The Project HEART Experience: Assessment of an HIV Care and

Treatment Program Amanda D. Castel, MD, MPHAssistant Research Professor

Michelle Gill, MPHEGPAF/GWU Partnership Executive Coordinator

Department of Epidemiology and BiostatisticsThe George Washington University School of Public

Health and Health Services

EGPAF/GWU Partnership

April 30, 2009

Assessment Goals

Examine different models of service delivery for care and treatment scale up in 3 of 5 PH countries

Examine different approaches to providing technical and programmatic support for care and treatment (not PMTCT focused)

Identify best practices, challenges, solutions, and obtain recommendations from the field

Identify ways to further support and integrate care and treatment in PH countries

Assessment Team Members

GWU Faculty and Staff– Amanda D. Castel, MD, MPH (Overall Assessment Team

Leader)– Michelle Gill, MPH (Zambia, TZ)– Irene Kuo, PhD, MPH (Team Leader for Zambia trip)– Jennifer Skillicorn, MPH (Cote d’Ivoire)

External Consultants– George Beatty, MD, MPH (UCSF) (TZ, Cote d’Ivoire)– Judith Justice, PhD, MPH (UCSF)( TZ, Zambia, Cote d’Ivoire)– Maureen Shannon, CNM, FNP, PhD (Univ. of HI)(Zambia, TZ)

EGPAF Staff– Lindsay Bonanno (Tanzania)– Nicole Buono, MPH (Cote d’Ivoire)– Stephen Lee, MD (Zambia)– Ric Marlink, MD – Rose McCullough, PhD (Tanzania)

Focus Areas

Management Models of Service Delivery Quality of Care/Continuum of Care Community Linkages Policy Analysis and Influence Training/Mentoring/Supportive

Supervision and Capacity Building Quantitative Evaluation Systems

Assessment Methods

Developed quantitative and qualitative tools

Conducted document review and desk audit of relevant program information

Conducted site visits Conducted in-depth interviews Wrote country level reports and

global report

Country-Level Interviews

EGPAF U.S. and country staff Centers for Disease Control and Prevention Other PEPFAR funded Track 1.0 Partners MOH programs: e.g., National AIDS Control

Program, TB/HIV, M & E, District or Regional AIDS Coordinator

Supply chain and drug procurement organizations/agencies

NGOs, CBOs, FBOs Sub-grantees Staff at clinical sites, N=49 sites

Country Visits Teams:

– 5-6 members for each trip– EGPAF, GW faculty and staff and external

consultants Zambia- June 2008

– 18 sites visited– Range: 494 - 7,453 patients per month*

Cote d’Ivoire-July 2008– 16 sites visited– Range: 43 - 3,026 patients per month

Tanzania- September 2008– 15 sites visited– Range: 123 - 3,997 patients per month

*Data not available for 2 sites

Sites Visited, N=49Characteristic Number

Setting

Capital city 13

Other Urban 17

Peri- Urban 8

Rural 11

Site Type

Public 30

Private/FBO 19

Service Provided

C and T/PMTCT 33

Site Level

Primary 31

Secondary 10

Tertiary 5

Peripheral 3

Summary Findings by Focus Area

Management

Strong and responsive U.S. and country management teams

Opening of sub-offices in some countries

Addressing challenges related to financial and contract management

Need for regular communication between U.S. and country offices

Policy Analysis and Influence

EGPAF or sub-partner playing major role in development of key policies related to C & T

Provide substantial technical assistance and guidance on development of guidelines and regulations

Recognized as a leader in area of HIV C & T Working to influence task-shifting in

response to healthcare worker shortages Coordination with other treatment partners

could be improved

Models of Service Delivery

Various partners and approaches used based on host country’s needs

District approach allows for sustainability and “standard” approach to C & T service delivery

Working with the public sector reaches the most people and solidifies EGPAF’s relationship with host MOH

Single-service sub-grantee may present challenges with regard to sustainability

Performance-based financing preliminary results are encouraging

Quality of Care/Continuum of Care

Clinical care that is generally based on WHO or national guidelines and standards

Beginning of task-shifting activities at a limited number of sites

Limited access to viral loads, RNA and DNA PCR and second line regimens

Healthcare worker shortages require creative solutions – use of PLWHAs, overtime allowances, task shifting

Variable linkages and integration of C & T with TB and PMTCT

Pediatric C & T lagging behind that of adults Need systematic mechanisms to track

patients lost to follow-up

Community Linkages

Community linkages were not consistently integrated into continuum of care

EGPAF U.S. and country offices beginning to recognize the importance of community and linkages

Varied approaches to implementation of community linkages programs and services

Creative use of PLWHA and expert patients Lack of nutritional support and transport

identified as barriers to continuity of care Limited coordination of referral systems

between community-related groups and C & T sites

Training/Mentoring/ Supportive Supervision/Capacity Building

Successful leveraging of available in-country expertise as a resource for training and guidelines development

High quality initial training in adult and pediatric ART

Methods to measure retention and application of knowledge still need to be determined

Health care worker shortages and rapid turnover of staff

Quantitative Evaluation Systems

Dedicated U.S. support staff to focus on programmatic, technical and M&E issues

Existence of electronic databases in countries which improve patient tracking and efficiency of data management

Attempts to harmonize indicators and develop standard reporting forms

Recognition of the importance of QI mechanisms to improve patient services

Limited feedback and use of data to improve programs

Major Recommendations

Major Recommendations

Continue to take a leadership role in formulating and advocating for policies related to the delivery of C & T, including task-shifting, transportation and supply chain management

Strengthen achievements in pediatric C & T Address issues related to quality of care such as

pediatric enrollment, TB, PMTCT and RCH linkages, health care worker shortages, community linkages and involvement including nutritional support

Develop EGPAF organizational and country specific guidelines and strategic plans for community linkages to ensure that community linkages are integrated into the continuum of care

Major Recommendations (2)

Create additional opportunities for technical discussions and sharing of experiences – Across the PH country office staff – With other treatment partners

Consider collecting indicators that may be more reflective of quality of care outcomes such as improved cohort reporting, additional treatment outcome measures and effectiveness of community linkages

Conduct regular review and assessment of PH programs

Limitations of Assessment

Limited time in clinics Chart audits, clinical observations

or patient interviews not conducted Did not assess PMTCT Did not have opportunity to meet

with non-PEPFAR partners Non-random sample of clinics Language barriers EGPAF staff as part of assessment

team

Next Steps

Share findings with:– EGPAF staff – Project HEART countries– CDC Atlanta and country

offices – International conferences– Peer-reviewed literature

Used findings in PY6 applications Incorporate information and

recommendations into program activities

Acknowledgements

EGPAF U.S. Staff US EGPAF Interviewees

EGPAF Country Office Staff Tanzania Cote d’Ivoire Zambia

GWU SPHHS Alan Greenberg Manya Magnus James Peterson

A special thanks to all those who were interviewed as part of the assessment