Transcript Experiences in Coastal Kenya ppt, 308kb

INTRODUCTION OF ART IN
COMPREHENSIVE HIV/AIDS
CARE AND SUPPORT:
MONITORING AND
EVALUATION
John A. Adungosi, MB Chb, MSc,
MRIT
ACKNOWLEDGEMENTS
• Dr. S.K. Sharif, PMO—Coast Province
• Dr. H. Shikely, Chief Administrator, Coast General Provincial
General Hospital
• Staff of CPGH, Port Reitz District Hospital, Mkomani-Bomu
Medical Centre and Magongo Health Centre
• USAID
• Technical Advisory Partners:
– Family Health International
– MSH/RPM Plus
– Population Council/HORIZONS
Purpose of HIV/AIDS care treatment and
support programmes:
• To reduce morbidity and mortality from HIV/AIDS
and related complications.
• To improve the quality of life of adults and children
living with HIV/AIDS and their families.
• To assure equitable access to diagnosis, medical
care, pharmaceuticals, and supportive care.
• To promote prevention opportunities within care and
support service delivery.
Elements of Comprehensive Care and Support
Socioeconomic Support
e.g.:
•Material support
•Economic security
•Food support
Medical & Nursing
Care
e.g.:
•VCT, Family Planning
•Preventive therapy
•OI treatment and HAART
•Palliative care
Human Rights and
Legal Support
e.g.:
PEOPLE AND
FAMILIES
AFFECTED BY
HIV/AIDS
•PLHA participation
•Stigma & discrimination
reduction
•Succession planning
Psychosocial Support
e.g.:
•Counseling
•Spiritual support
•Follow-up counseling
•Community support
Background
Why did the ART program start?
1. Availability of HAART in Kenya: from mid-90s
in private hospitals
2. Prohibitive cost of treatment amidst intense
public interest
3. Government responses to improve access
4. Increasing availability of ARV drugs due to
progressive reduction in prices and initiatives
to improve access
Background (2)
5. National consultative meeting on ART
– Convened by IMPACT in Sept. 2001
– Involved local and international stakeholders,
donors, researchers, PLHA and community
groups
– The purpose was to review the ART situation
in Kenya and chart the way forward
– The result was the setting up of a National
ART Task Force
Background (3)
• National ART task force
– Composed of local and international stakeholders,
community groups, PLHA, professional
associations,donors and development agencies
– Acts as an advisory board to the NASCOP and
Director of Medical Services
– Has many sub committees (Drugs, training,
Systems development
– Provides platform for sharing experiences on ART
implementation
Site Information: Kenya

