Satellite Roll Out and Lab Capacity Building in Harvard
PEPFAR
Dr. Toyin JolayemiAPIN/Harvard PEPFAR, Nigeria
Over two-thirds of Nigerians live in rural areasProgram focused on tertiary sites at the startGrowing concerns around access, coverage, scale
up etcAvailability of and access to ART improves lives
allowing PLWHAs to live productive livesIssues around inequality and inequity Concepts on “saturation” and “satellite” were
discussed
Context
The satellite and saturation concept was adopted 1. Moving beyond the prime sites to
satellites will expand access to care and treatment and offer greater impact in numbers of people served, geographic areas covered
2. Decongest care and treatment at the prime sites
4 Prime sites to develop 22 satellites sites JUTH Model
Concept
3o LevelJUTH
2o LevelJENGRE
2o LevelVOM
2o LevelPANYAM
Cadillac
Volkswagen
1o LevelPHC
1o LevelPHC
1o LevelPHC Bicycle
Communities CommunitiesDonkey
Homes and Families Homes and FamiliesFoot
3o LevelJUTH
2o LevelVOM
(Gen. Hosp.)
1o LevelPHC
CommunitiesNGOs/CBOs/PLHA/Volunteer
Homes and FamiliesNGOs/CBOs/PLHA/
volunteer
Prev. messageTreatment literacyTreatment support
AdherencePatient tracking
Comm. Based services-IEC-FP
-BCK-Condoms
-DOTSOut reaches
-BCC-Treatment message
-HCT-Advocacy
ReferralsART
PMCTCHCT
Labs – VL, DC4, Genotype, chem, FBC
FPQA/QC/QI
STI
ARTPMTCT
HCTLabs – CD4, FBC, Chemistry
FP, STIQC/QI
HCTPMTCT
STICXTBCK
DOTS?ART refills
FPMultivitamins
HBC-FMCT/DOTS/BCK/CXTPrevention for +veCondoms/STI/FP
MultivitaminsPatient tracking
Infrastructural developmentLab developmentHealth Systems StrengtheningReferral MechanismsTraining and Technical AssistanceMentoringSupervision
Satellite Development Effort
COCIN Health Centre, Panyam: Antenatal Clinic
APIN PlusAPIN PlusLaboratory Infrastructure, EQA
Lab Equipped
Training completed
EQA EQA provider
HIV Screening X X X CAP 2007
HepB & HepC Screening
X X X CAP 2007
CBC X X Ongoing Cross-site
Chemistry X X X CAP 2007
CD4- flow X X X UK-NEQAS2006
Viral Load X X X Harvard2006
Infant PCR X X X CDC/ Harvard2008
Nigeria -Laboratory InfrastructureHIV rapid
tests & immunoblot
CBC Chemistry CD4-flow
Viral load Infant PCR
Resistance
Genotyping
NIMR X X X X X X X
68MH X X X X X X
LUTH X X X X X X X
UCH X X X X X X X
JUTH X X X X X X
UMTH X X X X X X
ABUTH X X X X X X
FMC Benue
X X X X X X
UNTH
Enugu
X X X X X X
ART
satellites
X X X X
Enrollment JUTH JUTH Satellites
Satellite Contribution
New on ART (Apr-Jun 09) 392 203 (34%)
New on Care (Apr-Jun 09) 558 432 (44%)
Current on ART @ June 09 8903 1075 (11%)
Current on Care @ June 09 10672 2349 (18%)
Transfer in of ART patients from JUTH (Apr-June 09)
About 10 * Other issues involved in motivating patient transferTransfer in of Care
patients from JUTH (Apr-June 09)
About 13
Program Output
Enrollment Time period Achievement/Target
New on Care (COP09) Apr-Jun 09 40%
New on ART (COP09) Apr-Jun 09 65%
Program Output
Sites are functional and providing services Community efforts are driving the demand for service Satellites are currently @ 40% of Care target and 65%
of ART targets (3 months) Issues around the supply end Upfront investment has been made Maximizing return on initial investment at the current
output level is an issue Tracking enrollment At a crossroad.
◦ Slow down enrollment…ethical concerns◦ Continue enrollment…finance concerns
◦ Access.
Summary
Thank you!
