harvard pepfar: six years of implementation mark barnes december 17, 2009 [email protected]
TRANSCRIPT
Harvard PEPFAR: Background in Three Countries
Nigeria – Gates grant on HIV prevention (Phyllis Kanki)
Tanzania – NIH-funded HIV and nutrition research (Wafaie Fawzi, Walt Willett)
Botswana – collaboration with MOH on national HIV laboratory, and NIH-funded research (Max Essex, Ric Marlink)
Harvard PEPFAR in Nigeria
AIDS Prevention Initiative in Nigeria (APIN) - established in 2000 with grant from Bill & Melinda Gates Foundation
Harvard PEPFAR(APIN Plus) Program initiated in 2004
APIN, Ltd. - incorporated in October 2007 as a local NGO to assume the functions of Harvard PEPFAR in Nigeria
APIN Ltd and Harvard PEPFAR Sites
Nigerian states that currently include sites under APIN Ltd & Harvard PEPFAR
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Indicator Harvard APIN Total
BC and S
Current•Adults•Peds
50,7951,691
13,551716
64,3462,407
Cumulative (Ever) •Adults•Peds
80,8993,287
23,2541,126
104,1534,413
ART
Current •Adults•Peds
38,1571,727
10,163587
48,3202,314
Cumulative •Adults•Peds
51,5772,072
13,887656
65,4642728
September 2009
Sites by Types
Organizational type # Remarks
Primary 1 Kuramo
Secondary 15 Includes 5 FBOs and 1 private hospital
Tertiary 13 5 teaching hospitals, 2 FMCs, NIMR, 68 Mil, GHM, GHOnikan, GHOgbom, GHIOde
NGO 4 AAN, ARFH, HaltAIDS, Mashiah
Total 33
Harvard PEPFAR Sites Benue: Federal Medical Centre Makurdi Borno
University of Maiduguri Teaching Hospital State Specialist Hospital
Maiduguri Nursing Home Maiduguri
Ebonyi: Widowcare Abakiliki Enugu: University of Nigeria Teaching
Hospital Ituku-Ozalla Kaduna: Ahmadu Bello University
Teaching Hospital Plateau
Jos University Teaching Hospital 8 Satellite Hospitals, 44 PHCs
Our Lady of Apostles Hospital Jos Yobe: Federal Medical Centre Nguru
Lagos 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine
Mushin General Hospital PHC-Iru Victoria Island
Onikan Women’s Hospital
Ogun: Sacred Heart Catholic Hospital Lantoro Oyo
University of Ibadan College of Medicine 3 Satellites under UCH
Adeoyo Maternity Hospital
Harvard sites transitioning to APIN
Late 2007-2008 Oyo State
43 Oyo State DOTS Centres
Lagos State PHC Iru Victoria
Island Ogun State
Sacred Heart Catholic Hospital
$1.705m grant
2009 Nigerian Institute for
Medical Research
Lagos University Teaching Hospital
Mushin General Hospital
Onikan General Hospital
$Budget 12.3m
• Lagos• 68 Military Hospital, Yaba • Military Hospital, ‘Creek’
• Oyo
• University of Ibadan College of Medicine
• General Hospital Ijebu-Ode
• General Hospital Ogbomosho
• St. Mary’s Catholic Hospital Eleta
• Adeoyo Maternity Hospital
Proposed for 2010 ???
ARV Pick-up data for assessment of ARV
regimen and adherence in evaluation of treatment failure
Transcription error ofDrug name
(ciprofloxacin) inPharmacy DB
The Treatment Utility Graph – very useful for adherence and clinical progress
Chief Clinical Director
Program Director
Satellite Coordinators
(North&South)
PMTCT Coordinator
TB/ Palliative
Care Coordinator
Program Associate
Quality Assurance
Coordinator
I .T. Specialist
Prev. & Lab.Coordinator
Database Specialists
North&South)
Chief Financial Officer
Human
Resource & Benefits Manager
Program Associate
Chief Pharmacist
Snr. Finance Officer (Lagos Office)
Senior Admin Officer
Logistics Officer
Pharmacist
Admin Assistant
Finance Officer
Admin Associate
Front Desk Officer
Finance Officer
Office Assistant
Office Assistants (Lagos)
Drivers (Abuja)
Drivers (Lagos)
Office Assistant (Abuja)
Cleaners (Lagos)
Cleaners (Abuja)
AIDS Prevention Initiative In Nigeria Organization Chart
Procurement Specialist
I nternal Auditor
Cashier
Country Director/ Chief Executive Officer
APIN Board
Store Assistants
Snr. Finance Officer (Abuja Office)
Snr. Finance Officers (North &
South Sites)
HR Specialist
Laboratory Officer
Prevention Officer
Snr. Admin Associate
M & E Officers (North & South)
Care & Support Officer
Program Associate
I .T.Associate
Systems Development
Strategic InformationHuman ResourcesFinance and AdministrationPharmacy/LogisticsQI/QAProcurementAudits
Challenges
Stakeholders’ skepticism about formation of APIN
Overlapping Harvard/APIN responsibilities
Different funding cycles – anticipated gap for each year of transition
APIN’s lack of working capital
Challenges
Drug warehouse fire- April 26, 2008 Space constraints- regulations on
construction Loss of trained personnel to other
PEPFAR partners and international NGOs
Lack of institutional support at some sites
Harvard PEPFAR in Tanzania
Tanzania Country ProfileArea 945,087 sq. km
Population (as of 2007)
39,384,223
Per capita income - about $350/yr- 58% earns <$1/day
Annual population growth rate
2.9%
Life expectancy 54 yrs for males & 56 yrs for females
HIV/AIDS in Tanzania
SOURCE: THIMS, 2007/8
There is a down trend of HIV prevalence
7% (2004) Vs 5.7% (THIMS 2008)
Prevalence rate in Ante Natal Clinics among pregnant women 2008
8.4%
PLWHA 2.5 million
In need of ARV 500,000
Currently patients on ARVs countrywide
280,000 (56%)
The National Care and Treatment Program
Launched in 2004
Government Commitment to provide free ARVs to all
PEPFAR and Global
Fund are among major supporting partners
Harvard- PEPFAR Program
Collaborating institutions (MDH) Muhimbili University College of Health &
Allied Sciences (MUHAS) Dar es Salaam City Council Harvard School of Public Health
Total ever enrolled75,198
