Implementing ART Programme in a resourcelimited-setting: facilitating factors and challenges
G. Saporetti MD, PHD
G. Azzimonti*, G. Saporetti*, R. Larok*, S. Meihaho#, F. Ciantia* *AVSI (Associazione Volontari Servizio Internazionale) # Hoima Regional Referral Hospital
4th Uganda National AIDS Conference March 21-22, 2005
Introduction
• AVSI (Associazione Volontari Servizio Internazionale) has been providing specialized and technical support to the implementation of ARV Treatment for adults and children in Hoima Regional Referral Hospital • MoH (Ministry of Health) is supporting treatment free of charge for adults since July 2004 • JCRC (Joint Clinical Research Centre) is supporting ARVT free of charge for orphans and vulnerable children since May 2004
A package of interrelated activities
• The introduction of ARV Treatment is based on an on-going integrated approach on HIV/AIDS • Over the past 4 years, Hoima District Health Authorities have been committed in the promotion of initiatives focused on care and support of People Living With HIV/AIDS (PLWHA) in partnership with AVSI and community based organizations, as Meeting Point Hoima
Interralated supportive services offered to PLWHA in Hoima District supported by AVSI
AIDS Clinic and Home Based Care
(since 2001)
Nutritional Support
(since 2001)
PLWHA
OVCs support programme
(since 1994)
PMTCT
(since 2001)
Income Generating Activities (since
December 2004)
AIDS Clinic (1)
• AIDS Clinics have been instituted for
– Counseling – Treatment of patients with opportunistic infections – Cotrimoxazole prophylaxis
• AIDS Clinic is performed in Hoima Hospital and in 6 health centers (HCs). PMTCT Programme is implemented in 4 of these HCs
AIDS Clinic (2)
• No. of symptomatic HIV patients regularly assisted for each site of activity: – Hoima Hospital: 649 patients – Kigorobya HCIII: 175 patients – Buraru HCIII: 45 patients – Mparangasi HCIII: 43 patients – Butema HCIII: 50 patients – Buhanika HCIII: 45 patients – Kikuube HCIV: 24 patients • Total No. of patients registered and followed:
1,031
Home Based Care (HBC)
• HBC is conducted in partnership with Meeting Point Hoima and Hoima Hospital staff • Treatment of opportunistic infections and psychosocial support are offered to bedridden patients • No. of patients visited at home:
15/month (average)
PMTCT Programme
• PMTCT Programme is implemented in Hoima Hospital and in 6 peripheral HCs (Kigorobya, Butema, Kyangwali, Kabwoya, Kikuube, Bugambe) • Actually PMTCT Programme covers 70% of the mothers attending ANC (about 20,000 mothers) in Hoima District
PMTCT Programme Indicators Hoima District
Site Period ANC attendance Pre-Test Counselling Tested HIV positive Post-Test Counselling Mothers who took NVP Babies who took NVP
Hoima Sept 01 Regional Dec 04 Hospital Kyangwali April 03Dec04 HC kigorobya Dec 02Dec 04 HC Butema Aug 03Dec 04 H.C. Kikuube May 04Dec 04 H.C. Kabwoya Sep 04Dec 04 H.C. Bugambe Nov-Dec '04 H.C. TOTAL
10,836
9,636
6,778
529
5,587
300
149
2,785 3,849 1,220 960 341 94 20,085
2,429 3,304 1,269 788 291 94 17,811 89%
2,376 2,623 1,221 782 287 93 14,160 80%
171 106 90 53 13 1 963 6.8%
2,243 2,615 1,221 758 287 93 12,804 90%
69 57 51 27 8 1 513 53%
26 41 16 12 2 246 26%
PMTCT Programme Indicators Hoima District
Summary PMTCT Indicators
25,000
20,000
89% 80%
15,000
90%
10,000
5,000
6.8%
53%
26%
0
New ANC Clients Cl. Counselled Cl. Tested HIV Positive Post- Test Mothers who Babies who Counselled took NVP took NVP
Nutritional Support and OVCs programmes
• 751 families with an HIV
positive member are monthly supported with a Nutritional Support Programme conducted in partnership with WFP and Meeting Point Hoima • 499 OVCs are currently on Distant Support Programme in collaboration with Meeting Point Hoima
Income Generating Activities (IGAs)
