1. Harvard PEPFAR: Six Years of Implementation Mark Barnes December 17, 2009 mbarnes@hsph.harvard.edu

2. Harvard PEPFAR: Background in Three Countries  Nigeria – Gates grant on HIV prevention (Phyllis Kanki)  Tanzania – NIH-funded HIV and nutrition research (Wafaie Fawzi, Walt Willett)  Botswana – collaboration with MOH on national HIV laboratory, and NIH- funded research (Max Essex, Ric Marlink)

3. Harvard PEPFAR in Nigeria  AIDS Prevention Initiative in Nigeria (APIN) - established in 2000 with grant from Bill & Melinda Gates Foundation  Harvard PEPFAR(APIN Plus) Program initiated in 2004  APIN, Ltd. - incorporated in October 2007 as a local NGO to assume the functions of Harvard PEPFAR in Nigeria

4. APIN Ltd and Harvard PEPFAR Sites Nigerian states that currently include sites under APIN Ltd & Harvard PEPFAR 1 1

5. IndicatorHarvardAPINTotal BC and S Current Adults Peds 50,795 1,691 13,551 716 64,346 2,407 Cumulative (Ever) Adults Peds 80,899 3,287 23,254 1,126 104,153 4,413 ART Current Adults Peds 38,157 1,727 10,163 587 48,320 2,314 Cumulative Adults Peds 51,577 2,072 13,887 656 65,464 2728 September 2009

6. Sites by Types Organizational type #Remarks Primary1Kuramo Secondary15Includes 5 FBOs and 1 private hospital Tertiary135 teaching hospitals, 2 FMCs, NIMR, 68 Mil, GHM, GHOnikan, GHOgbom, GHIOde NGO4AAN, ARFH, HaltAIDS, Mashiah Total33

7. Harvard PEPFAR Sites  Benue: Federal Medical Centre Makurdi  Borno University of Maiduguri Teaching Hospital  State Specialist Hospital Maiduguri  Nursing Home Maiduguri  Ebonyi: Widowcare Abakiliki  Enugu: University of Nigeria Teaching Hospital Ituku-Ozalla  Kaduna: Ahmadu Bello University Teaching Hospital  Plateau Jos University Teaching Hospital  8 Satellite Hospitals, 44 PHCs Our Lady of Apostles Hospital Jos  Yobe: Federal Medical Centre Nguru  Lagos 68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research Military Hospital, ‘Creek’ Lagos University Teaching Hospital University of Lagos, College of Medicine  Mushin General Hospital  PHC-Iru Victoria Island  Onikan Women’s Hospital  Ogun: Sacred Heart Catholic Hospital Lantoro  Oyo University of Ibadan College of Medicine  3 Satellites under UCH Adeoyo Maternity Hospital

8. Harvard sites transitioning to APIN Late 2007-2008  Oyo State 43 Oyo State DOTS Centres  Lagos State PHC Iru Victoria Island  Ogun State Sacred Heart Catholic Hospital $1.705m grant 2009  Nigerian Institute for Medical Research  Lagos University Teaching Hospital  Mushin General Hospital  Onikan General Hospital $Budget 12.3m Lagos 68 Military Hospital, Yaba Military Hospital, ‘Creek’ Oyo University of Ibadan College of Medicine General Hospital Ijebu- Ode General Hospital Ogbomosho St. Mary’s Catholic Hospital Eleta Adeoyo Maternity Hospital Proposed for 2010 ???

9. ARV Pick-up data for assessment of ARV regimen and adherence in evaluation of treatment failure Transcription error of Drug name (ciprofloxacin) in Pharmacy DB

10. The Treatment Utility Graph – very useful for adherence and clinical progress

12. Systems Development  Strategic Information  Human Resources  Finance and Administration  Pharmacy/Logistics  QI/QA  Procurement  Audits

13. Challenges  Stakeholders’ skepticism about formation of APIN  Overlapping Harvard/APIN responsibilities  Different funding cycles – anticipated gap for each year of transition  APIN’s lack of working capital

14. Challenges  Drug warehouse fire- April 26, 2008  Space constraints- regulations on construction  Loss of trained personnel to other PEPFAR partners and international NGOs  Lack of institutional support at some sites

15. Harvard PEPFAR in Tanzania

16. Tanzania Country Profile Area945,087 sq. km Population (as of 2007) 39,384,223 Per capita income- about $350/yr - 58% earns <$1/day Annual population growth rate 2.9% Life expectancy54 yrs for males & 56 yrs for females

17. HIV/AIDS in Tanzania SOURCE: THIMS, 2007/8 There is a down trend of HIV prevalence 7% (2004) Vs 5.7% (THIMS 2008) Prevalence rate in Ante Natal Clinics among pregnant women 2008 8.4% PLWHA2.5 million In need of ARV 500,000 Currently patients on ARVs countrywide 280,000 (56%)

18. The National Care and Treatment Program  Launched in 2004  Government Commitment to provide free ARVs to all  PEPFAR and Global Fund are among major supporting partners

19. Harvard- PEPFAR Program  Collaborating institutions (MDH) Muhimbili University College of Health & Allied Sciences (MUHAS) Dar es Salaam City Council Harvard School of Public Health