Active on ARVs30,884Ever initiated ARVs
47,221
Harvard PEPFAR in Tanzania:Sept. 2009
September, 2009
29 sites Public 1 faith-based 18 sites Private
Urgent Need to initiate Care and Treatment in 2004
2004-2009 Priorities
Create more clinic space to accommodate increasing patients
Emergency staff hiring to meet increasing demand
Improve capacity of existing laboratories/establish new ones for patients monitoring
Training of service providers on HIV care
Addressing human resource problem
Through PEPFAR funding, we engaged more than 600 local staff to work with the program
Hired about 450 more staff Provided incentives to ensure staff
retention (training, good working environment, professional recognition)
Program paid staff are now being absorbed in the government system by phases
Training
MDH Program provided routine basic ART training according to national curriculum for the core and back up teams
1 month practical training Ongoing mentorship/preceptorship Video conferencing Later introduced other essential related
training according to needs Treatment adherence Nutrition
Strengthening of Laboratory Component
Huge investment in renovation to create space and meet standards (10 labs)
Procurement of equipments Procurement of reagents Training in GLP Quality assurance and quality control Putting in place supply chain
management
2009-2012 Priorities
1. System strengthening2. Quality Improvement Program3. Data management for decision making4. Transition Harvard core business to local
entity for sustainability
Quality Improvement (QI)
Building the culture of QI: regarding quality improvement program as important as meeting targets in numbers Development of indicators Regular assessment Feedback and strategies for improvement
Focusing on all 3 domains 1. Quality of care provided2. Ease of access to service 3. Patient satisfaction
Example: Addressing quality issues
Patients are less likely to stay in care if provided by overwhelmed health workers, at clinics far away
Innovations Size and proximity of services addressed
by scaling up and decentralization Prolonged working hours Visits scheduled by date and time block
Task Shifting Inadequate human resources Innovations to make use of available
resources Task shifting
Nurses dispensing drugs PLWHAs providing group counselling, tracking of
missing patients Using community lay workers to promote
adherence Integration of HIV care into general health
services (ANC, TB)
Patient retention – a major challenge
At least 20% of patients are lost to follow and are rarely traced
Patients not on ARVs are more likely to be lost to follow up
40% of lost to follow up patients are missed within their first 30 days of enrollment
Lost to follow up is often likely due to death LTFU has major public health implications
Patient tracking
Established a close monitoring system using available resources
At every visit, nurse/counselor updates map cue (phone number, physical address)
Patients are traced through mobile phones, or/and physical home visit
Community-Based Health Workers & volunteer PLWHAs follow-up patients with missed visits abnormal lab results that need immediate attention HIV exposed infants
Transitioning to Local Ownership
Plan is to transition the Harvard role to a local entity (MDH) by phases
During the process Harvard will continue providing TA and capacity building to the local entity
Local entity will continue to collaborate with Harvard in TA, training, research
Harvard PEPFAR in Botswana:Harvard PEPFAR in Botswana:Supporting the National ARV Therapy Programme (Masa)
Masa: Botswana National ARV Program
Total Population of Botswana – 1.8 millionStarted in 2002 – first African country to give
free ARVs to all citizensNovember 2009
110,000 on ARV treatment in Public Sector61.8% female6.8% children < 13131,444 - Total on Treatment (public and
private)
3535
Master Trainer/ARV Site Support Program
Clinical Laboratory
Monitoring & Evaluation Unit (within DHAPC):
Linked to:• All ARV sites
• Other MOH programs
Masa
BHP-PEPFAR ARV Site Support Program
Mother Sites Supported
Bokspit
Goodhope
Palapye
Masunga
Werda
Newxade
Each Mother Site has 3-4 Clinics
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CMT Cumulative Progress To Date
Originally 32 mother sites in regional hospitalsDirect support to:
29 District Hospitals2 Botswana Defence Force Hospitals138 Satellite Clinics – CMTs started and support60% of new patients initiated at new clinics
• Training (4,000 in formal training)– Nurse Prescriber & Dispenser – Nurse Dispenser– KITSO Introduction to AIDS Clinical Care– KITSO AIDS Clinical Care Fundamentals– Quality Assurance and Improvement (QAI)– Other topics as requested by MoH
37
38
LMT Cumulative Progress to Date:
Decentralized Labs: Set-up, Training and Support of 100% of labsCD4s - 21 labsVL – 8 labsPCR – 1 lab
Formal Lab Training (125 Lab Staff)CD4Viral LoadTraining ManualSample Collection and ProcessingRapid Testing for Nurses and Dried Blood Spot
Collection for Lay Counselors at sites without labs
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LMT Cumulative Progress to Date:
60% of CD4s now performed at decentralized labs
29% Viral Loads now performed at decentralized labs
Harvard PEPFAR in Botswana:2009-2012
Chartering of BHP, new not-for-profit entity in Botswana, with Harvard-MOH board of directors
BHP will become the prime recipient of PEPFAR funds in 2010
PEPFAR is only 20% of BHP activities
Thank You