Community Systems Strengthening for Improved HIV Care: The Uganda Experience

Dr. Ario Alex Riolexus, STD/ACP – Ministry of Health, Uganda 24th July 2014TASO Satellite Meeting, 20th International AIDS Conference, Melbourne – Australia

Uganda HIV Context After over a quarter century, HIV

epidemic in Uganda is still severe and generalized.

Current estimates of HIV prevalence is at 7.3% in adults but with marked geographical, socio-demographic and socio-economic heterogeneity.

Burden: About 1.5 million adults and children in a population of 35 million.

New infections:124,000 in 2009, 130,000 in 2010, 145,000 in 2011, 130,000 in 2013

60,000 annual mortality

Uganda HIV Context Cont:

Scale up of ART using a public health approach in 2004

Number in need of ART at 500 CD4 – 1,405,000 (1,207,000 adults and 193,000 children)

Current No. on treatment – 600,000Retention after 12 months of ART

initiation – 86%Adherence to ART at 95% and above -

91%, LTFU – 18.5%96.8% are on 1st line ARV regimen; 3%

are on 2nd line; a small percentage is on 3rd line

The National HIV Response

Appropriate policies Multi-sectoral response with broad based

stakeholder involvement NSP Decentralisation policy MoH Sectoral Policies and Guidelines

National Health policy HSSIP The Client Charter Public Private Partnership Policy ART , eMTCT, HCT, HBC Policies, Adherence Strategy etc

National Prevention Policy

The National HIV Response Cont:

National Development Policy Financing ARV procurement Decentralisation of ART to lower level HF Political commitment

eMTCT campaign – 1st Lady is Champion The President and 1st Lady openly

undergoing HIV Testing HIV Trust Fund

What is Community Systems Strengthening?

An approach that promotes the development and sustainability of communities and community organizations and actors, and enables them to contribute to the long term sustainability of health and other interventions at community level.

Background to Community Strengthening - 1 Experience from community based

organisations and lessons learnt The rapid scale up of ART using a public

health approach posed health systems challenges

The medical paradigm for control of the HIV epidemic was stretched to the limit in Uganda, where institutional and human resources were inadequate for the large numbers seeking care.

This called for task sharing and skills transfer

Background to Community Strengthening - 2

NHP and HSSIP recognises the role community plays in health delivery but notes its current weaknesses

Understanding the cause of weakness in a system is the first step towards recognising the solution

HSR of the HIV national response revealed serious gaps in all health systems building blocks

Background to Community Strengthening - 3

Recognition of the role of community systems in the whole HIV treatment cascade

Strengthening the community system and using PLHIV as part of the solution to the workforce needs to bridge the gap for a better national response

Grant proposal funding requirements

Institutions with improved Community – Facility Linkage Infectious Diseases Institute (IDI) The AIDS Support Organization (TASO) Joint Clinical Research Centre (JCRC) Mildmay Uganda Reach Out Mbuya Northern Uganda Health Integration to

Enhance Services (NUHITES) and STARs EGPAF SUSTAIN Uganda Cares, Mama’s Club, M2M etc VHTs in Public and PNFP Facilities

Program approaches to Strengthening Communities

A- Family-Centered Care: offering care and support to meet the needs of the entire family Using the Chronic Care Model Using Mother Baby Care Point Using the Male Involvement Strategy

Proposed Uganda Chronic Care Model

Community•Raise awareness and reducestigma

•Encourage better outcomes through leadership and support•Mobilize and coordinateresources•Provide complementaryservices

Health CareOrganization•Promote continuity and coordination•Encourage quality throughleadership and incentives•Organize and equip health careteams•Use information systems•Support self-management and

preventionPatient

Family

Positive Policy Environment•Integrate policies•Provide leadership and advocacy

Better Outcomes for Chronic Conditions

Pre

pare

d

Links

•Strengthen partnerships•Support legislative andregulatory frameworks•Reduce disparities in care

•Promote consistent financing•Assure workforce capacityand capability

The Chronic Care Model

The Chronic Care Model, depicted above emphasizes a patient-centred approach to handling chronic conditions, with the Community, Family, Health System and favourable policies all contributing to a patent’s wellbeing and health.

The core triad of Patients and Families, Community Partners, and the Health Care Team is the cornerstone of chronic care.

