via correspondence, with a registered South Africa Pharmacy Council tutor providing regular mentorship and supervision • Through a partnership with the provincial and local department of health, ICAP has managed to provide the trainees with tutors at the health facilities where training will take place • ICAP has already selected and hired 7 Pharmacist assistant trainees who will remain working in the supported health facilities whilst they continue with their training programme • This approach to training of pharmacist assistants is in the process of being replicated across other ICAP-South Africa supported regions in the Eastern Cape.

  29. More than 800 of associations in Rwanda; estimated 29,000 active members Coordinated nationally by the National Association of PLHA (RRP+) and regionally by RRP+ Regional coordinator Monthly meetings provide emotional and social support to members Concern that some PLWHA association members are “presumed” HIV+, but have never been tested Associations members are untapped human resource for HIV/AIDS programs in Rwanda Utilizing PLWHA to Increase HIV Testing in Families in Rwanda

  30. Family members of those in HIV care often have not been tested, and don’t participate in Associations Associations can be used to identify discordant couples, and also focus on PwP Associations are motivated to support their membership, and thus are a resource for VCT outreach and assuring links to C&T for those testing positive Rationale for New Strategy

  31. Overall Goals • To increase access to HIV care and treatment via family approach • Greater involvement of people living with HIV/AIDS • Increase early TB case detection and initiation of treatment

  32. Essential steps • RRP+ and ICAP jointly developed the model • Two pilot sites were selected: • Kabaya DH and Shyira DH • Five pilot associations were selected • 29 Peer Educators and 2 supervising Social Workers were selected • Peer Educator training developed and held • Strategy testing pilot phase • “Family Testing Days” were scheduled weekly at each site • Regular supervision, support and data collection by 2 ICAP Coordinators

  33. 1050 members from 258 families registered 713 (68%) had never had HIV test 649 (91%) tested during the pilot phase During the 8 family testing days of the pilot phase (Oct 18-Dec 06,07, the following results were achieved: Kabaya DH: Total number tested: 358 - Adults: 82 (1 HIV+) - Children: 276 (8 HIV+) Shyira DH: Total number tested : 291 - Adults: 131 (7 HIV+) - Children: 160 (1 HIV+) Results from the Pilot Phase

  34. Kabaya results

  35. Shyira results

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