Satellite Roll-out, Task Shifting, and
Laboratory Capacity Building
Botswana Harvard PEPFARClinical Master Trainer (CMT), Lab Master Trainer (LMT), and
Monitoring & Evaluation Unit of Ministry of Health (M&E)
15
Master Trainer/ARV Site Support Program
Clinical Laboratory
Monitoring & Evaluation Unit (within DHAPC):
Linked to:• All ARV sites
• Other MOH programs
Masa
BHP-PEPFAR ARV Site Support Program
Three Objectives of Master Trainer and Site Support Program
1) Capacity Building through Clinical Mentoring, Training and Overall Site support
2) Decentralization of laboratories
3) Support development of the Monitoring and Evaluation of the National ARV Program - Masa
Capacity-building:Commitment to use in-country experts
All but two are Batswana or African expats who had already been working in-country
Initial criticism of hiring most experienced doctors, nurses, lab staff, and pharmacists from the National Program
Current appreciation of results:More than 150 HCWs mentored by each of
the above expertsIncreased labs and capacityAdditional ARV sites staffed by fully trained
HCWs
ARV Site Roll Out Process:Clinical Master Trainers
Site and pharmacy readiness assessmentsAssistance with all aspects and systems to
set up a new siteTraining, mentoring, and on-site support – 2
weeksTelephone site supportQuality Improvement:
QI training at site levelDevelopment of QI teams at all ARV sitesImplementation of chart reviews and other
evaluation toolsFeedback and QI planning with site QAI team
Clinical Master Trainer Program : ARV Sites Assessed and Supported
Mother Sites Supported
MiddlepitBokspit
Goodhope
Palapye
Masunga
Werda
Kalkfontein
Newxade
Each Mother Site has 3-4 Clinics (only some shown)
Why Task Shifting?
To date no Medical School in BotswanaApproximately 400 doctors in
BotswanaMore than 4,000 Batswana nurses in-
countryMinimal number of pharmacy staff
How will the new ARV sites and their pharmacies be staffed?
Task Shifting
Nurse Prescriber & Dispenser Training to Date - 170 nurses trained in prescribing and dispensing
ARVs - 379 nurses trained in ARV dispensing only
Nurse training for Rapid HIV testing and Dried Blood Spot in collaboration with PMTCT38 trained to date
Roll-out of Nurse Prescribers and Dispensers to Clinics
65 clinics - stand alone clinics with full prescribing and dispensing capability
64 prescribe and dispense on an outreach basis - the doctor and pharmacist or pharmacy technician travel to and from the facility on the ARV clinic day.
7 facilities initiate and prescribe but drugs are collected from another facility within the site (a site is defined as a mother site/hospital and its satellite ARV clinics)
The Impact of the Nurse Prescriber
PFM
Comparison of the numbers of patients reviewed by doctors and
nurses per month at a major facilityDoctors,
1800Nurses,
1200
0
500
1000
1500
2000
Doctors Nurses
No
. of
pa
tie
nts
2323
Satellite Clinic Roll-out
• At start of PEPFAR in 2004– 32 hospital ‘Mother Sites’
• Currently – 29 District Hospitals– 2 Botswana Defence Force Hospitals– 1 Mine Hospital– 136 ARV Clinics (satellite facilities)
• This last month, 68.7% of new patients were initiated on ARVs at satellite clinics, rather than hospital clinics.
WHY Task Shifting for Labs?
2 Reference Labs21 decentralized labs for CD4 testing8 decentralized labs for VL testingNeed for Rapid Testing and Dried
Blood Spot testing at all ARV sites
Process of Laboratory Decentralization
Laboratory Master TrainersSite assessmentCentralized training at Botswana National
LaboratorySite training and equipment set-upReagent supply managementAcceptable Internal Quality Control
testingFollow-up site supportTelephone site support
Laboratory Capacity Building
At start of PEPFAR - 20042 hospital reference labs capable of
performing 100% of CD4 and Viral Load testing
Currently the Botswana Lab Master Trainers have trained and supported ALL decentralized labs and private sector labs which run Public Private Partnership (PPP) specimensCD4s - 21 decentralized labs performing
59% VL – 8 decentralized labs performing 30%
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CD4 Testing Comparison: 2004 – 2nd Qtr. 2009
Viral Load Testing Comparison: 2004 – 2nd Qtr. 2009