Public health approach to scaling-up ART using WHO IMAI/IMCI tools

Dr Sandy Govefor the IMAI team and partners

G-8 in Gleneagles, Scotland in July 2005

they will “work to meet the financing needs for HIV/AIDS”

called on WHO, UNAIDS and other international bodies "…to develop and implement a package of HIV prevention, treatment and care," specifying a target of “as close as possible to universal access to treatment for all those who need it by 2010.”

Includes: Includes: WHO model essential package for WHO model essential package for HIV prevention, care, treatment & supportHIV prevention, care, treatment & support• List of interventionsList of interventions• Normative guidelinesNormative guidelines• Operational tools, capacity building materialsOperational tools, capacity building materials• Core information system: standardized patient Core information system: standardized patient monitoringmonitoring• Drug and diagnostic supply management Drug and diagnostic supply management

Universal access requires a massive effort. This calls for -

• a standardized and streamlined approach that can scale-up

• a decentralized and integrated public health approach

- in context multiple programmes and focal points with separate

activities, funding • a coherent programme of work for broad

implementation

- may span several national programmes and involve both government, NGO, FBO, private practitioner and workplace teams

Public health approach to scaling up HIV/AIDS services– address the health needs of the population

• Identify essential package of integrated HIV prevention, care, treatment and support interventions for health sector delivery

• Decentralization and integration of health services• Standardization and simplification of protocols and

procedures (to enable broad coverage)• Clinical team approach to patient management, including

task-shifting• Strengthening HIV prevention in health-care settings• Community mobilization to promote HIV testing and

prevention and prepare communities for treatment and adherence support

• Population-based HIV drug resistance and pharmacovigilance

• Free ART at the point of service delivery

Public health approach to scaling up HIV/AIDS services– address the health needs of the population

• Identify essential package of integrated HIV prevention, care, treatment and support interventions for health sector delivery

• Decentralization and integration of health services• Standardization and simplification of protocols and

procedures (to enable broad coverage)• Clinical team approach to patient management, including

task-shifting• Strengthening HIV prevention in health-care settings• Community mobilization to promote HIV testing and

prevention and prepare communities for treatment and adherence support

• Population-based HIV drug resistance and pharmacovigilance

• Free ART at the point of service delivery

WHO model essential package

Facility-based interventions

Interventions through

outreach to most at-risk populations

Community-based

interventions

Within the WHO model essential package for HIV prevention, care, and treatment

WHO operational tools for integrating interventions within the model essential package. These include:

IMAI integrated management of adolescent and adult illness

IMCI integrated management of childhood illness•acute and chronic HIV care•ART•prevention by PLHA•infant feeding counselling•special interventions for other most at-risk populations

IMPAC integrated management of pregnancy and childbirthPMTCT interventions integrated in

• antenatal care• labour and delivery• post-partum • newborn care

Standardization and simplification of protocols and procedures

WHO updated normative guidelines, based on expert groups

• Standardized first- and second-line ARV regimens• When to start, substitute, switch and stop• Updated ART and ARV prophylaxis regimens for PMTCT• Cotrimoxazole and PEP recommendations

IMAI/IMCI further simplifies and operationalizes these guidelines and provides tools to support implementation:

• management support• job aids and training for clinical teams and CHWs• strong follow-up after training- clinical mentoring,

supportive supervision• standard, simple patient monitoring system

IMAI & IMCI tools to support decentralization of HIV prevention, treatment, and care- for equity

accessadherence

Primary care delivery - close to home

Community-based care

Central/RegionalHospitals

District hospital

Decentralization within a district network

Patient-centered: empower patients for self-management• Most symptoms; prevention by PLHA• When to seek care from health worker• Supported by treatment supporter/ CHW• In context community treatment literacy, prevention support

Nurse-led health centre teams (or clinical officers etc)• Acute and chronic HIV care and prevention• First-line ART in uncomplicated patients

