OPPORTUNISTIC INFECTIONS AND ART SERVICES DELIVERY COMMUNITY MONITORING REPORT

PRESENTED BY Stanley Takaona on behalf of PLHIV

Compiled by

Mr. Stanley Takaona

Mrs. Rosa Chimbindi

Ms Olive Mutabeni

Mr. Joao Zangaroti

On Behalf of PLHIV TEAM

With Technical Support from Mr. Silibele Mpofu

PRESENTATION OUT LINE

INTRODUCTION

ZHAAU Initiated visits to assess art services in the Mat. South.

Secured permission from MoHCW12 Member team from ZHAUU, ZNNP+ at national and

provincial levels , PLHIV in the NAC Board, PLHIV representative in the CCM, the MIPA Technical Working Group representative, PLAAZ and representative of the Harare Advocacy Committee.

Technical and logistical support from NAC MIPA Coordinator.

Visited Beitbridge, Gwanda, Esigodini, UBH and Mpilo hospitals and community support groups in each district.

OBJECTIVES OF VISIT

• (i) To assess the availability of ARVs in the OI clinics

• (ii) To discuss challenges facing OI clinics • ( iii) To discuss with OI clients the quality of

services they get from OI clinics • and challenges • (iii) To assess the state of OI key equipment

such as CD4 counting machines, • hematology machines etc.

Beit Bridge-Meeting with DACProvincial prevalence – 21% - Highest in the countryMSF is supporting ART Programme in the districtDonated a land cruiser for outreach programmesHas two doctors offering outreach twice a week.Has own pharmacy8 nurses have been trained to initiateNo user fees About 20 active support groups in townDistrict once experienced stock out of cotri. but now

situation has stabilized.

Meeting with B/B Lab. Staff Lab does most tests No user fees for lab tests 30-40 samples per day for CD4 at the static site and about 60

patients on outreach No viral load machine- MSF pays for tests and sends samples to SA.Challenges Staff shortages. LFT machine not working Shortage of reagents No viral load machines relies on MSF which does limited samples

(17 samples per month) and sends samples to South Africa and this proves to be costly.

No backup

B/B Pharmacy ARVs were well stocked and presently there are no stock out

except for the Peads efavirenz which was reported to be out of stock.

Stock outs are mainly averted by MSF which is providing most of the drugs at the moment.

Supplies from NatPharm had not been received at the time of the visit.

The centre experiences occasional stock-out of cotrimoxazole.

B/B OI CLINIC 3 doctors, 2 from Government and 1 from MSFNo consultation fees Prescriptions for OIs and patients pay btn USD 3

and 10 this beyond reach of most PLHIV.High fig. of lost to follow up –most patients are

from outside the districts and they tend to give false addresses which makes their tracing difficult

Paper based record keeping- loss of some records6985 adults on ART and 554 childrenSite not conducive in terms of location and space,

B/B Hospital recommendations OIC to have a pharmacy own its own to reduce queues . Nat Pharm to supply drugs to the site so that the site does not

entirely depend on MSF that is currently supplying most of the ARVs .

Antibiotics prices for OI patients should be competitive and affordable so that they are not more expensive than the private pharmacies. .

The OIC department should be computerized to improve data management

There is need to engage the Ministry of Finance to unfreeze posts to alleviate the critical shortage of staff in laboratory OIC and Pharmacy.

There is need to increase support groups member ‘s knowledge on BCC as well as improve health and treatment literacy education treatment.

B/B Hospital recommendations

There is need for decentralization of Early Infant Diagnosis testing to avert

deaths caused by the current delays.

ART Management committees should be in place and a person living with HIV

to be in the committee.

There is an urgent need to procure equipment and reagents to facilitate critical

tests such as viral load, CD4 liver function and FBC to enable screened of

patients before switching to another drug regimen.

MFS is doing a wonderful job in support of the ART services but the MoHCW

should come up with an exit strategy in the event of pull out by MSF.  

B/B CLIENTS

• No consultation fees -buy prescribed medicines for OIs of which prices are beyond reach of majority and hence no treatment for OIs for some.

• Long queues at pharmacy as they mix with other patients• Arrive at 0400hrs and leave Pharmacy at around 1500hrs.• Some times can go for 3 times without seeing doctor.

B/B Clients Challenges Cotrimoxazole has been out of stock for quite some time and

people are given prescriptions to buy from other pharmacies . At times patients are given pediatric doses of cotrimoxazole thus 8

tabs but there was one only one case that was cited. Occasionally peads are given adult ARVs doses instead of

suspension due to stock outs. Switching of patients to regimens , without any test such as FBC,

LFTs, Viral load, CD4 count being done Repeat CD4count very scarce, most clients have not been repeated

their CD4 during the course of ART since 2009 when they were initiated into ART.

