ICAP 2008 Growth and Innovation David Hoos Washington, DC
August 2008
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Outline Growth in coverage Growth in enrollment Expansion of
portfolio of services Innovations in country programs Site Support
and Site Independence
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Expansion of Coverage Rural/Urban and Types of Facilities
(n=244) n=158n=86 % sites
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Cameroon, Cote dIvoire, Kenya, Lesotho, Rwanda, S. Africa,
Tanzania Uganda, Thailand Mozambique Ethiopia Overall
ICAP-Supported Cumulative Enrollment in Care and Treatment (June
30, 2008) 510,474 in care 237,337 on ART Number of patients Number
of facilities Nigeria, Swaziland, Zambia 333 sites
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Cumulative in care (ART and non-ART) Cumulative on ART * Track
1.0 Supported Sites
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Current and Target Enrollment Six months into COP-08 Number of
patients
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A Focus on Women and Children
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Attaining Pediatric Targets n=214,722n=167,060 n=381,782*
Percent of Enrolled Patients
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57,659 in care 20,996 on ART Cameroon, Cote dIvoire, Kenya,
Lesotho, Rwanda, S. Africa, Tanzania Uganda, Thailand Mozambique
Ethiopia Nigeria, Swaziland, Zambia 333 sites 0 20,000 40,000
60,000 80,000 Apr 05 Apr 06 Apr 07 Apr 08 0 175 350 HIV
careARTFacilities ever reporting More than 57,000 children enrolled
in care and more than 20,000 on ART (June 30, 2008) Number of
patients Number of facilities
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ANC Labor & Delivery Vaccination or Well-baby Clinics Post-
Partum Follow- up of Women HIV testing of women CD4 test and
clinical staging of women & treatment for women with advanced
HIV More efficacious regimens for PMTCT Engaging and testing of
partners Complete package of interventions HIV testing of women and
linkage of HIV+ve women to HIV care services Engaging partners HIV
testing of women with unknown status & linkage of HIV+ to HIV
care Follow-up of all HIV-exposed infants Cotrimoxazole Growth
monitoring & monitoring for evidence of HIV disease Early HIV
diagnosis, linkage to Peds services and early ART initiation HIV
testing of women with unknown status Follow-up of women with HIV:
counseling on infant feeding CD4 test and clinical staging of women
ART for women with advanced HIV Complete package of interventions
Engaging & testing (partners, other children) Maternal and
Child Health Platform
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PMTCT Regimens Used Vary by Country April-December 2007
n=274n=535n=2,414n=1,610n=472 n=5,406 % women n=101
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Integration of TB-HIV Services
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Increasing Proportion of Newly Enrolled HIV Patients Screened
for TB at Enrollment n=8,685 n=13,950 n=17,563 n=24,484 New HIV
patients n=30,050
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Majority of New TB Patients Tested for HIV n=7,444 n=6,921
n=7,514 n=7,381 New TB patients
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Potpourri of Innovations Observation Design of Innovation
Implementation of Innovation Learning Scale-Up
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ICAP-Kenya
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Family HIV Testing Design of Family Testing Form Piloting of
the form Form filled by Nurse Counselor Review of pilot and
revision of form Community mobilization Fun activities for children
and families Testing on site Linkage of HIV+ to HIV care Scale-up
to all facilities
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Sensitization of site staff and leadership Compiling and
verification of defaulter Phone tracing Training of peer educators
for tracing activities Feedback and discussion with site teams
Intensive Defaulter Tracing
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LTFU: 40% LTFU still on ART!
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Tracing Focused on True LTFU
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ICAP-Mozambique
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Screening of HIV Patients for TB Increased TB screening of new
HIV patients at ICAP- supported facilities Q1 2007 26% Q1 2008 50%
(Q1 2008 4305/8611) ICAP TB screening tool adapted and adopted by
the Moz-MoH as national tool in 2008
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HIV Testing of TB Patients TB Clinics 74% of TB patients tested
95% Tb/HIV patients referred to ART facilities 89% of co-infected
patients provided with cotrimoxazole TB Day 2008 Nicodoala Health
Center
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Enhancing Pediatric Services Use of ICAP Paediatric Standards
of Care Indicators (SOCs) Nampula Central Hospital
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Dolls Used to Stimulate Discussion and Transmit HIV Information
Anatomically accurate and culturally appropriate dolls Patients
largely illiterate Used by healthcare and peer workers proper
breastfeeding practices condom use status disclosure treatment
adherence Stimulate discussions in counseling rooms, waiting areas
and support group meetings
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ICAP-Tanzania
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Bringing HIV Care & Treatment to Where PMTCT Takes Place--
Reproductive and Child Health Clinic (RCH) Tumbi Regional Hospital
Rationale: PMTCT services available at most hospitals (91%) &
health centers (88%) However, only 22% centers offer ARV treatment
usually through Care and Treatment Clinics (CTC) Bring ART services
to PMTCT sites at RHCs Activities: Garner support of facility
leadership and health care workers (at CTC and RCH) Training and
mentoring on ART/PMTCT Establish recordkeeping, pharmacy and
laboratory systems Modify patient flow Use family support groups to
complement clinic interventions
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Pregnant Women Successfully Received PMTCT and ART
