1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

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

11. 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

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

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

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

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

16. 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

17. 2018/11/21
WHO-WPRO; HIV Care

18. 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

19. 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, %. Why?
Remark: “Defaulter” is defined as missing appointment for more than 1 month
2018/11/21
WHO-WPRO; HIV Care
CDC 10 MOPH Thailand

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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