Western Pacific Regional Office Mechanisms for planning and implementing TB/HIV interventions at district level Masami Fujita WHO Western Pacific Regional Office Thank you very much, mister chair person. It is a great honor for me to present today. I will talk about an overview of comprehensive HIV/AIDS care based on the experiences of other countries including Thailand. Dr Somsak who has been working in Northern Thailand for 25 years will help me. My presentation will be followed by presentation on the issue of TB-HIV by Dr. Daniel Chin, WHO Office in China. THE 3rd GLOBAL TB/HIV WORKING GROUP MEETING MONTREUX, SWITZERLAND 4- 6 JUNE 2003

TB/HIV: Areas for Collaboration TB Program DOTS Strategy AIDS Program Prevention and Care Policy / Strategy Management / Coordination Service Delivery Based on the framework, each country may want to establish a national coordination mechanism on TB/HIV. It can identify areas for collaboration at the levels of policy and strategy, management and coordination, and service delivery, identifying responsibilities of each program. Strengths of each program should be fully utilized. For instance, AIDS program is good at multisectoral approach, advocacy and IEC, While TB program has functional DOTS integrated into district health system, on which HIV/AIDS care activities can be developed and reinforced. Bottleneck: HIV/AIDS Care ?? 2018/11/21 WHO-WPRO; HIV Care

Referral and TB/HIV care TB Program AIDS Program TB diagnosis TB treatment VCT HBC Care for asymptomatic and symptomatic Based on the framework, each country may want to establish a national coordination mechanism on TB/HIV. It can identify areas for collaboration at the levels of policy and strategy, management and coordination, and service delivery, identifying responsibilities of each program. Strengths of each program should be fully utilized. For instance, AIDS program is good at multisectoral approach, advocacy and IEC, While TB program has functional DOTS integrated into district health system, on which HIV/AIDS care activities can be developed and reinforced. 2018/11/21 WHO-WPRO; HIV Care

ARV treatment as driving force to establish HIV/AIDS care Increasingly available even in developing countries However, it is NOT easy 2018/11/21 WHO-WPRO; HIV Care

Effective ARV treatment requires … Acceptable selection process for ARV enrollment Educational support Psychosocial and economic support including counseling Continuous supply of quality ARV drugs Mechanism to ensure adherence and follow-up Capacity to monitor treatment & manage side-effect Capacity to prevent and treat OI Reduced stigma and discrimination, etc. Most of these requirements are beyond capacity of “clinical services” in most developing countries 2018/11/21 WHO-WPRO; HIV Care

PHA/peer support played critical roles in countries where major progress was made in HIV/AIDS care facilitated/supported by NGOs and health workers e.g. Thailand, Uganda, Brazil 2018/11/21 WHO-WPRO; HIV Care

An approach to develop continuum of care in resource poor settings Day care center (DCC) for/by PHA Place where PHA conduct various care & support activities, facilitated and supported by health workers. Attached to health facilities, but open to community Many are located at district level (e.g. Northern Thailand) - Not too far (transport) or not too close (stigma) - Sufficient number of PHA to form groups - Medical capacity to provide OI services and ARV I will show one example of comprehensive care in HFBC through day care center. The DCC is the place where PHA freely meet together everyday, or weekly or monthly and conduct wide range of activities, facilitated and supported by HCW. In Northern Thailand, many DCC were established attached to provincial (prefecture) and district (county) hospitals. DCC are established in some health centers, too. 2018/11/21 WHO-WPRO; HIV Care

DCC can be launched with a room and a staff, without capital investment The DCC can be launched with one room and one staff, without capital investment. 2018/11/21 WHO-WPRO; HIV Care

Functions of DCC 1) Peer support 2018/11/21 WHO-WPRO; HIV Care

Functions of DCC 2) Individual and group counseling 3) Spiritual support 2018/11/21 WHO-WPRO; HIV Care

Functions of DCC 4) Health education for PHA and family on self-care, home-care, health promotion, nutrition, and prevention 2018/11/21 WHO-WPRO; HIV Care

Functions of DCC 5) Base for home based care: (Capacity building of PHA and family, Home visit) 2018/11/21 WHO-WPRO; HIV Care