Including initiation in children and pregnant women

Multipurpose district doctor or medical officer• Backs up health centre and outpatient primary care clinical

teams • Good distance communication• Regular on-site clinical mentoring

Decentralization of HIV services

Health centre- nurse, PLHA lay providersHIV testing and counsellingHIV education and support Basic prevention for all: safer sex, condoms, STI managementPrevention by PLHAPMTCTChronic HIV care including OI prophylaxis, stagingManage common OIAdherence support**Preparation for ARTInitiate ART in uncomplicated patients ART dispensing and follow-upRecord-keeping

Hospital outpatient clinic, inpatient- doctorInitiation of ART in 'complicated,' sick and hospitalized patientsManage complicated opportunistic infectionsManage treatment failure and adverse effectsManage complications of ARTRecord-keeping

Acts as a primary care facility-all functions to the left but not by doctors!!

Benefits to decentralization

Better support for deep commitment to good adherence • Support by community, CHW, other treatment supporters• Reduced transport time and costs for periodic visits

Lifetime chronic care is more feasible when close to home

More feasible to reach patients unlikely to travel to ART hospital:• Pregnant women• Children Seriously under-represented in those on ART

IntegrationIntegration of multiple interventions• Prevention, care and treatment integrated at point of

service• Coherent acute and chronic HIV case management

approach (integrated management of multi-system disease)

• HIV services integrated with management other diseases and conditions

HIV integrated within existing health system• Strengthens the health system• Assure delivery of basic care • Builds a district network

Why an integrated approach?

HTCPMTCT

HIV Care/ART

TB/HIVNational level

District level -

primary care facility

STI Targeted Interventions

Community Preparedness

Where does integration occur for an essential package?

Global and regionalAgreement on a priority set of interventions

NationalFlexible package for country adaptation

DistrictCollaboration between those responsible for

various HIV services, TB, maternal and child careClinical team

Coherent management guidelines Family approach to care

Community Treatment literacy and prevention promotion Strong links with health facility

Integrated approach for efficient scale-up of the essential package

One scale-up of HIV services at district level– Chronic HIV care, ART, T&C, PMTCT– All ages

All adult HIV care/ART sites should integrate:– PMTCT, other 'positive prevention' by PLHA– Paediatric HIV care/ ART

• Most rapid way to scale-up is integrated• Family-based care• Build on basic IMCI and paediatric referral care for

the most common conditions• Special emphasis on paediatric training needed

Integrated approach better serves HIV clients with other diseases (TB, malaria, STI) or conditions (pregnancy, IDU)

• Clinical co-management• Co-supervision by district teams (HIV, TB. MCH)• Co-sponsorship by national programmes- shared programme of work

Efficient management for patient (single clinic visit)and clinical team:• TB-HIV co-management• IDU-HIV co-management

– Special care for IDU integrated with HIV care and ART within primary care, opioid substitution therapy

• Pregnancy-HIV co-management for PMTCT• updated ART or ARV prophylaxis delivery integrated in

antenatal, L&D, post-partum and newborn care• train midwives and obstetricians in first-line ART and rapid

adherence preparation and support

IMAI/IMCI approach to scaling up integrated HIV prevention, care and treatment

Establish good chronic HIV care with clinical teams working within a district network

– district network model (facility-community hybrid)• hospital plus satellite health centres

plus community-based care– linked facility and community interventions– no parallel systems- HIV services are

integrated

Central, Regional,

University,

DISTRICT HOSPITAL

COMMUNITY

Clinical care- nurses, pharm techs; ART aid.Sometimes clinical/ health officer

Treatment supporters, health extension officers, other community health workers, peer support groups, CBOs

Doctors/health officers/ inpatient RN

Specialisedreferral

HEALTH CENTRE

Drugs, diagnostics, commodities, logistic support

National, Regional and District ART Management

Referral, B

ack-Referral; C

linical mentoring;

Supervision by District H

IV Managem

ent Team

Emphasis onstrongfacility-

community link

IMAI/IMCIIMAI/IMCI

IMAI/IMCI provide a flexible toolkit, for country adaptation

Fit to HIV epidemiology• Generalized or concentrated epidemic• Which populations are most at-risk

IDU, sex worker, MSMDiscordant seronegative partners of PLHA

Adapt to health system

Sociocultural adaptation

Not one size fits all!Other service delivery models

How can IMAI/IMCI be scaled up in the midst of a human resource crisis?