Low levels of ART Literacy

Batsirai Wellness Centre 3 Main programmes Treat STIs Including HIV screening Family Planning/reproductive health BCC

Target – mainly Sex Workers and Truck DriversThe Centre provides counselling and testing services i.e. HIV screening.

HIV -positive clients are referred to respective hospitals for ART Initiation.

The Centre does follow up by mobile phone.

All antibiotics are in stock but for syphilis

Screened patients are referred to hospital.

2347 clients attended to in October – 1101 males and 1246 females

Batsirai Wellness Centre Challenges Centre is not an ART initiating Centre. There is risk of being given wrong phone numbers and delay in reaching the respective Hospitals. No CD4 count machines, LFT machines and Viral Load machine. The space is not conducive, there is inadequate counseling space visa-avis the increasing clientele

base. Low risk perception and low knowledge levels in terms of HIV and AIDS among truck drivers and

sex workers.Recommendations Centre to be accredited as an ART Initiating site to cater for Centre’s clientele. Centre to conduct a one stop shop for ARVs collection since the target groups is very delicate and

very busy people who can quickly spread HIV. Increase the number of trained staff on ART initiation, Provision of CD4 count, viral Load and FCB machines for testing and treating of the most at risk

population. Provision of more rooms for counseling services and ART initiation. More computers needed for data capturing. Consider PPP for more support of the Centre.

Gwanda District Meeting with Health Staff

OIC -open from Monday to Friday A total of 5 600 is on ART 3 initiating sites in the district No consultation fees for OI clinics but buy antibiotics for Opportunistic Infections. Hospital ordinarily does not distribute expired drugs except once in August 2012. CD4 only done to 20 people Mondays only. Samples taken before 0900hrs no samples after this time. Follow done by community sisters but weakened by inadequate staff and

resources No HIV Clinical, Management and ART committees in place. Stock outs are experienced due to Nat Pharm not delivering ARVs on time. No Viral load machine (nurses did not know such machine ever existed. Patients are switched on the regimen without repeat CD4, Viral load, HB check or

liver function check up.

Gwanda District Meeting with Health Staff

Approximately 80% of the OI patients present with side effects. There is a high number of defaulters and lost to follow up due to distance

and lack of transport. No doctors in the OIC except for a Clinical Officer who comes on Monday,

Wednesday and Friday, Pressure of work on clinical officer as the same person goes outreach. OIC is squashed up and some patients were seated on the floor due to

shortage of benches. Blood samples are sent to HCH and they return after 3 to 4 months and at

times results being mixed up (receiving results which are not for the Hospital).

There was no information on whether there is service contract for the lab machines since the lab technician was out on outreach.

Gwanda Challenges Inadequate space in the OIC Inaccessibility of CD4 – only 20 samples are collected per week and all

before 0900hrs. Infant diagnosis is not done well because there is no machine to do tests. There is a high risk of HIV positive infants dying before being diagnosed

or treated due to delays in returning results. There is inadequate space for OIC service as only two rooms are available

for consultation, observation, counselling and testing. Payments for OI treatment medicines beyond the reach of the majority

of clients resulting in failure to buy the antibiotics. Follow up care is not properly done due to challenges of staff and

vehicles. No evidence of teamwork among lab. staff.

Gwanda Community Meeting- Thandanani Support group

CD4 machine available done once per week to 20 people. Samples are collected before 0900hrs thus clients are forced to wake up

as early as 3am to try and beat the cut off time but often in vain. There is no room for repeat CD4 Counts-most of them from around 2009

to date. Clients are not aware of viral load screening and LFT testing, they are

switched on to the new regimen without being screened. Expired drugs were once given in August which had expired date of

March 2012 Critical shortage of cotrimoxazole tablets, patients/clients are given

prescriptions to buy from other pharmacies. No outreach program in Matshetsheni causing more people to come to

Hospital. Social Welfare not issuing Assistance Medical Treatment Order (AMTO)

for the reasons which clients did not understand. Allegations that officers do not assist clients who are well dressed.

Gwanda district –Recommendations

Need to conduct CD4 Count and viral load monitoring as a routine check up to all clients after every 6 months to one year.

Viral Load screening to be done before switching patients to a new regimen.

Need to increased staff capacity in all departments i.e. OIC, LAB and Pharmacy .