• AVSI offers Business Skills Training followed by provision of material items to initiate IGA or strengthen an existing activity, accordingly to the Business Plan prepared by the beneficiary • PMTCT mothers and patients on ARVT take priority • No. of beneficiaries trained on BST (since December 2004): 24
Facilitating factors in ARVT Programme
• This integrated AIDS care setting created suitable conditions for the launching of ARVT Programme • The package of initiatives offered to PLWHA is considered a facilitating factor to follow-up the patients on ARVT • AIDS patients actively participating in the mentioned initiatives take priority among eligible patients
ARVT Technical Committee
• In January 2004 the Committee has been instituted and AVSI is leading it • It is composed by 2 AVSI MDs, 2 Hoima Hospital MDs and some counselors involved in the Programme • Monthly meetings of the Committee take place
Priority criteria for ARVT in adults
•
• •
150 AIDS patients on ARVT have been the first target of MoH in Hoima Hospital (300 patients as second target) Patients attending AIDS Clinics supported by AVSI are 1,031 and about 50% of them are eligible for ARVT (WHO/MoH criteria) ARVT Technical Committee established priority criteria for ARVT in collaboration with DDHS and Hoima Hospital’s Medical Superintendent
1. 2. 3.
PMTCT Programme mothers Health workers of Hoima Hospital and District’s health centers Active volunteers of CBOs: Meeting Point Hoima and Little Hospice Hoima
ARVT - Adults
• 130 patients enrolled since July 2004
(followed by AVSI) average: 6 patients enrolled/month
• 121 on treatment at the present
– 9 died (mortality rate: 7%) – 0 lost at follow-up
Adults - Analysis
• Sex: • Age: • Entry point: 71% F, 29% M 36 years (average) (20-65) 4% PMTCT mothers 5% Health workers 4% Transfers (people transferred from JCRC, because not able to buy drugs) 87% CBOs (AIDS Clinics as entry point for ARVT) D4T, 3TC, NVP (fixed-dose drugs combination) 100%
• Regimen:
Who are the patients on ARVT?
4%
5%
4%
87%
PMTCT mothers
Health Workers
Transfers
CBOs
Adults – Evaluation after 6 months of ARVT
• Evaluation of 31 patients after 6 months of ARVT: 1. Cohort’s mortality rate: 4/31 died (13%) Body Weight’s analysis:
BW after 6 months of ARVT – BW at the beginning of ARVT=
2.
3.8 Kg (average) 3. Immunological parameter: CD4 cells count: not yet repeated after 6 month for technical reasons (reagents out of stock)
Adults – Follow-up
• July 2004 – February 2005:
– No relevant side effects – No switches to 2nd line therapy – 2 patients interrupted ARVT, because they had to start PTB treatment
• Adherence (WHO criteria): Good 85% Fair 9%
• Attendance to the scheduled visits: 100%
Poor 6%
Organization of ARVT Clinic (1)
• Enrollment: Hoima Hospital and HCs • ARV Clinic on tuesdays (adults) and on wednesdays (children) • MD and counsellor during each visit • Central role of the treatment supporter
Organization of ARVT Clinic (2)
• Scheduled visits every week during the first month (HIV test, CD4 cells count, counselling, starting treatment) • Checking ARVT adherence through the empty containers and the treatment supporter • MD’s mobile number • Collaboration with:
– ARV Adherence Mobile Group (once a week): 34 patients visited at home (Sept04-Feb05) – Home Based Care
Challenges
• The ARVT Programme in Hoima District represents itself an entry point for strengthening the services already in place and further undertake linked initiatives, as ARVT Adherence Mobile Group • ARVT Adherence Mobile Group is constituted by social workers and trained HIV positive community volunteers on ARVT with the aim of assessing the adherence among patients on ARVT and systematically addressing their needs through regular home visiting
Lesson learned
• The experience in Hoima Hospital shows that the implementation of ARVT Programme in limited-resource-settings is feasible, through a comprehensive package of supportive and interconnected services in collaboration with health authorities and CBOs
Thank you!