The Chronic Care Model

The three-tiered Uganda Chronic Care Model encompasses Patients and Family, Community Partners and Health Care Teams and focuses on a patient-centred approach helps programs control costs by enabling appropriate use of self-care and low-cost services based in the family and community.

The model also emphasizes a proactive approach to anticipated care needs.

Mother Baby Care Point

The mother baby care point is an improved service delivery model to optimize retention and adherence, EID uptake, and appropriate transitions for mothers and exposed infants

Keeps mother-infant pairs together at one "care point" through 18 months post-partum and beyond

Minimizes the number of transfers for the pair

Negative infant

discharged

Positive infant and mother referred to treatment

clinic

Mother referred to treatment

clinic

Antenatal Care for Mother

Mother - Baby Care point (post natal)

MCH Service Point

• Routine ANC care

• HTC, risk reduction counseling, condoms, & couples HTC

• ART initiation & management for HIV+ pregnant women

HIV Treatment Clinic

• ART for already enrolled HIV+ Postnatal mothers

• ART for newly diagnosed HIV+ postnatal mothers

• Family planning

• Routine PNC including Immunization, well child services, EID & care for HEI up to 18 months

• ART for all HIV+ infants through 18 months

Pregnancy Postpartum / Breastfeeding

Period

Ongoing care & support

18 months postpartu

m

HIV

N

egati

ve

Infa

nts

at

18

month

s

HIV

Infe

cted

infa

nts

at

18

month

s

Community Systems: FSG, Peer Mothers, Community Follow up

MBC Service Delivery Model

Program approaches to Strengthening Communities

B- Comprehensive Care: providing holistic care for people living with HIV/AIDS, TB, sexually transmitted infections, and other opportunistic infections. National Adherence Strategy Treatment Supporters Expert Clients

Program approaches to Strengthening Communities

C- Service Linkages: leveraging locally available existing resources, training health workers and improved reporting. Linkage Facilitators Peer Mothers/Fathers PLHIV Networks Village Health Teams (VHT) Family Support Groups (FSG) Home Visiting by Health workers Effective referral system mTRAC, DHIS2 MARPs strategy

Program approaches to Strengthening Communities

D- Sustainable Approaches: strengthening existing CSOs and increasing their capacity to mobilize and manage resources. Civil Society Fund Enhanced planning capacity of CSOs Local generation of revenue by CSOs Increased support to CSOs by government Encouragement of formation of indigenous

NGOs – TASO, Baylor Uganda, IDI, Mildmay, Mama’s Club etc

Program approaches to Strengthening Communities

E- Fostering Partnerships: promoting partnerships at all levels—local, regional, national, and international. Representation of CSO and ADP in TWGs, PC, HPAC Partnership Committee East African Community Partnership Frameworks with International Agencies JRM, JAR, NHA GIPA MoU with Implementing Partners

Other approaches to Strengthening Communities

1- Demand Creation and Advocacy: promoting uptake of services and improved lobbying for service provision and allocation of resources and accountability. Consumer advocates – CHAIN, PLHIV Networks CSOs – ICWEA, UGANET, NAFOPHANU, UDN

etc Parliamentary Committee on HIV/AIDS Tailored campaigns – eMTCT, HTC, WAD etc

eMTCT Campaign

Other approaches to Strengthening Communities

2- Improved Communication: promoting uptake of services, linkage and referral. Mobile phone text messaging as a reminder

tool for promoting adherence to ART Availability of many telecommunication

companies – MTN, Airtel, Orange, etc Booklets on HIV for political and cultural

leaders Use of local FM radios

Other approaches to Strengthening Communities

3- Capacity Building: improving the capacity of the community to respond and participate meaningfully in HIV care. Mentorship programs for service providers at

all levels Leadership and technical training of CSOs

and service providers Fellowship Program at MUSPH CSS Activity funding – GF, PEPFAR, Irish AID

etc

Other approaches to Strengthening Communities

4- Quality Improvement: improving the quality of HIV care using simple proven quality improvement models. National Quality Improvement

Framework Formation of Quality Improvement

Teams in all health facilities Inclusion of Expert Clients and CSO

representatives at Health Facility Quality Improvement Teams

I THANK YOU