User fees for antibiotics should be affordable Back up machine for CD4 count needed Computers needed for data capturing in OIC. ARVs should be delivered on time to avoid stock outs. Infant Diagnosis should be improved , this is a major concern to the

innocent babies who are dying before treatment Nutrition Support needed for all PLHIV. New OIC needed since the space is so limited to accommodate clients. Need to have own OIC pharmacy.

Esigodini District Hopsital

Hospital accredited for ART services in 2006. OIC operates 5 days i.e. Monday to Friday. Total of 2665 on ART as of 31 October 2012; 2398 Adults and 267Children. One initiating site and 14 outreach sites. Follow up mechanism by Environmental Health Technician (EHT) and the Village

Health Workers (VHW). A total of 81 Clients on waiting list – 78 Adults 78 and 3 Children. Reasons;

• delays of CD4 counts results from Mpilo Central Hospital, • non completion of sessions mainly by farm workers who are only allowed one day a month to attend

counselling sessions - delays in collection of results. Outreach programme not very functional due to shortage of staff and vehicles. No vehicle dedicated for ART Services. Sometimes the outreach team uses an ambulance which drops them at the

outreach point and collect them after transporting patients to referral hospital . CD4 count machine accommodates around 10 to 20 samples, most of the samples

are sent to Mpilo Central Hospital, results are received after a month or two.

Esigodini District Hopsital

There are instances where the outreach team arrives at the outreach centre as late as 1400 hours, yet patients/clients would have been at the site early in the morning.

Nurses are collected late from the outreach site and in some instance the teams return to station as late as 2200 hours.

There is only one Doctor and One Clinical Officer who attend to Hospital and outreach patients/clients. No ART Committees in place which involve PLHIV although hospital meetings are done

Esigodini District Hopsital

Stock outs of cotrimoxazole since beginning of this 2012 & 2nd line therapy for only 3 patients is usually out of stock.

Patients do not pay for review dates or consultations but prescription is given to them for antibiotics and other types of medication where they pay user fees

These user fees are not affordable to most members, defaulting treatment and untreated opportunistic infections.

Outreach allowances were last paid in May 2012.

Esigodini District Hopsital

• The CD4 machine is serviced by a company called BD and done three times per year.

• There is no viral load and FLT machines.• Task shifting was started last month where nurses are able to

initiate ART.• Infant diagnosis results take about 3 months.

Esigodini Challenges and Recommendations

Challenges Staff shortages Farm workers not given time to seek for medication No computers No vehicle for outreach programme Shortage of drivers Currently no samples being taken for EID because of the delays in getting the results.Recommendations OIC Site should be resembled from being too close to the mortuary. There is need for a workplace programme which involves PLHIV. Need for computers for data capturing. Vehicles for ART services needed. Increased number of Doctor, Nurses, Counselors, Drivers, Lab Tech and Pharm Tech/assistance. Improved Infant diagnosis for early detection of the disease. Outreach allowances should be in place. Need for CD4 count, Viral Load and LFT machines. Nutrition support needed

UBH – Findings • Site was accredited as an ART site on 01 April 2004 • Started initiating in November 2004. • OI operates from Monday to Friday & initiations are done an a daily basis. • PLHIV that have ever been initiated on ART was 8060 and the number

currently on ART was 8171.• No waiting list • No follow up sites • No ART Management committees in place

UBH- Findings

• No ART management meetings were held• No follow up mechanism in place “Some times you try and

phone a patient and you are told that he/she died 6 months ago and it appears as if you can opening fresh woods when relatives were almost healing up”.

• Stock out of combipack about three months ago• At the time of the visit, cotrimoxazole was out of stock and patients were

told to buy from private pharmacies.

UBH- Findings • Adults are sometimes given children’s doses to bridge the situation.

• Site takes an average of about 60 samples for CD4 / day and it processes about 350 a month from OI

• 400 tests are done per day from Monday to Friday for whole hospital.

• Machines -serviced by a company called Medsure contracted thru at point of donation of CD4 counting

machines

• Printer for CD4 machine had been without cartridge for long time.

• Hospital has just started doing viral load tests since the donation of the viral load in June 2012.

• Viral load is not used optimally because lab staff has to wait for the minimum samples of 30 before they

can do a run.

• Viral loads conducted twice a week on Mondays and Tuesdays

• Four people were interviewed for the lab posts but still awaiting clearance from treasury

UBH- Challenges

• Paper based data management system not reliable • Stock out for cotrimoxazole • Delays in getting EID results• Small for Lab and OIC. • Small space for pharmacy “ We sometimes disburse from

outside, there is no privacy”• No waiting place especially during the rainy season• Staff shortages e.g. lab has a complement of 7 out 20 in the

establishment.• Shortage of reagents

UBH –Recommendations

• Build waiting shelter for OI patients• Lobby for employment of 4 lab staff members

that had been interviewed.• Procure reagents and cartridge for CD4 machine • Computerise• Establish ART Management committees with

PLHIV representatives.• Establish follow up mechanism

Mpilo – Findings

• Hospital was accredited in April 2004 and started initiations in the same year.

