examples of scale up
DESCRIPTION
Scaling up HIV/TB programs The role of Capacity Building Dr Alex G Coutinho Infectious Diseases Institute Makerere University, Kampala, Uganda. EXAMPLES OF SCALE UP. NUMBER OF PEOPLE RECEIVING ANTIRETROVIRAL THERAPY IN LOW- AND MIDDLE-INCOME COUNTRIES 2002-2007. - PowerPoint PPT PresentationTRANSCRIPT
Scaling up HIV/TB programs The role of Capacity Building
Dr Alex G CoutinhoInfectious Diseases Institute
Makerere University, Kampala, Uganda
EXAMPLES OF SCALE UP
NUMBER OF PEOPLE RECEIVING ANTIRETROVIRAL THERAPY IN LOW- AND
MIDDLE-INCOME COUNTRIES 2002-2007
WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008
SCALE-UP OF CLINICAL SERVICES FOR SEX WORKERS UNDER THE AVAHAN INDIA AIDS
INITIATIVE
WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008
Trends in number of person on ART – 2003 - 2007
Source: Republic of Uganda. Ministry of Health. (2007). Annual health sector performance report : Financial year 2006/2007. Kampala: Ministry of Health.
SCALING UP – REQUIRES----
• The need – i.e. Disease Burden• The gap in service provision• The will and political/technical leadership• The knowledge on what/how to scale up• The people (with knowledge) to scale up• The policy framework• The financing• The monitoring and evaluation tools to track
progress and provide corrective solutions
Common Characteristics of “Success Countries”
• Top Leadership (sustained)
• Grassroots and community engagement, acceptance and involvement
• Stigma free environment ( general and for specific groups)
• Policies and programs
• Resources
• Metrics to track response
Kenya, 245,162
16%
Mozambique, 156,108
10%
Tanzania, 139,151
9%
Uganda, 78,769, 5%
Eritrea4,838 Madagascar
1,491Mauritius
584
Comoros28
South Africa, 473,499
31%
Zambia, 103,077
7%
Ethiopia, 94,489
6%
Malawi, 86,905, 6%
Rwanda, 9,225, 1%
Botswana, 13,518, 1%
Swaziland, 15,131, 1%
Namibia, 16,082, 1%
Angola, 21,777, 1%
Lesotho, 22,666, 1%
Zimbabwe, 45,652, 3%
Eastern & Southern Africa
1.5 million (57%)
Rest of the world1.2 million (43%)
Global new infections, 2.7 million
ESA new infections,1.5 million
Estimates of New HIV Infections in Eastern and Southern Africa, 2007 (Source UNAIDS RST)
TB Cases
THE GAP
THE KNOWLEDGE
HIV Prevalence among CSWs (Kampala - 2001 and 2003)
28.2
47.2
05
101520253035404550
HIV
pre
val
ence
(%
)
2001 2003
Year of study
Viral Load and Transmission Rates Among Discordant Couples by Gender In Uganda
0
5
10
15
20
25T
rans
mis
sion
Rat
e
HIV Viral Load, RNA Copies / mL
A. Sexual Transmission B. Perinatal Transmission
HIV Acquisition among Male Partners of HIV + Female Partners By Circumcision
Status In Rakai
40/137 uncircumcised men (16.7/100 py) vs. 0/50 of circumcised men became infected after two+ years (p = 0.004).Quinn et al NEJM 2000
Circumcision and HIV Transmission to Women
0
6.9
0
12.6
25 25.6
0
5
10
15
20
25
30
Transmission/100py
<10,000 10,000-49,999 >50,000
Circumcised
Uncircumcised
Of 47 couples in which circumcised male partner was HIV+ AND whose viral load was <50,000 particles, 0 of female partners were infected after two years, vs. 26 of 143 female partners of uncircumcised HIV+ men (9.6/100 py) (p = 0.02).
Male Viral load
Quinn et al NEJM 2000
The Three Trials: Study Results
South Africa Uganda Kenya
3128 4996 2784
HIV Incidence MC (N) 0.85 (20) 0.66 (22) 2.1 (22)
HIV Incidence Control (N) 2.1 (49) 1.33 (45) 4.2 (47)
Percent Protection (ITT) 60%* 51%* 53%*
As treated 76% 60% 60%
Adverse Events 54 (3.6%) 178 (7.7%) 21 (1.5%)
0.00
0.25
0.50
0.75
1.00
Pro
port
ion
alive
0 1 2 3 4 5Years from cohort enrolment
Entebbe CohortDART trial
Survival
How can we scale up circumcision while waiting for policy efforts to
catch up?
Communal drinking in Uganda –an ideal setting for TB infection
THE MONEY
THE HEALTH SYSTEM
Crumbling Health infrastructure in a rural District In Uganda
.
Capacity building is not just about existing knowledge but also
about the pursuit and discovery of new knowledge
.
