Ethiopia

Unlocking the confines of Illness

pMTCT Project Fekadu Chala Dabi, Christine Groff Nadia Nijim, Rebecca Noe, Cynthia Pearson

Ethiopia

A Regional Glance: Population

0

20,000

40,000

60,000

80,000

100,000

120,000

Nigeria

Ethiopia

Dem

ocratic Republic of the Congo

South Africa

United Republic of Tanzania

Kenya

Algeria

Uganda

Ghana

Mozam

biqueM

adagascarC

ôte d'IvoireC

ameroon

Angola

Zim

babwe

Burkina FasoM

aliM

alawi

Niger

Zam

biaSenegalG

uineaC

hadRw

andaBurundiBeninTogoSierra LeoneE

ritreaC

entral African Republic

Congo

LiberiaM

auritaniaLesothoN

amibia

Botswana

Gam

biaG

abonG

uinea-BissauM

auritius

A Regional Glance: GDP per Capita

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Mauritius

South A

frica

Botsw

ana

Gabon

Nam

ibia

Algeria

Zim

babwe

Guinea

Côte d'Ivoire

Lesotho

Angola

Dem

ocratic Republic of the C

ongo

Kenya

Togo

Cam

eroon

Central A

frican Republic

Ghana

Mauritania

Senegal

Congo

Gam

bia

Madagascar

Uganda

Nigeria

Zam

bia

Burkina F

aso

Benin

Rw

anda

Guinea-B

issau

Mozam

bique

Liberia

Sierra L

eone

Mali

Chad

Eritrea

Niger

Burundi

Malaw

i

United R

epublic of Tanzania

Ethiopia

Health System Structure

Budget $150 million US ~ 1.7% of GDP

3 medical schools train 200 doctors a year, but highest rate of brain drain in Africa

Physician to population ratio: 1 : 38,619

Health care facility to population is 1:172,000 – Health stations 1 : 27,456 persons – Hospitals 1 : 658,305 persons

Basic Health Determinants

Indicator Status

Life expectancy 43.8 years

Child Mortality < 5 years 170

Infant Death <1years 1 in 10

Child Stunting and Malnutrition 64%

Preventive Health Coverage <50%Access to Antenatal Services 34%

Adult literacy 29% females

41% males Access to Safe Water 35%

Ethiopia and HIV/AIDS

2,100,000 Ethiopian living with HIV/AIDS– 52% women; 38% men; 10% children

6.4% HIV/AIDS prevalence – Urban 13.7% rural 3.7%

87 % of all HIV/AIDS infections result from hetero-sexual transmission.

990,000 estimated orphans

Sources:UNAIDS,U.S.Census Bureau 7/2002

Ethiopia

The City: Nazret

Capital city of the largest region - Oromia– Population: 130,000

Worst health conditions in Ethiopia

75% of the endemic disease are communicable– Respiratory, Diarrhoeal– Malaria/TB– STI/HIV/AIDS

Health Structure of Nazret

LegendChurch School

Mosque

Pharmacy

FGAE

Hospital/MOH

Factory

Clinic

Highway

Railroad

Unpaved roads

Major pMTCT Interventions

Improved Maternal Child Health (MCH) Services

Voluntary Counseling & Testing (VCT)Safe infant-feeding choicesSafe Motherhood practicesAntiretroviral drugs (ARV): Nevirapine

http://www.coregroup.org/working_groups/hiv_resource_materials.pdf

Project Objectives

1. Offer voluntary counseling and STI testing (VCT) to all (100%) women who are receiving antenatal care (ANC).

2. Increase the acceptance of VCT from 50% to 80% of ANC participant.

3. Increase acceptance/delivery of nevirapine from 20% to 80% of HIV infected mothers who received ANC and who have

accepted VCT.

Provision of VCT and pMTCT– MOH hospital, 3 private clinics, 1 RH clinic

Training and program implementation – Family Guidance Association

Community groups for follow-up support:– 3 religious groups (2 Christian, 1 Muslim)– 4 NGOs– 1 PLWA group– 1 women/mother’s support group, and– 1 youth group

Community Partners

Input: Time - 3-year program

Training: VCT counselors – 2 weeks Clinics: ARV – 3 days

1-day refresher training every 6-months

Training for replacement VCT counselors and clinic staff

Bi-weekly visits by VCT and pMTCT trainers and supervisors (later monthly)

