1. ICAP 2008 Growth and Innovation David Hoos Washington, DC August 2008

2. Outline Growth in coverage Growth in enrollment Expansion of portfolio of services Innovations in country programs Site Support and Site Independence

3. Expansion of Coverage Rural/Urban and Types of Facilities (n=244) n=158n=86 % sites

4. Cameroon, Cote d’Ivoire, Kenya, Lesotho, Rwanda, S. Africa, Tanzania Uganda, Thailand Mozambique Ethiopia Overall ICAP-Supported Cumulative Enrollment in Care and Treatment (June 30, 2008) 510,474 in care 237,337 on ART Number of patients Number of facilities Nigeria, Swaziland, Zambia 333 sites

5. Cumulative in care (ART and non-ART) Cumulative on ART * Track 1.0 Supported Sites

7. Current and Target Enrollment Six months into COP-08 Number of patients

8. A Focus on Women and Children

9. Attaining Pediatric Targets n=214,722n=167,060 n=381,782* Percent of Enrolled Patients

10. 57,659 in care 20,996 on ART Cameroon, Cote d’Ivoire, Kenya, Lesotho, Rwanda, S. Africa, Tanzania Uganda, Thailand Mozambique Ethiopia Nigeria, Swaziland, Zambia 333 sites 0 20,000 40,000 60,000 80,000 Apr 05 Apr 06 Apr 07 Apr 08 0 175 350 HIV careARTFacilities ever reporting More than 57,000 children enrolled in care and more than 20,000 on ART (June 30, 2008) Number of patients Number of facilities

11. ANC Labor & Delivery Vaccination or Well-baby Clinics Post- Partum Follow- up of Women HIV testing of women CD4 test and clinical staging of women & treatment for women with advanced HIV More efficacious regimens for PMTCT Engaging and testing of partners Complete package of interventions HIV testing of women and linkage of HIV+ve women to HIV care services Engaging partners HIV testing of women with unknown status & linkage of HIV+ to HIV care Follow-up of all HIV-exposed infants  Cotrimoxazole  Growth monitoring & monitoring for evidence of HIV disease  Early HIV diagnosis, linkage to Peds services and early ART initiation HIV testing of women with unknown status Follow-up of women with HIV: counseling on infant feeding CD4 test and clinical staging of women ART for women with advanced HIV Complete package of interventions Engaging & testing (partners, other children) Maternal and Child Health Platform

14. PMTCT Regimens Used Vary by Country April-December 2007 n=274n=535n=2,414n=1,610n=472 n=5,406 % women n=101

15. Integration of TB-HIV Services

16. Increasing Proportion of Newly Enrolled HIV Patients Screened for TB at Enrollment n=8,685 n=13,950 n=17,563 n=24,484 New HIV patients n=30,050

17. Majority of New TB Patients Tested for HIV n=7,444 n=6,921 n=7,514 n=7,381 New TB patients

18. Potpourri of Innovations Observation Design of Innovation Implementation of Innovation Learning Scale-Up

19. ICAP-Kenya

20. Family HIV Testing Design of Family Testing Form Piloting of the form Form filled by Nurse Counselor Review of pilot and revision of form Community mobilization Fun activities for children and families Testing on site Linkage of HIV+ to HIV care Scale-up to all facilities

21. Sensitization of site staff and leadership Compiling and verification of defaulter Phone tracing Training of peer educators for tracing activities Feedback and discussion with site teams Intensive Defaulter Tracing

22. LTFU: 40% ‘LTFU’ still on ART!

23. Tracing Focused on True LTFU

24. ICAP-Mozambique

25. Screening of HIV Patients for TB Increased TB screening of new HIV patients at ICAP- supported facilities Q1 2007 26% Q1 2008 50% (Q1 2008 4305/8611) ICAP TB screening tool adapted and adopted by the Moz-MoH as national tool in 2008

26. HIV Testing of TB Patients TB Clinics 74% of TB patients tested 95% Tb/HIV patients referred to ART facilities 89% of co-infected patients provided with cotrimoxazole TB Day 2008 Nicodoala Health Center

27. Enhancing Pediatric Services Use of ICAP Paediatric Standards of Care Indicators (SOCs) Nampula Central Hospital

28. Dolls Used to Stimulate Discussion and Transmit HIV Information Anatomically accurate and culturally appropriate dolls Patients largely illiterate Used by healthcare and peer workers –proper breastfeeding practices –condom use –status disclosure –treatment adherence Stimulate discussions in counseling rooms, waiting areas and support group meetings

29. ICAP-Tanzania

30. Bringing HIV Care & Treatment to Where PMTCT Takes Place-- Reproductive and Child Health Clinic (RCH) Tumbi Regional Hospital Rationale: PMTCT services available at most hospitals (91%) & health centers (88%) However, only 22% centers offer ARV treatment usually through Care and Treatment Clinics (CTC) Bring ART services to PMTCT sites at RHCs Activities: Garner support of facility leadership and health care workers (at CTC and RCH) Training and mentoring on ART/PMTCT Establish recordkeeping, pharmacy and laboratory systems Modify patient flow Use family support groups to complement clinic interventions