• 11000 patients on ART• 18 outreach sites • Patients do not pay consultations fees neither do they pay for reviews• Relatively strong follow up programme• 4 nurses make follow ups at the clinic every Tuesday and Thursday

Mpilo -Findings

• No waiting list.• Currently stable drug situation. • Occasional shortage of cotri. • Centre once experienced stock outs of Zidolum N. for adults and calitra

mainly because of transport challenges.• Once a problem with peads Art now the situation has stabilized.• State of the ART lab. which does tests for the region. • The lab takes an average of 50 samples a day for five days/week.• CD4 machine is serviced by a South African Based company with a local

agent based in Harare • Hospital has a viral load which does 30 samples a day by 3 days a week

i.e. Monday, Tuesday, and Wednesday.

Challenges -Mpilo

• Congestion at the OI clinic • Small viral load machine• Poor lighting of the laboratory • Inadequate staff – affects statistics• Inadequate resources such as light bulbs • Inadequate computers for data management• Chemistry machine was broken down at time of

the visit. •

Mpilo-Recommendations

• Create more space for OIC clinic • Deal with perennial shortage of

cotrimoxazole • Lobby for more staff• Purchase enough reagents seeing the centre

does tests for districts in Byo, Mat. South and Mat. North.

Byo- Community meeting• Clients confirmed that CD4 count machines were

functioning well in both Mpilo and UBH.• About 20 – 30 samples per day are collected from

Monday – Friday at Central Hospitals while local clinics were collecting twice per week on Mondays and Fridays.

• For repeat CD4 count one has to book and is given a waiting period of one month.

• The clients did not have knowledge of Viral Load tests and LFT tests.

• ARVs are served 5 days per week at Mpilo and UBH, but in local clinics its 4 days.

Byo -Community –challenges • One month supply of ARVs not good enough since some come from long

distances.• Stigma and discrimination at local clinics and being shouted at.• Clients go to sites as early as 0300hrs but will be served well after 1000hrs may

leave the area around 1500hrs.• There are no chances to say out any problems as nurses will be so busy to listen to

client challenges. • ARVs 2nd line therapy some experience being given pediatric doses but this

happened 4 months ago.• Cotrimoxazole is never in stock, the reason given is donor funds dried out• Cotri- out of stock since May 2012 at Mpilo and Local Authority Clinics. • Consultation fees not paid but experience unaffordable prices of antibiotics if one

is given a prescription. • Local authority clinics are charging USD8-00 for consultation and go on to buy

prescribed medication at an average of USD10-00 .• Expired ARVs 1st line therapy was issued in June 2012.

Byo Community recommendations

• Involvement of PLHIV in Management, Clinical and ART committees.

• Increased staff in all areas of ART services thus OIC, lab and Pharmacy both in Hospitals and Local Clinics.

• PLHIV need trainings on treatment literacy.• Viral Load and LFT machines to be in place.• Nutrition support for PLHIV

Overall Recommendations

• Deal with issue of indirect user fees in the form of payment for OI medicines

• Establish a follow up mechanism to avoid lost to follow up.

• Computerization of records and ART records • Monitor patients in terms of vital tests such as CD4,

viral load, LFTs etc before changing them to new regimens

• Ensure regular checks of CD4, viral load so as to quickly address any side effects before they get out of hand.

• Decentralise EID services to avert deaths of infants.

Overall recommendations

• Establish ART management committees that involve PLHIV

• Sort the problem of perennial shortage of Cotrimoxazole

• Address the transport challenges for the outreach programme.

• Lobby for the unfreezing of posts for Ministry of Health to enable provision of services.

• Purchase more viral load machines at least for district hospital, provincial and Central hospitals.

• Treatment literacy education for PLHIV

Overall conclusion• The team is of the view that the OIC services are operating to the

best of their abilities inspite of challenges highlighted. • The shortages of drugs cannot be considered as being at crisis

levels but have the potential of escalating into crisis if nothing is done to correct some of the bottlenecks highlighted.

• There is urgent need to address the side effects that some clients are experiencing.

• There is therefore need for close collaboration and partnership between the health providers, coordinators of the response and networks of PLHIV to jointly resolve some of the problems bedeviling the national ART response.

• We wish to thank the Ministry of Health and National AIDS Council for the support they have given us to undertake this exercise.