Scaling up HIV/TB programs The role of Capacity Building

Dr Alex G CoutinhoInfectious Diseases Institute

Makerere University, Kampala, Uganda

EXAMPLES OF SCALE UP

NUMBER OF PEOPLE RECEIVING ANTIRETROVIRAL THERAPY IN LOW- AND

MIDDLE-INCOME COUNTRIES 2002-2007

WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

SCALE-UP OF CLINICAL SERVICES FOR SEX WORKERS UNDER THE AVAHAN INDIA AIDS

INITIATIVE

WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

Trends in number of person on ART – 2003 - 2007

Source: Republic of Uganda. Ministry of Health. (2007). Annual health sector performance report : Financial year 2006/2007. Kampala: Ministry of Health.

SCALING UP – REQUIRES----

• The need – i.e. Disease Burden• The gap in service provision• The will and political/technical leadership• The knowledge on what/how to scale up• The people (with knowledge) to scale up• The policy framework• The financing• The monitoring and evaluation tools to track

progress and provide corrective solutions

Common Characteristics of “Success Countries”

• Top Leadership (sustained)

• Grassroots and community engagement, acceptance and involvement

• Stigma free environment ( general and for specific groups)

• Policies and programs

• Resources

• Metrics to track response

Kenya, 245,162

16%

Mozambique, 156,108

10%

Tanzania, 139,151

9%

Uganda, 78,769, 5%

Eritrea4,838 Madagascar

1,491Mauritius

584

Comoros28

South Africa, 473,499

31%

Zambia, 103,077

7%

Ethiopia, 94,489

6%

Malawi, 86,905, 6%

Rwanda, 9,225, 1%

Botswana, 13,518, 1%

Swaziland, 15,131, 1%

Namibia, 16,082, 1%

Angola, 21,777, 1%

Lesotho, 22,666, 1%

Zimbabwe, 45,652, 3%

Eastern & Southern Africa

1.5 million (57%)

Rest of the world1.2 million (43%)

Global new infections, 2.7 million

ESA new infections,1.5 million

Estimates of New HIV Infections in Eastern and Southern Africa, 2007 (Source UNAIDS RST)

TB Cases

THE GAP

THE KNOWLEDGE

HIV Prevalence among CSWs (Kampala - 2001 and 2003)

28.2

47.2

05

101520253035404550

HIV

pre

val

ence

(%

)

2001 2003

Year of study

Viral Load and Transmission Rates Among Discordant Couples by Gender In Uganda

0

5

10

15

20

25T

rans

mis

sion

Rat

e

HIV Viral Load, RNA Copies / mL

A. Sexual Transmission B. Perinatal Transmission

HIV Acquisition among Male Partners of HIV + Female Partners By Circumcision

Status In Rakai

40/137 uncircumcised men (16.7/100 py) vs. 0/50 of circumcised men became infected after two+ years (p = 0.004).Quinn et al NEJM 2000

Circumcision and HIV Transmission to Women

0

6.9

0

12.6

25 25.6

0

5

10

15

20

25

30

Transmission/100py

<10,000 10,000-49,999 >50,000

Circumcised

Uncircumcised

Of 47 couples in which circumcised male partner was HIV+ AND whose viral load was <50,000 particles, 0 of female partners were infected after two years, vs. 26 of 143 female partners of uncircumcised HIV+ men (9.6/100 py) (p = 0.02).

Male Viral load

Quinn et al NEJM 2000

The Three Trials: Study Results

South Africa Uganda Kenya

3128 4996 2784

HIV Incidence MC (N) 0.85 (20) 0.66 (22) 2.1 (22)

HIV Incidence Control (N) 2.1 (49) 1.33 (45) 4.2 (47)

Percent Protection (ITT) 60%* 51%* 53%*

As treated 76% 60% 60%

Adverse Events 54 (3.6%) 178 (7.7%) 21 (1.5%)

0.00

0.25

0.50

0.75

1.00

Pro

port

ion

alive

0 1 2 3 4 5Years from cohort enrolment

Entebbe CohortDART trial

Survival

How can we scale up circumcision while waiting for policy efforts to

catch up?

Communal drinking in Uganda –an ideal setting for TB infection

THE MONEY

THE HEALTH SYSTEM

Crumbling Health infrastructure in a rural District In Uganda

.

Capacity building is not just about existing knowledge but also

about the pursuit and discovery of new knowledge

.

