Public health approach to scaling-up ART using WHO IMAI/IMCI tools Dr Sandy Gove for the IMAI team and partners

G-8 in Gleneagles, Scotland in July 2005 they will “work to meet the financing needs for HIV/AIDS” called on WHO, UNAIDS and other international bodies "…to develop and implement a package of HIV prevention, treatment and care," specifying a target of “as close as possible to universal access to treatment for all those who need it by 2010.”

Includes: WHO model essential package for HIV prevention, care, treatment & support List of interventions List of interventions Normative guidelines Normative guidelines Operational tools, capacity building materials Operational tools, capacity building materials Core information system: standardized patient monitoring Core information system: standardized patient monitoring Drug and diagnostic supply management Drug and diagnostic supply management

Universal access requires a massive effort. This calls for - a standardized and streamlined approach that can scale-up a decentralized and integrated public health approach - in context multiple programmes and focal points with separate activities, funding a coherent programme of work for broad implementation - may span several national programmes and involve both government, NGO, FBO, private practitioner and workplace teams

Public health approach to scaling up HIV/AIDS services– address the health needs of the population Identify essential package of integrated HIV prevention, care, treatment and support interventions for health sector delivery Decentralization and integration of health services Standardization and simplification of protocols and procedures (to enable broad coverage) Clinical team approach to patient management, including task-shifting Strengthening HIV prevention in health-care settings Community mobilization to promote HIV testing and prevention and prepare communities for treatment and adherence support Population-based HIV drug resistance and pharmacovigilance Free ART at the point of service delivery

Public health approach to scaling up HIV/AIDS services– address the health needs of the population Identify essential package of integrated HIV prevention, care, treatment and support interventions for health sector delivery Decentralization and integration of health services Standardization and simplification of protocols and procedures (to enable broad coverage) Clinical team approach to patient management, including task-shifting Strengthening HIV prevention in health-care settings Community mobilization to promote HIV testing and prevention and prepare communities for treatment and adherence support Population-based HIV drug resistance and pharmacovigilance Free ART at the point of service delivery

WHO model essential package Facility-based interventions Interventions through outreach to most at-risk populations Community- based interventions

Within the WHO model essential package for HIV prevention, care, and treatment WHO operational tools for integrating interventions within the model essential package. These include: IMAI integrated management of adolescent and adult illness IMCI integrated management of childhood illness acute and chronic HIV care ART prevention by PLHA infant feeding counselling special interventions for other most at-risk populations IMPAC integrated management of pregnancy and childbirth PMTCT interventions integrated in antenatal care labour and delivery post-partum newborn care

Standardization and simplification of protocols and procedures WHO updated normative guidelines, based on expert groups Standardized first- and second-line ARV regimens When to start, substitute, switch and stop Updated ART and ARV prophylaxis regimens for PMTCT Cotrimoxazole and PEP recommendations IMAI/IMCI further simplifies and operationalizes these guidelines and provides tools to support implementation: management support job aids and training for clinical teams and CHWs strong follow-up after training- clinical mentoring, supportive supervision standard, simple patient monitoring system

IMAI & IMCI tools to support decentralization of HIV prevention, treatment, and care- for equity access adherence Primary care delivery - close to home Community-based care Central/ Regional Hospitals District hospital

Decentralization within a district network Patient-centered: empower patients for self-management Most symptoms; prevention by PLHA When to seek care from health worker Supported by treatment supporter/ CHW In context community treatment literacy, prevention support Nurse-led health centre teams (or clinical officers etc) Acute and chronic HIV care and prevention First-line ART in uncomplicated patients Including initiation in children and pregnant women Multipurpose district doctor or medical officer Backs up health centre and outpatient primary care clinical teams Good distance communication Regular on-site clinical mentoring

Decentralization of HIV services Health centre- nurse, PLHA lay providers HIV testing and counselling HIV education and support Basic prevention for all: safer sex, condoms, STI management Prevention by PLHA PMTCT Chronic HIV care including OI prophylaxis, staging Manage common OI Adherence support** Preparation for ART Initiate ART in uncomplicated patients ART dispensing and follow-up Record-keeping Hospital outpatient clinic, inpatient- doctor Initiation of ART in 'complicated,' sick and hospitalized patients Manage complicated opportunistic infections Manage treatment failure and adverse effects Manage complications of ART Record-keeping Acts as a primary care facility- all functions to the left but not by doctors!!

Benefits to decentralization Better support for deep commitment to good adherence Support by community, CHW, other treatment supporters Reduced transport time and costs for periodic visits Lifetime chronic care is more feasible when close to home More feasible to reach patients unlikely to travel to ART hospital: Pregnant women Children Seriously under-represented in those on ART

Integration Integration of multiple interventions Prevention, care and treatment integrated at point of service Coherent acute and chronic HIV case management approach (integrated management of multi-system disease) HIV services integrated with management other diseases and conditions HIV integrated within existing health system Strengthens the health system Assure delivery of basic care Builds a district network

Why an integrated approach? HTC PMTCT HIV Care/ART TB/HIV National level District level - primary care facility STI Targeted Interventions Community Preparedness

Where does integration occur for an essential package? Global and regional Agreement on a priority set of interventions National Flexible package for country adaptation District Collaboration between those responsible for various HIV services, TB, maternal and child care Clinical team Coherent management guidelines Family approach to care Community Treatment literacy and prevention promotion Strong links with health facility