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ICAP-South Africa
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Model of TB Infection Control Program in TB Endemic Settings
High prevalence of unrecognized TB among HIV-infected individuals
Motherwell CHC: 22% of 597 HIV patients screened diagnosed with TB
Assessment of TB infection control situation Facilities Procedures
Knowledge, Attitudes, Beliefs and IC Practices
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Assessment at Two Facilities Cecilia MakewaniMotherwell CHC
Infrastructure No separate waiting area for TB suspects Waiting
area crowded No separate waiting area for TB suspects Waiting area
crowded Infection Control Management General IC team in place TB IC
not addressed IC coordinator in place No TB IC team/plan Patient
Triage No screening for cough No TB screening checklist Cough
screening in early morning only TB screening checklist used
consistently
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Baseline Assessment-2 Cecilia Makewani HMotherwell CHC Cough
Etiquette/ Respiratory hygiene No tissues/waste baskets available
in waiting area Surgical masks for high risk patients No
tissues/waste baskets available in waiting area TB Diagnosis No
safe collection of sputum specimens Good transport system On-site
laboratory No safe collection of sputum specimens Sputum
turn-around time 72 hrs TB Treatment & Referrals Delays in
initiation of TB Rx for outpatients ART patients treated onsite TB
register not available No feedback on patients treated off-site
Most patients referred off- site No feedback on patients treated
off-site Good clinic-based DOTS system and tracing
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Baseline Assessment-3 Cecilia Makewani HMotherwell CHC
Environmental Infection Control Measures Windows too high to open
easily Mechanical ventilation not used adequately Mainly relying on
natural ventilation Unused open courtyards Personal Respiratory
Protection Limited use of N95 respiratorsNo N95 respirators in HIV
clinic Staff Capacity Building No staff trained on TB IC, very
limited on TB/HIV integration No staff trained on TB IC Staff
Protection Annual Chest X Ray for staff Staff health clinic with
confidential HIV C&T Limited TB screening Confidential HIV
C&T available
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Infection Control Related Activities Establishment of:
Infection Control committee TB Infection Control plan
Implementation of Infection Control procedures Renovation of
facilities Information, training, mentoring of staff, patients,
families Mobilization of community
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Unused Courtyard: Possible waiting area for patients with
suspected TB? Motherwell Community Health Centre High ceilings
Windows inaccessible Unused exhaust system Cecilia Makiwane
Hospital HIV clinic
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ICAP-Ethiopia
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PLWHA Support Group PE counseling Tents One-to-One adherence
counseling Home visit - Defaulter Tracing Group-Education Peer
Educators in Action Task Shifting
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ICAP-Rwanda
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A Focus on Pregnant Women and Children More efficacious PMTCT
regimens and ART for treatment of pregnant women Establishment of
district CD4 count testing system Expansion of CD4 testing of
pregnant women Enhanced linkages between ART clinic and PMTCT
program Identification of HIV-infected children admitted to
hospitals
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CD4 Testing of Pregnant Women July 06 Dec. 07 Implementation of
the district CD4 count testing system
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Shift from sd-NVP to Multidrug PMTCT and HAART for Pregnant
Women
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HIV Testing of All Children Admitted to Central
Hospital-Kigali
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ICAP-Nigeria
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HIV Information and Testing at Motor Parks Motor parks draw
large numbers of people, including drivers, vendors, and artisans
Partnered with Benue Links Motor Park & the JIREH Foundation, a
community- based organization Rally inaugurated free- standing HIV
testing & counseling center First day, 202 individuals tested
and 13 HIV positive linked to care and treatment
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ICAP-Cote dIvoire Map here
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Challenges in a Post-Conflict Setting ICAP supports facilities
in 5 regions, areas severely affected by recent conflict Fragmented
government has created weakened national planning and leadership In
some regions, facilities including hospitals stripped of equipment
and furnishings Need for basic refurnishing to enable program
initiation Low service utilization during conflict, mobility
restricted due to need to pass through multiple roadblocks, fear of
violence Need to inform population of availability of HIV services;
facilitate access
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From Site Start-up to Site Independence Clinical Systems
Mentorship Standards of Care (SOCs) Wiki Space for Clinicians
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Goal 1: Implement a chronic care model of HIV care and
treatment (comprehensive, family focused) Goal 2: Build capacity to
promote program sustainability and independence Site Start-up Site
Independence Assess and Build Capacity Time Assess and improve
implementation Assess and improve quality Site support team Onsite
team Developing district- and national-level capabilityDeveloping
patient-and provider-level capability
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Way Forward Continue expansion of coverage and diversification
of delivery methods Continue with core fundamentals of ICAP
approach Family focus in all programmatic components Build on
framework of existing health systems Partnerships with national and
local organizations Capacity building at all levels through
mentorship Expand prevention interventions Develop innovations to
guide programs Enhance overall health systems
