INTRODUCTION OF ART IN INTRODUCTION OF ART IN COMPREHENSIVE HIV/AIDS COMPREHENSIVE HIV/AIDS

CARE AND SUPPORT:CARE AND SUPPORT:MONITORING AND MONITORING AND

EVALUATIONEVALUATION

John A. Adungosi, John A. Adungosi, MB Chb, MB Chb, MSc, MRITMSc, MRIT

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

• Dr. S.K. Sharif, PMO—Coast ProvinceDr. S.K. Sharif, PMO—Coast Province

• Dr. H. Shikely, Chief Administrator, Coast General Dr. H. Shikely, Chief Administrator, Coast General Provincial General HospitalProvincial General Hospital

• Staff of CPGH, Port Reitz District Hospital, Mkomani-Staff of CPGH, Port Reitz District Hospital, Mkomani-Bomu Medical Centre and Magongo Health CentreBomu Medical Centre and Magongo Health Centre

• USAIDUSAID• Technical Advisory Partners:Technical Advisory Partners:

– Family Health InternationalFamily Health International– MSH/RPM PlusMSH/RPM Plus– Population Council/HORIZONSPopulation Council/HORIZONS

Purpose of HIV/AIDS care treatment Purpose of HIV/AIDS care treatment and support programmes:and support programmes:

• To reduce morbidity and mortality from HIV/AIDS and To reduce morbidity and mortality from HIV/AIDS and related complications.related complications.

• To improve the quality of life of adults and children living To improve the quality of life of adults and children living with HIV/AIDS and their families.with HIV/AIDS and their families.

• To assure equitable access to diagnosis, medical care, To assure equitable access to diagnosis, medical care, pharmaceuticals, and supportive care.pharmaceuticals, and supportive care.

• To promote prevention opportunities within care and To promote prevention opportunities within care and support service delivery.support service delivery.

  

PEOPLE AND FAMILIES

AFFECTED BY HIV/AIDS

Human Rights and Legal Supporte.g.: •PLHA participation•Stigma & discrimination reduction•Succession planning

Socioeconomic Supporte.g.:•Material support•Economic security•Food support

Medical & NursingCaree.g.:•VCT, Family Planning•Preventive therapy•OI treatment and HAART•Palliative care

Psychosocial Supporte.g.:•Counseling•Spiritual support•Follow-up counseling•Community support

Elements of Comprehensive Care and Support

BackgroundBackground

Why did the ART program start?Why did the ART program start?1.1. Availability of HAART in Kenya: from mid-Availability of HAART in Kenya: from mid-

90s in private hospitals90s in private hospitals

2.2. Prohibitive cost of treatment amidst Prohibitive cost of treatment amidst intense public interestintense public interest

3.3. Government responses to improve accessGovernment responses to improve access

4.4. Increasing availability of ARV drugs due to Increasing availability of ARV drugs due to progressive reduction in prices and progressive reduction in prices and initiatives to improve accessinitiatives to improve access

Background (2)Background (2)

5.5. National consultative meeting on ARTNational consultative meeting on ART

– Convened by IMPACT in Sept. 2001Convened by IMPACT in Sept. 2001

– Involved local and international Involved local and international stakeholders, donors, researchers, PLHA stakeholders, donors, researchers, PLHA and community groups and community groups

– The purpose was to review the ART situation The purpose was to review the ART situation in Kenya and chart the way forwardin Kenya and chart the way forward

– The result was the setting up of a National The result was the setting up of a National ART Task ForceART Task Force

Background (3)Background (3)• National ART task forceNational ART task force

– Composed of local and international stakeholders, Composed of local and international stakeholders, community groups, PLHA, professional community groups, PLHA, professional associations,donors and development agencies associations,donors and development agencies

– Acts as an advisory board to the NASCOP and Director Acts as an advisory board to the NASCOP and Director of Medical Servicesof Medical Services

– Has many sub committees (Drugs, training, Systems Has many sub committees (Drugs, training, Systems developmentdevelopment

– Provides platform for sharing experiences on ART Provides platform for sharing experiences on ART implementationimplementation

National Adult HIV Prevalence: 10.2%

Project Site: Coastal city of Mombasa

Health Facilities1. Coast General Provincial Hospital: 700-bed

tertiary referral hospital with >70% of beds occupied by HIV/AIDS patients.

2. Port Reitz District Hospital: Government referral hospital.

3. Mkomani Bomu Clinic: Semi-private primary health care clinic.

4. Magongo Health Center: Local government primary health care clinic.

Site Information: KenyaSite Information: Kenya

Where is the program Where is the program implemented?implemented?

