Expanding IMAI: Driving a decentralized approach in Senegal

and in other West and Central African Countries

Papa Salif SOW MD, MScDepartment of Infectious Diseases Dakar University Teaching Hospital

SénégalWHO Satellite Meeting, ICASA Abuja, December

5th, 2005

The Senegalese Initiative on Access to Antiretroviral Drugs

(ISAARV): August 1998

HIV Seroprevalence in Senegal in the general population

2,2%

0,5%

0,8%

1,0%

2,8%

2,0%

2,3%

1,7%

1,2%

0,7%

2,6%

Decentralization for access to care and treatment

• 17 Hospitals level 1 • 58 Health Districts • 828 Health Posts

National Level

Regional Level )

District Level

The Senegalese Initiative for Access to ARV: (ISAARV): The

challenges • Decentralization: from pilot study (98-01)

to public health reality (from 2001)

– Limited Human Ressources outside the capital

city– Limited Capacity of Health infrastructures – Necessity for assuring the Continuum of care– Challenges of integrating HIV monitoring into

the public health system

• Need to build a model of decentralization

The Senegalese Model• Training health staff in the regions

– Theoric training– Pratic training

• Harmonisation of the ARV regimens 1st and 2nd line• Regional Laboratories equipment for CD4

(Dynabeads)• Regional Hospitals : reference center for the region • Update of guidelines • Mentoring approach by national expert• Regional Coordination Team • Simplified and Standardized questionnaire for data• IMAI Approach for scaling up at district level +++

The mentoring approach

• Mentoring – « Coaching »• National expert on charge for one

region– Permanent contact with his région (Tel,

Email…)– Diagnostic and therapeutic advices– Discussion on the indications and ARV

regimens• Regular supervision mission every 3

months by a multidisciplinary team– Medical record – update training sessions– Capacity building

The Impact of the model

• Increase of the ARV sites prescription – From 6 sites (1998 – 2001)– To 32 sites today 2005 -

• Increase the number of MD ARV prescriptors– 12 (1998 – 2001)– 94 today 2005 -

• Significant decrease of distance for access to ARV

The Senegalese target

• December 2005 = 4200 patients on ARV

• October 2005 = 3825 patients traited

Number of patients on ARV in all the 11 regions in Senegal 30th

Octob. 05

91

147

152

166

88

200

194

2366

8

110

57

The impact of the model

• The decentralization of HIV Counseling and Testing sites– VCT : 13 in all the country– VST : 76 (voluntary services testing)

• The decentralization of PMTCT– 1998 – 2004 : 1 region (Dakar , capital

city)– 2004 – 2005 : 9 other regions

Monitoring and Evaluation

• Documents for data collection in all sites

• Computer available at regional level for data collection

• Low process to set up the M&E system

ISAARV: lessons learnt

• Political committment : gratuity for care– HIV testing, drugs for OI , ARV, hospitalisation,

artificial breasfeeding

• Collaboration between NACP and the university expertise

• Public-private parternship– Pfizer Foundation : Diflucan Donation Program

• South – North Collaboration • Research : Clinical trials for one daily

regimens and improving adherence

Scaling-up HIV care and antiretroviral therapy

using the IMAI approach

IMAI process in Senegal

•Adoptation•Adaptation•Validation•Implementation

IMAI implementation in Senegal

• First step: IMAI introduction workshop Ouagadougou , November 8-13th, 2004

• Second step: Translation into French and adaptation to the Senegalese context : december 2004 – March 2005

• Third step: National workshop for IMAI documents validation, April 2005

• Fourth step: International workshop for IMAI TOT, Dakar May 2005 (20 Francophone countries)

IMAI implementation in Senegal

• Last step: Utilization of the IMAI approach for boosting the decentralization for access to care and treatment: Package for Integrated Management of HIV/AIDS, care, treatment and prevention – Health post: Nurses and midwives– Health Center: MD, nurses, widwives, social

workers– Regional Hospital– University Teaching Hospital

IMAI Manuels Senegal

IMAI Manuels in Senegal

IMAI Manuels in Senegal

IMAI process in Senegal

• Health district HIV Care implementaition– August – September 2005 : 15 districts trained– The 38 other districts will be trained during 2006

• Dakar: collaboration WHO for IMAI approach– Sharing experience with other countries on IMAI

• Burkina Faso : june 2005• Burundi : august 2005 • Haiti : september 2005

Increase the Entry Points to care: HIV serology testing

• VCT

• PMTCT-Plus

• Centres for Tuberculosis Treatment

• Centres for Sexual Treatment Infections

• Vulnerables groups

• Clinical Services

L’insuffisance de traitement antirétroviral: une urgence sanitaire mondiale

Pour atteindre l’objectif de “3 millions d’ici 2005”, il faut un nouvel engagement et des nouvelles méthodes de travail pour l’ensemble de la communauté sanitaire mondiale.

LEE Jong-wook, Directeur Général OMS, 22 Sept 2003

Assemblée Générale de l’ONU,New York

"3 by 5""3 by 5"

For a Universal Access For a Universal Access to Care, treatment to Care, treatment and Preventionand Prevention