LANDMARK RESEARCH FROM UGANDA

• PMTCT nevirapine regimen (HIVNET 012 trial)• Male circumcision as an HIV prevention intervention• Basic care package including cotrimoxazole

prophylaxis to reduce morbidity• Impact of ART on Mortality and morbidity• Influence of viral load on HIV transmission• HIV incidence in a rural cohort 1990 -2005• Home based Delivery of ART and HIV testing

Number of Uganda and Congo HIV/AIDS Research Publications by

Year:1983-2008

JUMP

• Integrated management• On-site training• Team approach (clinicians, lab and records staff)• Training on smear microscopy and rapid diagnostic

tests for fever• Test diagnosis-based targeted treatment• Avoids misdiagnosis, overuse of antimalarials, and

delays in treatment of other illnesses

Akokoro

Omugo

KasambyaIganga

WalukubaKyenjojo

Kabale

Nagongera

Kiryandongo

Kamwezi

KIhihi

Aboke

Apac

Aduku

Aber

BuwengeMukujju

Mulanda

Bugembe

Ogur

Amac

AlebtongAnyeke

Orum

Kibalinga & Butawata HCII

Wakitaka & Megamaga

Paya & Kisoko HCW

KisoroDistrict HCW

Rukungiri District HCIIs

OliAdumi

Aroi

NebbiPakwach

St Paul

Kilembe

Exxon Cascade IMM sites

Exxon RDT sites

Exxon IMM Sites trained at IDI

PMI IMM Sites trained at IDI

IDRC RDT sitesWHO RDT sites

The whole district

The whole districtWas trained The whole

district was trained

Impact: JUMP On-Site Follow-Up

• Developed a monitoring and evaluation system that demonstrates the impact of training and capacity building on improved case management for malaria at health facility level

• Improved surveillance systems and data collection in the target health facilities.

• QA/QC for 45 Districts by 2013

Impact: JUMP On-Site Follow-UpIndicator Baseline 6 wks ARR(CI) 12 wks ARR(CI)

Proper Hx 20% 42% 1.41 (0.48-2.35)

60% 2.71(1.54-3.88)

Proper PE 18% 57% 1.94(1.18-2.71)

82% 3.28(2.30-4.26)

Correct Dx 47% 96% 3.41(2.03-4.78)

97% 3.66(2.05-5.26)

C/W Nat’l Policy

42% 86% 2.27(1.51-3.05)

92% 2.96(1.94-3.97)

Adequate pt education

17% 83% 4.36(2.71-6.02)

87% 4.68(2.92-6.44)

Impact: JUMP On-Site Follow-Up

Indicator Baseline 6 wks 12 wks

%BS prepared correctly 22% 67% 63%

%BS read correctly 49% 71% 70%

%(+)BS read correctly 49% 71% 70%

%(-)BS read correctly 72% 77% 91%

Ssekabira Am J Trop Med Hyg, Dec 2008; 79: 826 - 833

*Generalized estimating equations controlling for history of fever and age, adjustment for repeated measures on the same day.

Site

Relative change in proportion of patients prescribed antimalarial

Antimalarial doses saved per

1000 patientsRR (95% CI)* p-value

Mubende 0.32 (0.29 – 0.36) <0.001 420

Jinja 0.44 (0.39 – 0.50) <0.001 358

Tororo 0.73 (0.70 – 0.77) <0.001 183

Impact of RDT training interventionon anti- malarial prescribing

TASO COMMUNITY ART PROGRAMME

THE HOLISTIC APPROACH

Health System Capacity building : a pyramid as a guide for effective investment ?

Staff and Infrastructure

Structures, Roles & Systems

Tools

Skills

require enable effective use of ...

Cognisance of local context

require

require

require

enable effective use of ...

enable effective use of ...

enable effective use of ...

Sub-optimal capacity building

Structural capacityCognisance of local context

Staff and Infrastructure

Skills

no inputs

eg equipment

eg technical training

Technical training and equipment supplied, but relatively ineffective because staff overstretched, supervision weak, and funding for maintenance

inadequate.

Structures, Roles & Systems

no inputs

no inputsTools

Pyramid of effective Health System capacity building

Tools

Staff and lnfrastructure

Structures, Roles and Systems

Skills

Personal capacity

Workload capacitywith

Supervisory capacity

Inputs to build capacity

eg management bodies, forum for stakeholders, decentralized powers

Structural capacity

Systems capacity

Role capacity

Facility capacitywith

Support Service capacity

Performance capacity

Inputs to build capacity

eg financial, logistics, workforce, IT

eg technical skills

eg clinics

eg lab technicians

eg lab management

eg sufficient staff, appropriate skill mix

eg equipment

Cognisance of Local Context

Cultural factors

Alignment with Gov’t policies and strategies

Local ownership

Trust between develop’t partners

Can it Happen?

Lessons from Uganda and IDI

Before

After

Simple improvements allow better and reliable drug supplies

Relatively small investments can change labs from dumps to quality labs that can provide accurate TB diagnosis

Before After

Record keeping and tracking is key to an excellent TB programme

Community programs to de-stigmatize TB, generate demand and provide adherence support

Community education about HIV and TB

THANKYOU AND PLEASE HELP!

.