Mombasa: Rationale for Site Selection (1)Mombasa: Rationale for Site Selection (1)

High HIV prevalence and disease burdenHigh HIV prevalence and disease burden

Sites provide the opportunity to introduce ART Sites provide the opportunity to introduce ART at different levels of health care services as well at different levels of health care services as well as multiple entry points to ART services within as multiple entry points to ART services within the same catchment areathe same catchment area

Sites are linked through a referral network Sites are linked through a referral network system and to some services that provide system and to some services that provide elements of comprehensive care and supportelements of comprehensive care and support

• Rationale for Site Selection (2):Rationale for Site Selection (2):– USAID supported programs in Mombasa provide USAID supported programs in Mombasa provide

elements of comprehensive care and supportelements of comprehensive care and support

• IMPACT: Prevention activities (BCC, STI IMPACT: Prevention activities (BCC, STI management) & care activities (VCT, management management) & care activities (VCT, management of OI, psychological support to PLHA)of OI, psychological support to PLHA)

•COPHIA: Home-based care activitiesCOPHIA: Home-based care activities

•PSI: Condom promotionPSI: Condom promotion

•Strong political commitmentStrong political commitment

Where is the program Where is the program implemented?implemented?

How is the program How is the program implemented?implemented?

1.1. Establish the Technical Advisory Partners Establish the Technical Advisory Partners and define the role of each partner:and define the role of each partner:– Partners’ rolesPartners’ roles

• FHI/IMPACT: overall implementation and M&E FHI/IMPACT: overall implementation and M&E

• MSH/RPM Plus: strengthening drug and MSH/RPM Plus: strengthening drug and commodity managementcommodity management

• Population Council/Horizons: conducting Population Council/Horizons: conducting operational research related to the introduction of operational research related to the introduction of ART programART program

How is the program How is the program implemented?implemented?

2.2. Develop a concept paper describing the Develop a concept paper describing the implementation of the programimplementation of the program

3.3. Convene a workshop with local Convene a workshop with local stakeholders to discuss the concept paperstakeholders to discuss the concept paper

• The TAP described the ART ProgramThe TAP described the ART Program

• Local stakeholders provided Local stakeholders provided recommendations on key programmatic recommendations on key programmatic issues and the framework for the programissues and the framework for the program

• Local stakeholders provided their Local stakeholders provided their commitment to support and promote the commitment to support and promote the programprogram

How is the program How is the program implemented?implemented?4.4. Establish the ART program management Establish the ART program management

structurestructure• Steering Committee:Steering Committee:

o Composition:Composition: LLocal stakeholdersocal stakeholders

o Responsibility:Responsibility: Overseeing program implementation Overseeing program implementation

• Scientific Committee: Scientific Committee:

o Composition:Composition: Local and international researchers Local and international researchers and and scientistsscientists

o Responsibility:Responsibility: Developing realistic minimum Developing realistic minimum package package of activities (e.g eligibility of activities (e.g eligibility criteria, Rx criteria, Rx treatment monitoring schedules)treatment monitoring schedules)

How is the program How is the program implemented?implemented?4.4. Establish the ART program management structureEstablish the ART program management structure

• Operational Management teamOperational Management team::o Composition: Composition: Program coordinator, ART site team Program coordinator, ART site team

leader, partners’ field officersleader, partners’ field officers

o Responsibility: DResponsibility: Daily management of the programaily management of the program

• Technical Advisory PartnerTechnical Advisory Partner: :

o Composition:Composition: RPM Plus, Horizons, IMPACT, USAIDRPM Plus, Horizons, IMPACT, USAID

o Responsibility:Responsibility: Providing technical support to the Providing technical support to the program and the different program and the different

committeescommittees

How is the programHow is the program implementedimplemented??

5.5. Conduct assessment of existing Conduct assessment of existing capacity for implementing HIV care capacity for implementing HIV care program including ART program including ART

6.6. Strengthen the capacity based on Strengthen the capacity based on the findings from the assessmentthe findings from the assessment

7.7. Develop implementation plansDevelop implementation plans

8.8. Execute, monitor and evaluate the Execute, monitor and evaluate the implementationimplementation

What have we done so far?What have we done so far?

1.1. All committees have been establishedAll committees have been established– Scientific Committee has defined eligibility criteria Scientific Committee has defined eligibility criteria

and treatment monitoring schedule, Steering and treatment monitoring schedule, Steering Committee approvedCommittee approved

2.2. Assessment of existing capacity was Assessment of existing capacity was conductedconducted

3.3. Based on findings from the assessment, an Based on findings from the assessment, an implementation plan was developed with each implementation plan was developed with each facilityfacility

What have we done so far? (2)What have we done so far? (2)

• The capacity of the CPGH has been The capacity of the CPGH has been strengthened:strengthened: – Training of 37 clinicians, pharmacists and Training of 37 clinicians, pharmacists and

laboratory staff was completed in April, 2003;laboratory staff was completed in April, 2003;– Standard Operating Procedures and clinical data Standard Operating Procedures and clinical data

collection tools are in place; collection tools are in place; – Procurement of laboratory equipment is underway Procurement of laboratory equipment is underway

(CD4 instrument); (CD4 instrument); – Drug storage and security at pharmacy have been Drug storage and security at pharmacy have been

developed;developed;– Nurse adherence counselors were trained in Nurse adherence counselors were trained in

adherence monitoringadherence monitoring..

