1. Expanding IMAI: Driving a decentralized approach in Senegal and in other West and Central African Countries Papa Salif SOW MD, MSc Department of Infectious Diseases Dakar University Teaching Hospital Sénégal WHO Satellite Meeting, ICASA Abuja, December 5th, 2005

3. The Senegalese Initiative on Access to Antiretroviral Drugs (ISAARV): August 1998

4. HIV Seroprevalence in Senegal in the general population 2,2% 0,5% 0,8% 1,0% 2,8% 2,0% 2,3% 1,7% 1,2% 0,7% 2,6%

5. Decentralization for access to care and treatment 17 Hospitals level 1 58 Health Districts 828 Health Posts National Level Regional Level ) District Level

6. The Senegalese Initiative for Access to ARV: (ISAARV): The challenges Decentralization: from pilot study (98-01) to public health reality (from 2001) –Limited Human Ressources outside the capital city –Limited Capacity of Health infrastructures –Necessity for assuring the Continuum of care –Challenges of integrating HIV monitoring into the public health system Need to build a model of decentralization

7. The Senegalese Model Training health staff in the regions –Theoric training –Pratic training Harmonisation of the ARV regimens 1st and 2nd line Regional Laboratories equipment for CD4 (Dynabeads) Regional Hospitals : reference center for the region Update of guidelines Mentoring approach by national expert Regional Coordination Team Simplified and Standardized questionnaire for data IMAI Approach for scaling up at district level +++

8. The mentoring approach Mentoring – « Coaching » National expert on charge for one region –Permanent contact with his région (Tel, Email…) –Diagnostic and therapeutic advices –Discussion on the indications and ARV regimens Regular supervision mission every 3 months by a multidisciplinary team –Medical record – update training sessions –Capacity building

9. The Impact of the model Increase of the ARV sites prescription –From 6 sites (1998 – 2001) – To 32 sites today 2005 - Increase the number of MD ARV prescriptors –12 (1998 – 2001) –94 today 2005 - Significant decrease of distance for access to ARV

10. The Senegalese target December 2005 = 4200 patients on ARV October 2005 = 3825 patients traited

11. Number of patients on ARV in all the 11 regions in Senegal 30th Octob. 05 91 147 152 166 88 200 194 2366 8 110 57

12. The impact of the model The decentralization of HIV Counseling and Testing sites –VCT : 13 in all the country –VST : 76 (voluntary services testing) The decentralization of PMTCT –1998 – 2004 : 1 region (Dakar, capital city) –2004 – 2005 : 9 other regions

13. Monitoring and Evaluation Documents for data collection in all sites Computer available at regional level for data collection Low process to set up the M&E system

14. ISAARV: lessons learnt Political committment : gratuity for care –HIV testing, drugs for OI, ARV, hospitalisation, artificial breasfeeding Collaboration between NACP and the university expertise Public-private parternship –Pfizer Foundation : Diflucan Donation Program South – North Collaboration Research : Clinical trials for one daily regimens and improving adherence

15. Scaling-up HIV care and antiretroviral therapy using the IMAI approach

16. IMAI process in Senegal Adoptation Adaptation Validation Implementation

17. IMAI implementation in Senegal First step: IMAI introduction workshop Ouagadougou, November 8-13th, 2004 Second step: Translation into French and adaptation to the Senegalese context : december 2004 – March 2005 Third step: National workshop for IMAI documents validation, April 2005 Fourth step: International workshop for IMAI TOT, Dakar May 2005 (20 Francophone countries)

18. IMAI implementation in Senegal Last step: Utilization of the IMAI approach for boosting the decentralization for access to care and treatment: Package for Integrated Management of HIV/AIDS, care, treatment and prevention –Health post: Nurses and midwives –Health Center: MD, nurses, widwives, social workers –Regional Hospital –University Teaching Hospital

19. IMAI Manuels Senegal

20. IMAI Manuels in Senegal

22. IMAI process in Senegal Health district HIV Care implementaition –August – September 2005 : 15 districts trained –The 38 other districts will be trained during 2006 Dakar: collaboration WHO for IMAI approach –Sharing experience with other countries on IMAI Burkina Faso : june 2005 Burundi : august 2005 Haiti : september 2005

23. Increase the Entry Points to care: HIV serology testing VCT PMTCT-Plus Centres for Tuberculosis Treatment Centres for Sexual Treatment Infections Vulnerables groups Clinical Services

24. Linsuffisance de traitement antirétroviral: une urgence sanitaire mondiale Pour atteindre lobjectif de 3 millions dici 2005, il faut un nouvel engagement et des nouvelles méthodes de travail pour lensemble de la communauté sanitaire mondiale. LEE Jong-wook, Directeur Général OMS, 22 Sept 2003 Assemblée Générale de lONU, New York

25. "3 by 5" For a Universal Access For a Universal Access to Care, treatment and Prevention