Functions of DCC 6) Base for learn and work with community 2018/11/21 WHO-WPRO; HIV Care

Functions of DCC 7) Occupational promotion 8) Support for orphans 2018/11/21 WHO-WPRO; HIV Care

Functions of DCC 9) Health check-up including early TB detection 2018/11/21 WHO-WPRO; HIV Care

Functions of DCC 10) Clinical service Comprehensive care and support User-friendly one stop service (short waiting time, intimate staff) improve adherence of OI prophylaxis and treatment TB, PCP, Cryptococcosis ARV treatment 2018/11/21 WHO-WPRO; HIV Care

2018/11/21 WHO-WPRO; HIV Care

Hospital where IPT is managed separately from DCC Another hospital has achieved low completion rate and high drop-out rate. Remark: “Defaulter” is defined as missing appointment for more than 45 days. 2018/11/21 WHO-WPRO; HIV Care CDC 10 MOPH Thailand

Hospital where IPT is integrated in DCC services I will show one example of DCC function on TB preventive therapy, In Northern Thailand, around half of the public hospitals have been providing TB preventive Therapy. However completion rate is generally low, less than 50 % in many hospitals. But this hospital A achieved exceptionally high completion rate, 80-90 %. Why? Remark: “Defaulter” is defined as missing appointment for more than 1 month 2018/11/21 WHO-WPRO; HIV Care CDC 10 MOPH Thailand

DCC as “Heart” / “Hub” of HIV/AIDS care Day Care Center - Peer support - Psychosocial - Occupational - Medical/Health PHO Prov Hosp OPD/AIDS Clinic Other sectors - Link with hosp/HC service (VCT, Health promotion, Counseling, Home visit Sympt/Palliative care, OI, ARV) - Link with community (Anti-discrimination, Home visit, Orphan) DHO Dist Hosp OPD NGO - Link with home (Family training, counseling) HC Com. org HC PHA PHA PHA 2018/11/21 WHO-WPRO; HIV Care

ART DOT or Buddy system could not be developed and sustained in the vacuum. The partnership mechanism at the intermediate (district) level is essential. 2018/11/21 WHO-WPRO; HIV Care

Example: Cambodia Reinforce Oper.Dist with DCC function (“MMM”) PHO Prov Hosp Reinforce Oper.Dist with DCC function (“MMM”) Other sectors Link with hosp/HC Link with community Dist Hosp HIV office PHA group Funding from abroad Link with home Com. org NGOs HC HC PHA PHA PHA 2018/11/21 WHO-WPRO; HIV Care

Example: Viet Nam DCC functions at Dist Health Center PHO Prov Hosp Link with hosp/HC Other sectors Link with community Dist HC HIV in Prev.Med PHA group Link with home HC Com. org HC PHA PHA PHA 2018/11/21 WHO-WPRO; HIV Care

Referral and TB/HIV care TB Program AIDS Program TB diagnosis TB treatment VCT HBC Care for asymptomatic and symptomatic Based on the framework, each country may want to establish a national coordination mechanism on TB/HIV. It can identify areas for collaboration at the levels of policy and strategy, management and coordination, and service delivery, identifying responsibilities of each program. Strengths of each program should be fully utilized. For instance, AIDS program is good at multisectoral approach, advocacy and IEC, While TB program has functional DOTS integrated into district health system, on which HIV/AIDS care activities can be developed and reinforced. 2018/11/21 WHO-WPRO; HIV Care

HIV/AIDS care as program is essential for effective TB/HIV interventions TB Program DOTS Strategy AIDS Program Prevention and Care Policy / Strategy Management / Coordination Service Delivery Based on the framework, each country may want to establish a national coordination mechanism on TB/HIV. It can identify areas for collaboration at the levels of policy and strategy, management and coordination, and service delivery, identifying responsibilities of each program. Strengths of each program should be fully utilized. For instance, AIDS program is good at multisectoral approach, advocacy and IEC, While TB program has functional DOTS integrated into district health system, on which HIV/AIDS care activities can be developed and reinforced. 2018/11/21 WHO-WPRO; HIV Care