sixth annual presidents emergency plan for aids relief track 1.0 art program meeting

© 2006 Baylor College of Medicine

Provider Initiated Testing and Counseling and Decentralization of

Pediatric HIV Care and Treatment in Africa

Sixth Annual Presidents Emergency Plan for AIDS Relief Track 1.0 ART Program Meeting

August 11-12, 2008Washington, D.C.


Goals of Presentation To present a preliminary data for a

provider initiated counseling and testing program of inpatient pediatric patients at Kamuzu Central Hospital in Lilongwe, Malawi

To describe the process for the scale up and decentralization of pediatric care and treatment services in the Mokhotlong Health Services Area in Lesotho


Malawi Hospitals in Malawi continue to be important

healthcare access points for undiagnosed HIV infected children

In 2006, < 10% of pediatric admissions at Kamuzu Central Hospital in Lilongwe, Malawi received HIV and testing and counseling

In late 2007 the Malawi Ministry of Health approved systems of routine HIV testing and counseling for certain settings, including hospitals

No prior routine pediatric inpatient or outpatient testing was being done. No detailed national government policy on pediatric HIV testing for hospitalized patients


VCT vs. PITCVoluntary Voluntary

Individual pre-test counseling

Group pre-test counseling

Non-routine patient initiated testing

Routine provider initiated testing

Individual post-test counseling

Individual post-test counseling

Risk assessment and risk reduction done pre-test

Risk assessment and risk reduction done post-test

Opt in Opt out


Program IndicatorsIndicator TargetPercent of total admissions in children’s ward offered testing

70%

Test acceptance rate of mother-infant pairs with unknown status

95%

Proportion of newly diagnosed HIV infected children and newly recognized HIV-E infants successfully referred to inpatient HIV care

90%

Proportion of newly diagnosed HIV infected children and newly recognized HIV-E infants successfully referred to outpatient HIV care

75%


PITC 8 Step SystemStep 1 Pre-test group counseling (4)

Step 2 Routine provider referral

Step 3 Patient escort (4)

Step 4 Opt-out/verbal consent

Step 5 HIV test

Step 6 Post-test counseling (pos or neg)

Step 7 Inpatient referral-clinical review by HIV trained clinician

Step 8 Outpatient referral to ART clinic


Clinical Review of HIV Exposed Infants

Document DNA PCR has been done Prescribe CPT if > 6 weeks of age Infant feeding counseling Nutritional evaluation (weight/height) Review for danger signs of HIV-

infection Refer for follow up of DNA PCR

testing


Clinical Review of HIV Infected Patients

Determine if ART eligible, check WHO stage, CD4 count

Prescribe CPT Screen TB Nutritional evaluation (weight/height) Infant feeding counseling Refer to outpatient HIV clinic upon

discharge


Month Admissions Offered Testing (%)

Unknown Status (US)

US Tested

Oct ’07 1019 109 (11) 109 98%

Nov ’07 1047 242 (23) 242 92%

Dec ’07 1087 260 (24) 260 99%

Jan ’08 1513 254 (17) 249 100%

Feb ’08 1344 306 (23) 293 99%

Mar ’08 1315 269 (20) 247 98%

Apr ’08** 1442 437 (30)** 437 100%

May ’08 1484 578 (39) 575 99.8%

June ’08 993 679 (68) 662 98%

July ‘08 791 565 (71) 519 95%

** 4 patient escorts were added in April ‘08


KCH PITC Results October 2007-June 2008

HIV Infected HIV Exposed HIV Negative

85%

10%

5%


Follow-up of New Positives

0

10

20

30

40

50

60

70

Number of Patients

Oct'07

Dec'07

Feb'08

Apr'08

June'08

Total Positive Inpatient Review ART Clinic


Lessons Learned Addition of patient escorts allowed the

program to reach the goal of 70% of new admissions being tested

Once testing is offered, > 92% of parents accept testing for the child

Linkage back to the HIV physician on the ward has not been consistent

Linkage from ward to outpatient ART is not optimal


Way Forward Working on methods to increase

communication with the inpatient HIV specialist so that children that have been screened can be reviewed

Investigating the reasons for poor outpatient follow up to ART clinic and methods to remedy this

Starting to expand this pediatric testing program to other regional hospitals in Malawi


Decentralization of Care and Treatment in Lesotho

Goal of universal access to HIV/AIDS care and treatment

Reaching rural populations and children have been identified as major challenges to this goal

Both of these challenges are quite pertinent to Lesotho


Lesotho Mokhotlong Health Service Area (MHSA) Population of MHSA: 96,000 with 29,000 (30%)

<12 years of age; adult prevalence of HIV is 18% Rural and mountainous 1 MOHSW and 0 private hospitals 8 MOHSW health centers, 3 other clinics – most

staffed by a nurse and nurse assistant only and will receive 1 physician visit per month if there are physicians

Current physician staff – 2 Congolese, 2 Zimbabwean, 2 Cuban but has been 0


BIPAI-Lesotho

BIPAI-Lesotho began work in Mokhotlong in partnership with the MOHSW and UNICEF to provide pediatric-focused family HIV care and treatment scale-up in October 2006

Prior to the initiative, 20 children on ART in the entire Mokhotlong region


Scale Up of Services Focus on strengthening existing ART clinic – at

the district hospital Site selection outside district hospital prioritized

based on public health need Sustained intermittent training through biweekly 5-

day physician clinical mentor placements Encouraging local providers to implement their

increasing skills and identify skill gaps while mentors are absent

Direct patient care when the need exists Determine resource needs in partnership with

local staff and seeking solutions locally and through the MOHSW


Results

To date, over 25 local staff intensively trained on HIV care and treatment

Introduced DBS DNA PCR at the district hospital and 3 village health centers

Improved inpatient pediatric care Nearly 100% HIV testing on the Children’s

Medical Ward Much improved linkages to the ART clinic


Pediatric Data

5 fold increase in children on ART from 20 in Oct 06 to 100 in April 08

Large relative increase, especially in comparison to similar centers in Lesotho

4 village health centers with nurse based ART now provide care and treatment to children

Increase in % of ART patients at district ART clinic who are children from 12% to 18%


Lessons Learned

In rural districts ART needs to be able to be delivered to children at the village health center level

Task shifting to nurses at this level is required These services need to be integrated into the

daily services at this level Requires intensive hands on mentoring, not

workshop mentality This is not a rapid process if it is done

correctly


Next steps LERATO Project: Lesotho Expansion of

Rural AIDS Treatment and Outreach Accelerate and further decentralize HIV

care in Mokhotlong and other HSA’s through health system strengthening

1. Infrastructure improvements

2. Infusion of human resource capacity

3. Continue mentoring efforts to village health center level

4. Continue strengthening of district hospitals into regional referral centers


Goals of Presentation To present a preliminary data for a

provider initiated counseling and testing program of inpatient pediatric patients at Kamuzu Central Hospital in Lilongwe, Malawi

To describe the process for the scale up and decentralization of pediatric care and treatment services in the Mokhotlong Health Services Area in Lesotho

sixth annual presidents emergency plan for aids relief track 1.0 art program meeting

Documents

pediatric hiv testing

pediatric testing program

outpatient testing

hiv physician

outpatient hiv clinic

monthadmissionsoffered

testedonce testing

inpatient hiv specialist