20. Total ever enrolled 75,198 Active on ARVs 30,884 Ever initiated ARVs 47,221 Harvard PEPFAR in Tanzania: Sept. 2009 September, 2009  29 sites Public  1 faith-based  18 sites Private

21. Urgent Need to initiate Care and Treatment in 2004

22. 2004-2009 Priorities  Create more clinic space to accommodate increasing patients  Emergency staff hiring to meet increasing demand  Improve capacity of existing laboratories/establish new ones for patients monitoring  Training of service providers on HIV care

23. Addressing human resource problem  Through PEPFAR funding, we engaged more than 600 local staff to work with the program  Hired about 450 more staff  Provided incentives to ensure staff retention (training, good working environment, professional recognition)  Program paid staff are now being absorbed in the government system by phases

24. Training  MDH Program provided routine basic ART training according to national curriculum for the core and back up teams  1 month practical training  Ongoing mentorship/preceptorship  Video conferencing  Later introduced other essential related training according to needs Treatment adherence Nutrition

25. Strengthening of Laboratory Component  Huge investment in renovation to create space and meet standards (10 labs)  Procurement of equipments  Procurement of reagents  Training in GLP  Quality assurance and quality control  Putting in place supply chain management

26. 2009-2012 Priorities 1.System strengthening 2.Quality Improvement Program 3.Data management for decision making 4.Transition Harvard core business to local entity for sustainability

27. Quality Improvement (QI)  Building the culture of QI: regarding quality improvement program as important as meeting targets in numbers Development of indicators Regular assessment Feedback and strategies for improvement  Focusing on all 3 domains 1.Quality of care provided 2.Ease of access to service 3.Patient satisfaction

28. Example: Addressing quality issues  Patients are less likely to stay in care if provided by overwhelmed health workers, at clinics far away  Innovations Size and proximity of services addressed by scaling up and decentralization Prolonged working hours Visits scheduled by date and time block

29. Task Shifting  Inadequate human resources  Innovations to make use of available resources  Task shifting Nurses dispensing drugs PLWHAs providing group counselling, tracking of missing patients Using community lay workers to promote adherence Integration of HIV care into general health services (ANC, TB)

30. Patient retention – a major challenge  At least 20% of patients are lost to follow and are rarely traced  Patients not on ARVs are more likely to be lost to follow up  40% of lost to follow up patients are missed within their first 30 days of enrollment  Lost to follow up is often likely due to death  LTFU has major public health implications

31. Patient tracking  Established a close monitoring system using available resources  At every visit, nurse/counselor updates map cue (phone number, physical address)  Patients are traced through mobile phones, or/and physical home visit  Community-Based Health Workers & volunteer PLWHAs f ollow-up patients with missed visits abnormal lab results that need immediate attention HIV exposed infants

32. Transitioning to Local Ownership  Plan is to transition the Harvard role to a local entity (MDH) by phases  During the process Harvard will continue providing TA and capacity building to the local entity  Local entity will continue to collaborate with Harvard in TA, training, research

33. Harvard PEPFAR in Botswana: Harvard PEPFAR in Botswana: Supporting the National ARV Therapy Programme (Masa)

34. Masa: Botswana National ARV Program  Total Population of Botswana – 1.8 million  Started in 2002 – first African country to give free ARVs to all citizens  November 2009 110,000 on ARV treatment in Public Sector 61.8% female 6.8% children < 13 131,444 - Total on Treatment (public and private)

35. 35 Master Trainer/ARV Site Support Program ClinicalLaboratory Monitoring & Evaluation Unit (within DHAPC): Linked to: All ARV sites Other MOH programs Masa BHP-PEPFAR ARV Site Support Program

36. Clinical Master Trainer Program : ARV Mother Sites Assessed and Supported Mother Sites Supported Bokspit Goodhope Palapye Masunga Werda Newxade Each Mother Site has 3-4 Clinics

37. 37 CMT Cumulative Progress To Date  Originally 32 mother sites in regional hospitals  Direct support to: 29 District Hospitals 2 Botswana Defence Force Hospitals 138 Satellite Clinics – CMTs started and support 60% of new patients initiated at new clinics Training (4,000 in formal training) – Nurse Prescriber & Dispenser – Nurse Dispenser – KITSO Introduction to AIDS Clinical Care – KITSO AIDS Clinical Care Fundamentals – Quality Assurance and Improvement (QAI) – Other topics as requested by MoH 37

38. 38 LMT Cumulative Progress to Date:  Decentralized Labs: Set-up, Training and Support of 100% of labs CD4s - 21 labs VL – 8 labs PCR – 1 lab  Formal Lab Training (125 Lab Staff) CD4 Viral Load Training Manual Sample Collection and Processing Rapid Testing for Nurses and Dried Blood Spot Collection for Lay Counselors at sites without labs 38

39. LMT Cumulative Progress to Date:  60% of CD4s now performed at decentralized labs  29% Viral Loads now performed at decentralized labs

40. Harvard PEPFAR in Botswana: 2009-2012  Chartering of BHP, new not-for-profit entity in Botswana, with Harvard- MOH board of directors  BHP will become the prime recipient of PEPFAR funds in 2010  PEPFAR is only 20% of BHP activities

42. Thank You