AIDS Medicines and Diagnostics

Service (AMDS)

Annual Stakeholders and

Partners Meeting

Geneva, Switzerland

May 7-8, 2013

Francis Aboagye-Nyame, Program Director David Mabirizi, Principal Technical Advisor, HIV and AIDS

Systems for Improved Access to

Pharmaceuticals and Services (SIAPS) Program Improved Access. Improved Services. Better Health Outcomes.

SIAPS Goal and Objective

• Goal

• To assure the availability of quality pharmaceutical

products and effective pharmaceutical services to

achieve desired health outcomes

• Objective

• To promote and use a systems-strengthening

approach consistent with the Global Health

Initiative that will result in positive and sustainable

health impact

Health Outcomes

Services

Products

Intermediate Results

• Strengthen pharmaceutical sector governance

• Build individual, organizational, and institutional capacity for pharmaceutical supply management and services

• Address the information for decision-making challenges in the pharmaceutical sector

• Strengthen financing strategies and mechanisms to improve access to medicines

• Improve pharmaceutical services to achieve desired health outcomes

Where SIAPS/SPS Works

• TA in 30 countries

• Offices in ~22 countries

• 340+ staff worldwide

• 80+% of staff from host country

SIAPS 2011-13

• Angola

• Bangladesh

• Brazil

• Burundi

• Cameroon

• Dominican Republic

• DRC

• Ethiopia

• Haiti

• Jordan

• Lesotho

• Liberia

• Rwanda

• Guinea

• Mali

• Mozambique

• Namibia

• Philippines

• South Africa

• South Sudan

• Swaziland

• Tajikistan

• Turkmenistan

• Ukraine

• Uzbekistan

• Vietnam

SPS AA

• Afghanistan

• Kenya

SIAPS Funding By Health Element

Total Field/Regional Support

HIV & AIDS

50%

Malaria

20%

MNCH

16%

TB

14%

Cross Cutting

1%

HIV & AIDS

43%

Malaria

18%

MNCH

18%

Nutrition

0%

TB

20%

SIAPS Systems Strengthening Approach

Selected TA Activities (1)

• Strengthening quantification

• Dominican Republic, Democratic Republic of the Congo (DRC), and Cameroon

• Strengthening procurement management systems

• Cameroon and Lesotho

• Improving storage of medicines

• Cameroon and DRC

• Strengthening Information systems

• Cameroon, DRC, Lesotho, South Africa, Namibia, Uganda, Kenya, Ethiopia, and Dominican Republic

Selected TA Activities (2)

• Prevention of substandard medicines and ensuring

patient safety

• Lesotho, Namibia, Swaziland, Kenya

• Develop and implement treatment guidelines

• Mitigate antimicrobial/drug resistance

• Build human resource capacity for Pharmaceutical

services

• Enhance coordination

Implementation and

monitoring of

HIV Drug Resistance

Early Warning Indicators: The Case of Namibia

Dr. David Mabirizi

Principal Technical Advisor – HIV &AIDS

SIAPS

Objectives

Share an experience

• The Early Warning Indicators (EWI) and the strategy

of the HIV Drug resistance monitoring

• The importance and implementation of EWI

monitoring

• The results and challenges

Background: HIV-DR Early Warning

Indicators (EWIs)

• WHO HIV drug resistance (DR) prevention strategy

• Assesses antiretroviral therapy (ART) sites and program

factors associated with HIV-DR

• Uses routinely collected data (medical & pharmacy records)

• Collects data annually or quarterly at representative sites

• Provides evidence for making programmatic adjustments at

• ART site

• Country level

Background: HIV and ART in Namibia

• Population of 2.1 million

• Nov. 2011, ~200,000 People Living with HIV and AIDS (PLWHA)

• Among 15-49-year-olds, ~18.2% HIV-infected

• High ART coverage ~90% by Dec. 2010

• ART available in private sector since 1997 and public sector since 2003

• ART at all 35 public hospitals and at >140 satellite sites

• ARVs are provided free of charge following a public health approach

Background: Minimizing HIV-DR in

Namibia • With support from SIAPS, The Namibia Ministry of Health and Social Services

(MoHSS) undertook the WHO strategy and published first report in 2012 • HIV-DR indicators evaluated in the quarterly reports

