Best Practices Pediatric HIV Care and Treatment
Document Sample
Best Practices ICAP - Rwanda 2007
MENTORING AS A MEANS TO BUILD STAFF CAPACITY IN
PEDIATRIC HIV CARE AND TREATMENT IN RWANDA
CONTEXT:
In Rwanda, a total of 23,807 patients including 2124 children (9%) were on antiretroviral therapy (ART) by June 2006.
The number of children on ART accounted for less than 10% of the 25000 estimated HIV infected children in the
country. More than 50 % of children on ART were all living in Kigali while rural regions had no structured pediatric
ART services. Limiting factors were the absence of a national pediatric HIV care program; a centralized system of HIV
care particularly pediatric care; the health staff shortage and limited pediatric expertise in sites; the weak organization
of post-natal maternal and child care system particularly for HIV exposed infants; limited access to early HIV infant
diagnosis and ultimately the limited awareness of sites staff on pediatric HIV care.
In line with the decentralization of the pediatric HIV care initiated by the Government of Rwanda, decided partners
including the International Center for AIDS Care and Treatment Program (ICAP) of Columbia University were
organized to support the national program in scaling up a comprehensive package for HIV infected children.
ICAP/Columbia University pediatric program aim was to foster pediatric HIV care and treatment decentralization by
building up two pediatric model centers in Kigali University Teaching Hospital (KUTH) and Butare University
Teaching Hospital (BUTH). These would extend support to 18 district hospitals in Western and Southern Provinces in
Rwanda. In addition, 29 MCAP supported sites would also gradually benefit from that decentralization process.
METHODS:
Sub agreements were signed between ICAP/Columbia University and the two model centers respectively (BUTH,
CHUK). Through these centers, the program aimed to develop an innovative model of pediatric HIV care and to expand
it to 18 DH of the southern and western province by March 2008. So, 18 sites affiliated to the model centers and 6
others with a high number of HIV children among MCAP supported sites were prioritized for pediatric program
initiation. Main strategies and procedures used for the pediatric program initiation included:
Initial sites assessment
This was conducted from July to September 2006 in South Province then from October to December in the West
Province. The aim of this assessment was to ascertain the needs and challenges for the pediatric program initiation. .
Capacity building on pediatric HIV care and treatment
We conducted in collaboration with TRAC during the months of June and September 2006, a five-day formal training
on pediatric HIV care and treatment for 38 health staff of the BUTH and its 9 affiliated District Hospitals and 44 for
the KUTH and its 9 affiliated District Hospitals respectively. A core multidisciplinary team from each affiliated DH
was so trained. An emphasis was given during the training on fostering HIV exposed infants follow up, prevention and
management of opportunistic infections, early diagnosis of HIV infection, initiation of ART and follow up, disclosure
of HIV results to children and psychosocial support
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Best Practices ICAP - Rwanda 2007
The pediatric HIV care mentoring strategy
At the end of each training session, post training follow up and procedures for program mentoring were discussed with
participants. The mentoring aimed to increase staff knowledge, to improve their skills and to strengthen children system
of care in sites
Through the 2 model centers, sites staff mentoring on pediatric care was initiated in October 2006. By March 2007, a
total of 26 sites staffs were mentored with the support of ICAP to implement pediatric HIV care activities. Components
of the mentoring strategy included:
The mentoring team
It included a pediatrician experienced in pediatric HIV care and treatment, one junior medical doctor, a nurse, and a
children counselor from one of the reference center. Individual mentoring was provided by each member of the team to
the corresponding site staff during a five day period. A daily debriefing was conducted among the members of the
mentoring team to discuss achievements and identify challenges.
Procedures and content of the mentoring activity
The site was notified at least one week earlier prior to the visit of the mentoring team.
On the first day of the visit, the objectives and methodologies of the mentoring exercise were discussed with the site
team and a work plan with schedule and responsible persons was adopted.
Every morning, the staff was mentored in their routine activity (ward rounds and out patients consultations) In the
afternoon, a topic on pediatric HIV care was presented and subsequently discussed around a specific case study. These
discussions implicated all site staff involved in general pediatric care in the site in order to foster skills in providing care
to HIV children, to address practical issues in implementing a site specific pediatric HIV care system and in raising
awareness toward pediatric HIV care within a multidisciplinary team building up. Mentors reflected on the practical
experiences of site staff to encourage good practices and to address identified weaknesses. Key area of discussion
included pediatric patient flow, HIV testing in children, CD4 screening system including calculation of percentage for
less than 5 years, WHO pediatric HIV staging, Cotrimoxazole and ART prescription, treatment follow up and
psychosocial support, identification and tracking system for loss to follow up, growth and development monitoring and
filling of patient dossier.