Emergency human resource strategy, supported by concrete tools for country adaptation:

• Task-shifting• PLHA workforce- to expand clinical team; as CHWs- trained

and paid • Prevention and care for health workers

– PEP, safe injections, universal precautions– Recognize and respond to burn-out– Clinical mentoring- attention to health worker needs, help with difficult

patients, career support• Rapid preparation of clinical teams with in-service training• Rapidly into pre-service training

Other WHO and partner efforts: retention schemes; special testing, care and treatment services for health workers (TTR)

Task-shifting

Specialized physiciansdoctorsDoctors health officers and nurses Nurses PLHA on clinical team:

ART aid (counsellor), triage/data clerkClinical team patient: self-management **Clinical team community- for case detection, treatment support, home-based care, simple monitoring

Build functional clinical teams linked to the community within a district system

HIV learning programmes to support task-shifting

Specialized physicians → doctors

Doctors → nurses, clinical officers

Nurses → Nursing assts, PLHA on clinical team, CHW

Clinical team → patient (self-management)

Second level learning programme

Basic ART, HIV care, prevention clinical course; Acute care/OIs

Basic ART Aid /Prevention course

Patient self-management &community tools

All use PLHA "expert patient-trainers" to present cases, provide feedback

IMAI-IMCI: harmonized, modular short courses

TB-HIV

Week 1

Week 2,

follow-on

Chronic HIV Care with ART and Prevention

Acute Care:OI

IMCI-HIV

STI

PITC

Patient Monitoring

Reproductive choice/FP

Palliative care

PMTCT: infant feeding

PMTCT: antenatal/PP/L&D

Adolescents

Mental health

MSM, IDU, sex workers

Rapid scale-up is feasible

Ethiopia: 130 health centre clinical teams already prepared this year

Scale-up training is feasible • Continuous training over weeks

Challenges:• Volume clinical mentoring and supportive supervision

after training• Systematic linkages with community and outreach to

most at-risk populations• Drug and diagnostic supply management, logistics

Clinical mentoring: combine some individualized patient care with public health approach

For complicated patients: consultation, referral, on-site case review during on-site visits ,

Public health framework with more intensive clinical content for certain patients

Management support- HIV district coordinators course-

precedes clinical training

Planningintegratedservices

Targetedcommunity

interventions for

populationsat high risk

HIV care/ART

patientmonitoring

Capacitybuilding:

- clinical team:

- CHWs

Organizingpregnancy

relatedservices Antenatal,

PP/newbornPMTCTpatient

monitoring

Follow-upafter

training

Drug and diagnostic supply management

=

District hospital

HIV care/ART clinic

TB clinic:TB-HIV

Co-management

Antenatalclinic:

ART for PMTCT

=

Health centres:HIV care, ART, preventionTB-HIV co-managementPMTCT including ART

Decentralize, expand number of sitesDecentralize, expand number of sites

Standardized guidelines, training, management tools Share training, mentors, patient monitoring system within a district

Hospital

Health Centre

Health Centre

Health Centre

Health Centre

Health Post

Health Post

Health Post

Health Post

Health Post

Health Post

Health Post

Health Post

Health Post

Health Post

Health Post

Health Post

MOH

NGO or FBO

WorkplaceHIV

services

Scale up toward universal access is more feasible, sustainable

Privateproviders

Militaryservices

Challenges• Get patients on ART sooner:

• to reduce preART and early mortality on ART• easier for primary care teams to manage patient• prioritized use of CD4

• Inpatient testing and preparation/initiation of ART (severe wasting; persistent diarrhoea)- modify outpatient materials to prepare inpatient staff

• How to systematically scale-up home-based delivery through CHWs (linked with health facilities):– HIV testing and counselling, provide and link with services– more effective prevention with home delivery

• disclosure support, partner testing, risk reduction counselling especially for discordant couples

– cotrimoxazole, ART, TB, TB-ART treatment support