Integrated approach for efficient scale-up of the essential package One scale-up of HIV services at district level –Chronic HIV care, ART, T&C, PMTCT –All ages All adult HIV care/ART sites should integrate: –PMTCT, other 'positive prevention' by PLHA –Paediatric HIV care/ ART Most rapid way to scale-up is integrated Family-based care Build on basic IMCI and paediatric referral care for the most common conditions Special emphasis on paediatric training needed

Integrated approach better serves HIV clients with other diseases (TB, malaria, STI) or conditions (pregnancy, IDU) Clinical co-management Co-supervision by district teams (HIV, TB. MCH) Co-sponsorship by national programmes- s hared programme of work Efficient management for patient (single clinic visit) and clinical team: TB-HIV co-management IDU-HIV co-management –Special care for IDU integrated with HIV care and ART within primary care, opioid substitution therapy Pregnancy-HIV co-management for PMTCT updated ART or ARV prophylaxis delivery integrated in antenatal, L&D, post-partum and newborn care train midwives and obstetricians in first-line ART and rapid adherence preparation and support

IMAI/IMCI approach to scaling up integrated HIV prevention, care and treatment Establish good chronic HIV care with clinical teams working within a district network –district network model (facility-community hybrid) hospital plus satellite health centres plus community-based care –linked facility and community interventions –no parallel systems- HIV services are integrated

Central, Regional, University, DISTRICT HOSPITAL COMMUNITY Clinical care- nurses, pharm techs; ART aid. Sometimes clinical/ health officer Treatment supporters, health extension officers, other community health workers, peer support groups, CBOs Doctors/health officers/ inpatient RN Specialised referral HEALTH CENTRE Drugs, diagnostics, commodities, logistic support National, Regional and District ART Management Referral, Back-Referral; Clinical mentoring; Supervision by District HIV Management Team Emphasis on strong facility- community link IMAI/IMCI

IMAI/IMCI provide a flexible toolkit, for country adaptation Fit to HIV epidemiology Generalized or concentrated epidemic Which populations are most at-risk IDU, sex worker, MSM Discordant seronegative partners of PLHA Adapt to health system Sociocultural adaptation Not one size fits all! Other service delivery models

How can IMAI/IMCI be scaled up in the midst of a human resource crisis? Emergency human resource strategy, supported by concrete tools for country adaptation: Task-shifting PLHA workforce- to expand clinical team; as CHWs- trained and paid Prevention and care for health workers –PEP, safe injections, universal precautions –Recognize and respond to burn-out –Clinical mentoring- attention to health worker needs, help with difficult patients, career support Rapid preparation of clinical teams with in-service training Rapidly into pre-service training Other WHO and partner efforts: retention schemes; special testing, care and treatment services for health workers (TTR)

Task-shifting Specialized physicians  doctors Doctors  health officers and nurses Nurses  PLHA on clinical team: ART aid (counsellor), triage/data clerk Clinical team  patient: self-management ** Clinical team  community- for case detection, treatment support, home-based care, simple monitoring Build functional clinical teams linked to the community within a district system

HIV learning programmes to support task-shifting Specialized physicians → doctors Doctors → nurses, clinical officers Nurses → Nursing assts, PLHA on clinical team, CHW Clinical team → patient (self-management) Second level learning programme Basic ART, HIV care, prevention clinical course; Acute care/OIs Basic ART Aid / Prevention course Patient self-management &community tools All use PLHA "expert patient-trainers" to present cases, provide feedback

IMAI-IMCI: harmonized, modular short courses TB-HIV Week 1 Week 2, follow-on Chronic HIV Care with ART and Prevention Acute Care: OI IMCI-HIV STI PITC Patient Monitoring Reproductive choice/FP Palliative care PMTCT: infant feeding PMTCT : antenatal/PP/L&D Adolescents Mental health MSM, IDU, sex workers

Rapid scale-up is feasible Ethiopia: 130 health centre clinical teams already prepared this year Scale-up training is feasible Continuous training over weeks Challenges: Volume clinical mentoring and supportive supervision after training Systematic linkages with community and outreach to most at-risk populations Drug and diagnostic supply management, logistics

Clinical mentoring: combine some individualized patient care with public health approach For complicated patients: consultation, referral, on-site case review during on-site visits, Public health framework with more intensive clinical content for certain patients

Management support - HIV district coordinators course- precedes clinical training Planning integrated services Targeted community interventions for populations at high risk HIV care/ ART patient monitoring Capacity building: - clinical team: - CHWs Organizing pregnancy related services Antenatal, PP/newborn PMTCT patient monitoring Follow-up after training Drug and diagnostic supply management

= District hospital HIV care/ ART clinic TB clinic: TB-HIV Co- management Antenatal clinic: ART for PMTCT = Health centres: HIV care, ART, prevention TB-HIV co-management PMTCT including ART Decentralize, expand number of sites

Standardized guidelines, training, management tools  Share training, mentors, patient monitoring system within a district Hospital Health Centre Health Post Health Post Health Post Health Centre Health Post Health Post Health Post Health Centre Health Post Health Post Health Post Health Centre Health Post Health Post Health Post MOH NGO or FBO Workplace HIV services  Scale up toward universal access is more feasible, sustainable Private providers Military services

Challenges Get patients on ART sooner: to reduce preART and early mortality on ART easier for primary care teams to manage patient prioritized use of CD4 Inpatient testing and preparation/initiation of ART (severe wasting; persistent diarrhoea)- modify outpatient materials to prepare inpatient staff How to systematically scale-up home-based delivery through CHWs (linked with health facilities): –HIV testing and counselling, provide and link with services –more effective prevention with home delivery disclosure support, partner testing, risk reduction counselling especially for discordant couples –cotrimoxazole, ART, TB, TB-ART treatment support