National Adult HIV Prevalence: 10.2%

Project Site: Coastal city of Mombasa

Health Facilities
1. Coast General Provincial Hospital: 700-bed
tertiary referral hospital with >70% of beds
occupied by HIV/AIDS patients.
2. Port Reitz District Hospital: Government
referral hospital.
3. Mkomani Bomu Clinic: Semi-private primary
health care clinic.
4. Magongo Health Center: Local government
primary health care clinic.
Where is the program
implemented?
Mombasa: Rationale for Site Selection (1)
High HIV prevalence and disease burden
Sites provide the opportunity to introduce ART
at different levels of health care services as well
as multiple entry points to ART services within
the same catchment area
Sites are linked through a referral network
system and to some services that provide
elements of comprehensive care and support
Where is the program implemented?
• Rationale for Site Selection (2):
– USAID supported programs in Mombasa provide
elements of comprehensive care and support
• IMPACT: Prevention activities (BCC, STI
management) & care activities (VCT, management
of OI, psychological support to PLHA)
• COPHIA: Home-based care activities
• PSI: Condom promotion
• Strong political commitment
How is the program implemented?
1. Establish the Technical Advisory Partners
and define the role of each partner:
– Partners’ roles
• FHI/IMPACT: overall implementation and M&E
• MSH/RPM Plus: strengthening drug and
commodity management
• Population Council/Horizons: conducting
operational research related to the introduction of
ART program
How is the program implemented?
2. Develop a concept paper describing the
3.
implementation of the program
Convene a workshop with local stakeholders to
discuss the concept paper
• The TAP described the ART Program
• Local stakeholders provided recommendations on
•
key programmatic issues and the framework for
the program
Local stakeholders provided their commitment to
support and promote the program
How is the program implemented?
4. Establish the ART program management
structure
•
Steering Committee:
o Composition:
Local stakeholders
o Responsibility: Overseeing program implementation
•
Scientific Committee:
o Composition:
Local and international researchers
and
scientists
o Responsibility: Developing realistic minimum package
of activities (e.g eligibility criteria, Rx
treatment monitoring schedules)
How is the program implemented?
4. Establish the ART program management structure
•
Operational Management team:
o Composition: Program coordinator, ART site team
leader, partners’ field officers
o Responsibility: Daily management of the program
•
Technical Advisory Partner:
o Composition: RPM Plus, Horizons, IMPACT, USAID
o Responsibility: Providing technical support to the
program and the different committees
How is the program implemented?
5. Conduct assessment of existing capacity
for implementing HIV care program
including ART
6. Strengthen the capacity based on the
findings from the assessment
7. Develop implementation plans
8. Execute, monitor and evaluate the
implementation
What have we done so far?
1. All committees have been established
–
Scientific Committee has defined eligibility criteria
and treatment monitoring schedule, Steering
Committee approved
2. Assessment of existing capacity was conducted
3. Based on findings from the assessment, an
implementation plan was developed with each
facility
What have we done so far? (2)
•
The capacity of the CPGH has been
strengthened:
– Training of 37 clinicians, pharmacists and
laboratory staff was completed in April, 2003;
– Standard Operating Procedures and clinical data
collection tools are in place;
– Procurement of laboratory equipment is underway
(CD4 instrument);
– Drug storage and security at pharmacy have been
developed;
– Nurse adherence counselors were trained in
adherence monitoring.
What have we done so far? (3)
• The CPGH Comprehensive HIV Care Center
is operational, providing HIV clinical
services, ART, nutritional counseling, TB,
STI, and referral to home care, inpatient
services, MCH/ANC, PMTCT, and the
Pediatric Clinic.
• On May 23, 2003, patients started ART in
accordance with eligibility criteria.
PATIENT DATA
• The Comprehensive HIV Care Centre:
– Began clinical care on April 17, 2003
–
number of HIV infected patients
followed:
• Female
• Male
WHO Clinical Staging:
– II
– III
– IV
PATIENT DATA (2)
• The First Month of ART at CPGH:
–
–
–
–
Total: HIV Care- 123; ART 11
Gender-=Female/
Male
Range of CD4 counts—03-201
Adherence counseling—all patients participated in a
minimum of 3 mandatory adherence counseling
sessions prior to starting ARVs
– Response to ARVs:
• Incidence of adverse symptoms—
MONITORING AND EVALUATION
• Objectives:
1. To improve the capacity of HIV/AIDS clinics, laboratory
2.
3.
4.
and pharmacy services in selected public health
facilities in Mombasa to support the introduction of
comprehensive care including ART
To provide ART to 300 patients over a period of five
years in accordance with eligibility criteria
To sensitize and strengthen communities and PLHA
support groups in HIV/AIDS comprehensive care,
including ART
To explore Operations Research Questions (e.g., What
is the effect of DAART upon ARV adherence?)
FORMATIVE ASSESSMENT DATA
COLLECTION TOOLS
• Needs Assessment Tool:
--National Clinical Guidelines
--Physical infrastructure
• Laboratory services
• Pharmacy
--Human resources and staff capacity
--Clinical services and referral mechanism
--HIV diagnosis
--ARV management
--Management Information Systems
--Cost Issues
STANDARD OPERATING PROCEDURES
• Clinical Care and Patient Flow
– Adult and Paediatric
• Post-exposure prophylaxis
• Drug and Commodity Management
• Laboratory and Other Investigations
DATA COLLECTION TOOLS (2)
• Patient Clinical Monitoring Forms:
--Comprehensive Care Centre Registration Form
--Nursing Assessment for Triage Form
--Clinical Management of HIV Patients: First Visit
--Follow-Up Review of HIV Patients
--Enrollment Form for Adult ARV Treatment
--Medical Follow-up of Adult Patients on ART
--Referral System Form
--Clinic Attendance and Treatment Follow-Up
Register
MONITORING AND EVALUATION
(3)
Indicator Categories:
Clinical/biological outcomes
ARV treatment adherence
Occurrence of adverse drug effects
Occurrence of OIs, including TB
Drug management and inventory control
Laboratory monitoring and equipment utilization
Referral for community based services, including home
care and psychosocial support
Training and refresher courses
Impact of community outreach on stigma and treatment
seeking
MOMBASA PROJECT: M&E PLAN SAMPLE
Specific Objective 2: To provide ART to 300 patients over a period of five years in accordance with
eligibility criteria
Activities/resources
Indicators
Outputs
Long term
outcomes
(impact)
Definition (key indicators)
Sources of
data and
methods
Periodicity
of
collection
Responsible
Sub-Objective 2.1: Develop and implement client monitoring system including development of adherence system
Develop clients
monitoring system
including development
of adherence system
Client
monitoring
and adherence
system
developed
Implement client
Monitoring system
including adherence
# and % of
clients
referred
eligible for
ART
Forms for
clients
monitoring
Numerator: # of HIV + clients
who attended the sites and who
are eligible according to criteria
upon agreed by the steering
committee/local guidance
Denominator: total # of HIV+
clients who attending the sites
in a given period
# of clients
who started
ART and
adhere to
treatment
% of clients
who
demonstrate
95%
adherence
to treatment
Numerator: # of clients who
show 95% adherence to ARV
therapy during the life of the
project
Denominator: total # of clients
enrolled at the start of the
project
FHI and MOH
staff
Clinic
records
Regular
basis
Sites
monitoring
reports
Quarterly
reports
Clinic staff
M&E officer
Annual
reports
Clients
records
Sites
reports
Regular-basis
but to be
compiled every
quarter
NEXT STEPS
• Scale-up project at 3 satellite sites in Mombasa
• Progressively develop computer-based data
•
entry system at each site
November 2003: completion of 6 months of
ART at CPGH
– Collect, analyze and report on key findings
– Document lessons learned from start-up of
ART project
– Disseminate data and conclusions to key
stakeholders and service providers