At the end of the site visit, the mentoring team restituted their activities to the site staff, and suggested solutions to
address identified challenges. Mentored sites staff were then visited once quarterly for supportive supervision
Results
Fig 1: HIV+ children enrolment and on ART in BUTH
Enrolment of children in BUTH and affiliated and
district hospitals affiliated DHs (N=10) Dec 06-Jun 07
Figure 1 shows an increasing trend in the number of 1400
1200 1190
children enrolled in care between December 2006 1000
1075 BUTH+D
Hs enrol.
and June 2007 for BUTH and its 9 affiliated DH. The 800 784
600 BUTH+
program inherited most of the patients enrolled in a 488 494
400 416 DHs ART
previous program supported by MAP. Similarly, we 200
0
Dec-06 Mar-07 Jun-07
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Best Practices ICAP - Rwanda 2007
observed a slight increase in the number of children on ART during the same period.
Enrolment of children in CHUK and affiliated district
Figure 2 shows the increasing trend in HIV
Fig 2: Cum ulative HIV+ children enrolm ent in
enrolment in CHUK and its affiliated DH during the CHUK
first quarter 2007. During the second quarter 2007, a and affiliated DHs (N=10) by Jun 07
data base cleaning was conducted to exclude all
12 0 0
dropped out patients. This could explained the 10 0 0 1060 1009
decrease in the number of enrolled children observed 800 773
600 C H UK+D H s
during the same period 444
e nro l.
400
360 399 C H UK+D H s
200 ART
0
Dec-06 Mar-07 Jun-07
Figure 3 shows the increasing trend in the enrolment
Fig 3: Children enrolment in CHUK - Rwanda
and ART initiation in CHUK since January 2007. Jan - Jun 07
Prior to January 2007, though providing care to HIV 50
Number of HIV+ children
46
infected children, CHUK had no cohort and HIV 40
infected children seen in that hospital were on Enrol
30
27 ART
discharge referred for follow up consultations in the
20 20
nearby TRAC clinic. 11
10 9
The situation is has changed with the onset of this 4
0
program in CHUK and since January 2007 a cohort Jan-07 Mar-07 Jun-07
is being constituted.
Enrolment of HIV children in MCAP supported sites in Rwanda
These sites (n=12) were prioritized to
Fig 4: Cumulative HIV+ children enrolment in targeted
receive mentoring in pediatric care MCAP sites (n=12) in Rwanda
Number of children
and treatment. At least one visit was Jan-Jun 07
conducted for each site. Figure 4 & 5 400
300 Jan-07
shows an overall increasing trend in 200 Mar-07
100
the number of HIV+ infants enrolled Jun-07
0
and those initiated on ART across the
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ICAP Rwanda/Pediatrics
Best Practices ICAP - Rwanda 2007
Fig 6: Cum ulative MCAP sites enrolm ent on ART (N=12)
Dec 06 - Jun 07
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CHALLENGES
Major challenges encountered included extreme mobility of trained staff in search of better position, multiple demands to
the sites staff already limited in number and who has to attend to adults and children patients as well as to other
administrative duties, weak system of care related to uncoordinated multiple partners interventions in sites and irregularity
of supervision due to very large number of sites to cover against limited number of supervision team members.
CONCLUSION AND WAY FORWARD
The combination of formal training and on-site staff mentoring has the potential to increase staff awareness and
confidence in providing pediatric HIV services. The mentoring momentum among care providers led to the increasing
trend in pediatric program enrolment and provided an opportunity to sharing experiences and best practices among
partners.
However, challenges related to national definition of pediatric HIV care norms and procedures at the central level, to
the staff shortage and weak maternal and child health care system at sites level are still hindering full expansion of
pediatric HIV care program.
Addressing those challenges will foster pediatric HIV care and treatment expansion in Rwanda.
Implementing organisation
ICAP Columbia University
Contact persons:
Ruben Sahabo, M.D., Country Director (rs2462@columbia.edu)
Gilbert Tene M.D., Pediatrician, Pediatric HIV Care Advisor (gt2159@columbia.edu)
Evangeline Dushimeyesu, Pediatric Nurse (ed2289@columbia.edu)
Tel Office: +250 503798; Fax: +250 50 37 97
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ICAP Rwanda/Pediatrics