LANDMARK RESEARCH FROM UGANDA
• PMTCT nevirapine regimen (HIVNET 012 trial)• Male circumcision as an HIV prevention intervention• Basic care package including cotrimoxazole
prophylaxis to reduce morbidity• Impact of ART on Mortality and morbidity• Influence of viral load on HIV transmission• HIV incidence in a rural cohort 1990 -2005• Home based Delivery of ART and HIV testing
Number of Uganda and Congo HIV/AIDS Research Publications by
Year:1983-2008
JUMP
• Integrated management• On-site training• Team approach (clinicians, lab and records staff)• Training on smear microscopy and rapid diagnostic
tests for fever• Test diagnosis-based targeted treatment• Avoids misdiagnosis, overuse of antimalarials, and
delays in treatment of other illnesses
Akokoro
Omugo
KasambyaIganga
WalukubaKyenjojo
Kabale
Nagongera
Kiryandongo
Kamwezi
KIhihi
Aboke
Apac
Aduku
Aber
BuwengeMukujju
Mulanda
Bugembe
Ogur
Amac
AlebtongAnyeke
Orum
Kibalinga & Butawata HCII
Wakitaka & Megamaga
Paya & Kisoko HCW
KisoroDistrict HCW
Rukungiri District HCIIs
OliAdumi
Aroi
NebbiPakwach
St Paul
Kilembe
Exxon Cascade IMM sites
Exxon RDT sites
Exxon IMM Sites trained at IDI
PMI IMM Sites trained at IDI
IDRC RDT sitesWHO RDT sites
The whole district
The whole districtWas trained The whole
district was trained
Impact: JUMP On-Site Follow-Up
• Developed a monitoring and evaluation system that demonstrates the impact of training and capacity building on improved case management for malaria at health facility level
• Improved surveillance systems and data collection in the target health facilities.
• QA/QC for 45 Districts by 2013
Impact: JUMP On-Site Follow-UpIndicator Baseline 6 wks ARR(CI) 12 wks ARR(CI)
Proper Hx 20% 42% 1.41 (0.48-2.35)
60% 2.71(1.54-3.88)
Proper PE 18% 57% 1.94(1.18-2.71)
82% 3.28(2.30-4.26)
Correct Dx 47% 96% 3.41(2.03-4.78)
97% 3.66(2.05-5.26)
C/W Nat’l Policy
42% 86% 2.27(1.51-3.05)
92% 2.96(1.94-3.97)
Adequate pt education
17% 83% 4.36(2.71-6.02)
87% 4.68(2.92-6.44)
Impact: JUMP On-Site Follow-Up
Indicator Baseline 6 wks 12 wks
%BS prepared correctly 22% 67% 63%
%BS read correctly 49% 71% 70%
%(+)BS read correctly 49% 71% 70%
%(-)BS read correctly 72% 77% 91%
Ssekabira Am J Trop Med Hyg, Dec 2008; 79: 826 - 833
*Generalized estimating equations controlling for history of fever and age, adjustment for repeated measures on the same day.
Site
Relative change in proportion of patients prescribed antimalarial
Antimalarial doses saved per
1000 patientsRR (95% CI)* p-value
Mubende 0.32 (0.29 – 0.36) <0.001 420
Jinja 0.44 (0.39 – 0.50) <0.001 358
Tororo 0.73 (0.70 – 0.77) <0.001 183
Impact of RDT training interventionon anti- malarial prescribing
TASO COMMUNITY ART PROGRAMME
THE HOLISTIC APPROACH
Health System Capacity building : a pyramid as a guide for effective investment ?
Staff and Infrastructure
Structures, Roles & Systems
Tools
Skills
require enable effective use of ...
Cognisance of local context
require
require
require
enable effective use of ...
enable effective use of ...
enable effective use of ...
Sub-optimal capacity building
Structural capacityCognisance of local context
Staff and Infrastructure
Skills
no inputs
eg equipment
eg technical training
Technical training and equipment supplied, but relatively ineffective because staff overstretched, supervision weak, and funding for maintenance
inadequate.
Structures, Roles & Systems
no inputs
no inputsTools
Pyramid of effective Health System capacity building
Tools
Staff and lnfrastructure
Structures, Roles and Systems
Skills
Personal capacity
Workload capacitywith
Supervisory capacity
Inputs to build capacity
eg management bodies, forum for stakeholders, decentralized powers
Structural capacity
Systems capacity
Role capacity
Facility capacitywith
Support Service capacity
Performance capacity
Inputs to build capacity
eg financial, logistics, workforce, IT
eg technical skills
eg clinics
eg lab technicians
eg lab management
eg sufficient staff, appropriate skill mix
eg equipment
Cognisance of Local Context
Cultural factors
Alignment with Gov’t policies and strategies
Local ownership
Trust between develop’t partners
Can it Happen?
Lessons from Uganda and IDI
Before
After
Simple improvements allow better and reliable drug supplies
Relatively small investments can change labs from dumps to quality labs that can provide accurate TB diagnosis
Before After
Record keeping and tracking is key to an excellent TB programme
Community programs to de-stigmatize TB, generate demand and provide adherence support
Community education about HIV and TB
THANKYOU AND PLEASE HELP!
.