31. Pregnant Women Successfully Received PMTCT and ART

32. ICAP-South Africa

33. Model of TB Infection Control Program in TB Endemic Settings High prevalence of unrecognized TB among HIV-infected individuals –Motherwell CHC: 22% of 597 HIV patients screened diagnosed with TB Assessment of TB infection control situation –Facilities –Procedures –Knowledge, Attitudes, Beliefs and IC Practices

34. Assessment at Two Facilities Cecilia MakewaniMotherwell CHC Infrastructure No separate waiting area for TB suspects Waiting area crowded No separate waiting area for TB suspects Waiting area crowded Infection Control Management General IC team in place TB IC not addressed IC coordinator in place No TB IC team/plan Patient Triage No screening for cough No TB screening checklist Cough screening in early morning only TB screening checklist used consistently

35. Baseline Assessment-2 Cecilia Makewani HMotherwell CHC Cough Etiquette/ Respiratory hygiene No tissues/waste baskets available in waiting area Surgical masks for high risk patients No tissues/waste baskets available in waiting area TB Diagnosis No safe collection of sputum specimens Good transport system On-site laboratory No safe collection of sputum specimens Sputum turn-around time 72 hrs TB Treatment & Referrals Delays in initiation of TB Rx for outpatients ART patients treated onsite TB register not available No feedback on patients treated off-site Most patients referred off- site No feedback on patients treated off-site Good clinic-based DOTS system and tracing

36. Baseline Assessment-3 Cecilia Makewani HMotherwell CHC Environmental Infection Control Measures Windows too high to open easily Mechanical ventilation not used adequately Mainly relying on natural ventilation Unused open courtyards Personal Respiratory Protection Limited use of N95 respiratorsNo N95 respirators in HIV clinic Staff Capacity Building No staff trained on TB IC, very limited on TB/HIV integration No staff trained on TB IC Staff Protection Annual Chest X Ray for staff Staff health clinic with confidential HIV C&T Limited TB screening Confidential HIV C&T available

37. Infection Control Related Activities Establishment of: –Infection Control committee –TB Infection Control plan –Implementation of Infection Control procedures –Renovation of facilities –Information, training, mentoring of staff, patients, families –Mobilization of community

38. Unused Courtyard: Possible waiting area for patients with suspected TB? Motherwell Community Health Centre High ceilings Windows inaccessible Unused exhaust system Cecilia Makiwane Hospital HIV clinic

39. ICAP-Ethiopia

40. PLWHA Support Group PE counseling ‘Tents’ One-to-One adherence counseling Home visit - Defaulter Tracing Group-Education Peer Educators in Action Task Shifting

41. ICAP-Rwanda

42. A Focus on Pregnant Women and Children More efficacious PMTCT regimens and ART for treatment of pregnant women –Establishment of district CD4 count testing system –Expansion of CD4 testing of pregnant women –Enhanced linkages between ART clinic and PMTCT program Identification of HIV-infected children admitted to hospitals

43. CD4 Testing of Pregnant Women July 06 – Dec. 07 Implementation of the district CD4 count testing system

44. Shift from sd-NVP to Multidrug PMTCT and HAART for Pregnant Women

45. HIV Testing of All Children Admitted to Central Hospital-Kigali

46. ICAP-Nigeria

47. HIV Information and Testing at Motor Parks Motor parks draw large numbers of people, including drivers, vendors, and artisans Partnered with Benue Links Motor Park & the JIREH Foundation, a community- based organization Rally inaugurated free- standing HIV testing & counseling center First day, 202 individuals tested and 13 HIV positive linked to care and treatment

48. ICAP-Cote d’Ivoire Map here

49. Challenges in a Post-Conflict Setting ICAP supports facilities in 5 regions, areas severely affected by recent conflict Fragmented government has created weakened national planning and leadership In some regions, facilities including hospitals stripped of equipment and furnishings –Need for basic refurnishing to enable program initiation Low service utilization –during conflict, mobility restricted due to need to pass through multiple roadblocks, fear of violence Need to inform population of availability of HIV services; facilitate access

50. From Site Start-up to Site Independence Clinical Systems Mentorship Standards of Care (SOCs) Wiki Space for Clinicians

51. Goal 1: Implement a chronic care model of HIV care and treatment (comprehensive, family focused) Goal 2: Build capacity to promote program sustainability and independence Site Start-up Site Independence Assess and Build Capacity Time Assess and improve implementation Assess and improve quality Site support team Onsite team Developing district- and national-level capabilityDeveloping patient-and provider-level capability

56. Way Forward Continue expansion of coverage and diversification of delivery methods Continue with core fundamentals of ICAP approach –Family focus in all programmatic components –Build on framework of existing health systems –Partnerships with national and local organizations –Capacity building at all levels through mentorship Expand prevention interventions Develop innovations to guide programs Enhance overall health systems