• National program mandates the use of • standardized national ART prescribing practices,

• WHO prequalified drugs, and

• standardized medical and pharmacy record-keeping systems

• Uses three data sources— • Pharmacy-based tool—Electronic Dispensing Tool (EDT) for collection, reporting,

analysis, and use of routine pharmacy data

• Clinical data tools—Electronic Patient Management System (ePMS)

• Patient care booklet

• The USAID’s SPS and SIAPS programs have supported EDT

• USAID has also supported implementation of ePMS

Background: Comparison of ART Data

Systems

Intervention: Data Abstraction • MoHSS selected 5 of the 7 WHO EWIs for Namibia based on—

• Available data

• Anticipated impact of interventions related to these

indicators

• Data abstraction follows database queries created in the EDT

for calculating the EWI indicators

• Data abstracted centrally from National Database

• for 33 ART sites following WHO guidelines on sample size

and selection

• Abstracted data exported to an Ms Excel® tool provided by

WHO, which calculated results for each indicator

Results (1) • Available data records allowed for monitoring of 3 of 5 EWIs

• Data from 3,875 patients abstracted and analyzed

• EWI 1: appropriate initial ART regimen prescriptions

• 22 of 33 (67%) sites met the target of 100% appropriate initial

ART regimen

• 9 of 11 sites not meeting the target had appropriate ART

regimen for 98%–99% of their patients

• The 1%–2% with “inappropriate first-line regimen” had a protease

inhibitor-based regimen

• Results are comparable to other African settings

Results (2)

• EWI 2: Lost to follow-up (LTFU) 12 months after ART initiation

• 17 of 33 (52%) sites met the target of ≤ 20% LTFU at 12 months

• Similar to other African reports

• The LTFU rates ranged from 3% to 68%

• EWI 3: Patients on appropriate first-line regimen at 12 months

• 15 of 33 (45%) sites achieved 100% target

• In 55% of sites, only 1%-8% patients switched to a second-line regimen

before the 12-month date

• EWIs 4 and 6: (on-time pill pick-up ) and (ARV drug stock-outs*)

• Could not be calculated because of data-related inconsistencies

* It has been documented that Namibia has > 99% availability of ARVs but

existing data systems did not allow a thorough analysis for all sites

Discussion • 2010 EWI data extraction exercise provides Namibia with a

evidence for national and site-specific programmatic monitoring of potential HIV-DR

• The initial evidence is further investigated to contextualise results and identify facilities with major shortcomings

• guides design and implementation of interventions

• Strengthening standardization of dispensing practices and addressing gaps in ART data quality at facility level

• MoHSS has initiated interventions to address gaps

Challenges

• Data quality issues

• At ART sites with a high turnover of pharmacy staff

• Weak paper-based record-keeping practices in the regions

especially rapidly decentralizing ART services from district

to health centres and clinics

• Analysis and use of EWI data for decision making at facility

level

• Most health facilities grappling with shortage of health

workers (doctors, nurses, pharmacists) and high workload

Conclusion

• Implementation of robust electronic data collection systems

facilitated quick and efficient central abstraction of EWI data

• EWI abstraction identifies areas that require MoHSS

intervention to improve quality of ART service delivery and

prevent HIV-DR

• On-going efforts required to improve

• ART data quality

• Availability and accuracy of ART data and reports for all the

EWIs

Way Forward

• Continued support to MoHSS —

• data analysis capacity and implementation of targeted

interventions for “at risk” ART sites

• Improve data quality

• Promote discussion of EWI results at facility level

• Work to ensure that health information systems at facility

level are compatible and complementary in their data

systems to minimize duplication

References and Acknowledgments

• Bibliography

• Alcorn. Keith. 2011. Is HIV drug resistance spreading? Early

warning signals say ‘yes.’ NAM AIDSMAP

http://www.aidsmap.com/Is-HIV-drug-resistance-spreading-

Early-warning-signals-say-yes/page/1684209/

• Ministry of Health and Social Services. 2012. Report on World

Health Organization Early Warning Indicators - Namibia for

2010. MoHSS Namibia

• WHO. 2012. WHO HIV drug resistance report 2012. Geneva:

WHO.

• Acknowledgments

• MoHSS Namibia; USAID Namibia; WHO Namibia Field Office;

Tufts University School of Medicine; SIAPS team