Every 3 months overall project meeting

Input: Staff

Trainer of trainers - 1

Trainers: 2 VCT; 2 clinic pMTCT

Project coordinator: 1

Supervisors: 1 VCT; 1 pMTCT

VCT staff: 6 (2-hospital, 1-RH clinic, 3-private clinic)

pMTCT clinic staff (~14) doctors, nurses, midwifes

p M TC T P rog ram C h art

V C T T rainer

V C T T rainer

M T C T T rainer

M T C T T rainer

T ra ining S uperv iso r

H o spita l V C TC o unselo r

H o spita l V C TC o unselo r

P rivate C linicV C T C o unselo r

P rivate C linicV C T C o unselo r

P rivate C linicV C T C o unselo r

R epro ductiveH ealth C linic

V C T C o unselo r

V C TS uperv iso r

5 P harm acis ts1 f ro m each

Lo cal P harm acy

H o spita l H eadP hysic ian

3 P hys ic ians1 f ro m each

P rivate C linic

3 N urses1fro m each

P rivate C linic

P hysic ianR epro ductiveH ealth C linic

N urseR epro ductiveH ealth C linic

M T C TC linica l T eam

S uperv iso r

P ro gram S taf f

G rants & FundingO f f icer

P ro gram A cco untant

M edica l S upplyM anager

M edica l S upplyW o rker

A dm inis trative D iv is io n

C o m m unityL iaso n

C o m m unityL iaso n

C o m m unity P artnerships

O ro m ia B ureau o f H ealthpM T C T P ro ject C o o rd inato r

Input: Other Resources

Funding

Training materials (rooms, lunch, supplies, kits)

VCT and pMTCT guideline manuals for all participants

Space to ensure VCT can be provided and will be confidential

Supply of HIV rapid test kits, Nevirapine– 6 months inventory maintained on hand at local

hospital warehouse

Present Model of VCT Service Delivery

Pre-test counseling

Testing (as desired by the client and after informed consent is provided

Post-test counseling (more than one visit if needed)

Individual risk assessment & risk reduction planning

Model for Nevirapine Delivery

Sustainable HIV kits/drug supply

Strengthen delivery infrastructure

Nevirapine HIV+ pregnant women– To women at the onset of labor: 200mg– To baby within 72 hrs. of delivery:

2mg/kg body weight

p M TC T P rog ram C h art

V C T T rainer

V C T T rainer

M T C T T rainer

M T C T T rainer

T ra ining S uperv iso r

H o spita l V C TC o unselo r

H o spita l V C TC o unselo r

P rivate C linicV C T C o unselo r

P rivate C linicV C T C o unselo r

P rivate C linicV C T C o unselo r

R epro ductiveH ealth C linic

V C T C o unselo r

V C TS uperv iso r

5 P harm acis ts1 f ro m each

Lo cal P harm acy

H o spita l H eadP hysic ian

3 P hys ic ians1 f ro m each

P rivate C linic

3 N urses1fro m each

P rivate C linic

P hysic ianR epro ductiveH ealth C linic

N urseR epro ductiveH ealth C linic

M T C TC linica l T eam

S uperv iso r

P ro gram S taf f

G rants & FundingO f f icer

P ro gram A cco untant

M edica l S upplyM anager

M edica l S upplyW o rker

A dm inis trative D iv is io n

C o m m unityL iaso n

C o m m unityL iaso n

C o m m unity P artnerships

O ro m ia B ureau o f H ealthpM T C T P ro ject C o o rd inato r

Process (1)

Develop plan: initial training manuals

Train VCT counselors and pMTCT clinic staff

Monitor quality of training and quality of teaching

Teach trainees to use the manual as a resource

Initial follow-up: bi-weekly trainee meeting to discuss barriers/problems

Process (2)

After 6 month in field – secondary training

Ongoing support and feedback

Monthly site visits by supervisors

Monthly reports from project supervisors to coordinator

Consumer satisfaction feedback

Outputs and Outcomes:

Trained 6 VCT counselors; 14 clinic staff in pMTCT

Track quality – Pre-post-test

• % Increase in knowledge• Areas to improve curriculum

– Focus groups at 6-month training

Availability of HIV test/Nevirapine – % Of time in 3 years with no shortage of

HIV test kits or Nevirapine

Outputs and Outcomes: (2)

Use of pre-test counseling: – % of women who received counseling

[initial use]

Use of HIV testing/post-counseling:– % of women who received HIV testing

during pregnancy [Measures initial use &continuity]

Use of Nevirapine:– % of women who HIV+ and request

treatment and receive course [measures continuity of service]

VCT/ARV Impact

100% ANC participants offered VCT

80% acceptance of VCT services

100% of HIV + women identified through VCT will have access to Nevirapine

80% of these (HIV + mothers & newborn) will complete Nevirapine regimen.

Amesegnalehu (Thank you for your attention)