What have we done so far? (3)What have we done so far? (3)

• The CPGH Comprehensive HIV Care The CPGH Comprehensive HIV Care Center is operational, providing HIV Center is operational, providing HIV clinical services, ART, nutritional clinical services, ART, nutritional counseling, TB, STI, and referral to home counseling, TB, STI, and referral to home care, inpatient services, MCH/ANC, care, inpatient services, MCH/ANC, PMTCT, and the Pediatric Clinic.PMTCT, and the Pediatric Clinic.

• On May 23, 2003, patients started ART in On May 23, 2003, patients started ART in accordance with eligibility criteria.accordance with eligibility criteria.

PATIENT DATAPATIENT DATA

• The Comprehensive HIV Care Centre:The Comprehensive HIV Care Centre:– Began clinical care on April 17, 2003Began clinical care on April 17, 2003– number of HIV infected patients number of HIV infected patients

followed:followed:• FemaleFemale

• MaleMale

WHO Clinical Staging:WHO Clinical Staging:– IIII– IIIIII– IVIV

PATIENT DATA (2)PATIENT DATA (2)

• The First Month of ART at CPGH:The First Month of ART at CPGH:– Total: HIV Care- 123; ART 11Total: HIV Care- 123; ART 11– Gender-- =Female/ MaleGender-- =Female/ Male– Range of CD4 counts—03-201Range of CD4 counts—03-201– Adherence counseling—all patients participated Adherence counseling—all patients participated

in a minimum of 3 mandatory adherence in a minimum of 3 mandatory adherence counseling sessions prior to starting ARVscounseling sessions prior to starting ARVs

– Response to ARVs:Response to ARVs: • Incidence of adverse symptoms—Incidence of adverse symptoms—

MONITORING AND EVALUATIONMONITORING AND EVALUATION

• Objectives:Objectives:1.1. To improve the capacity of HIV/AIDS clinics, To improve the capacity of HIV/AIDS clinics,

laboratory and pharmacy services in selected laboratory and pharmacy services in selected public health facilities in Mombasa to support the public health facilities in Mombasa to support the introduction of comprehensive care including ARTintroduction of comprehensive care including ART

2.2. To provide ART to 300 patients over a period of five To provide ART to 300 patients over a period of five years in accordance with eligibility criteriayears in accordance with eligibility criteria

3.3. To sensitize and strengthen communities and PLHA To sensitize and strengthen communities and PLHA support groups in HIV/AIDS comprehensive care, support groups in HIV/AIDS comprehensive care, including ARTincluding ART

4.4. To explore Operations Research Questions (e.g., To explore Operations Research Questions (e.g., What is the effect of DAART upon ARV adherence?)What is the effect of DAART upon ARV adherence?)

FORMATIVE ASSESSMENT DATA FORMATIVE ASSESSMENT DATA COLLECTION TOOLSCOLLECTION TOOLS

• Needs Assessment Tool:Needs Assessment Tool:--National Clinical Guidelines--National Clinical Guidelines--Physical infrastructure--Physical infrastructure

•Laboratory servicesLaboratory services•PharmacyPharmacy--Human resources and staff capacity--Human resources and staff capacity

--Clinical services and referral mechanism--Clinical services and referral mechanism--HIV diagnosis--HIV diagnosis--ARV management--ARV management--Management Information Systems--Management Information Systems--Cost Issues--Cost Issues

STANDARD OPERATING STANDARD OPERATING PROCEDURESPROCEDURES

• Clinical Care and Patient FlowClinical Care and Patient Flow– Adult and PaediatricAdult and Paediatric

• Post-exposure prophylaxisPost-exposure prophylaxis

• Drug and Commodity ManagementDrug and Commodity Management

• Laboratory and Other InvestigationsLaboratory and Other Investigations

DATA COLLECTION TOOLS (2)DATA COLLECTION TOOLS (2)

• Patient Clinical Monitoring Forms:Patient Clinical Monitoring Forms:--Comprehensive Care Centre Registration --Comprehensive Care Centre Registration

FormForm--Nursing Assessment for Triage Form--Nursing Assessment for Triage Form--Clinical Management of HIV Patients: First --Clinical Management of HIV Patients: First

VisitVisit--Follow-Up Review of HIV Patients--Follow-Up Review of HIV Patients--Enrollment Form for Adult ARV Treatment--Enrollment Form for Adult ARV Treatment--Medical Follow-up of Adult Patients on ART--Medical Follow-up of Adult Patients on ART--Referral System Form--Referral System Form--Clinic Attendance and Treatment Follow-Up --Clinic Attendance and Treatment Follow-Up

Register Register

MONITORING AND MONITORING AND EVALUATION (3)EVALUATION (3) Indicator Categories:Indicator Categories:

Clinical/biological outcomesClinical/biological outcomesARV treatment adherenceARV treatment adherenceOccurrence of adverse drug effectsOccurrence of adverse drug effectsOccurrence of OIs, including TBOccurrence of OIs, including TBDrug management and inventory controlDrug management and inventory controlLaboratory monitoring and equipment utilizationLaboratory monitoring and equipment utilizationReferral for community based services, including home Referral for community based services, including home care and psychosocial supportcare and psychosocial supportTraining and refresher coursesTraining and refresher coursesImpact of community outreach on stigma and Impact of community outreach on stigma and treatment seekingtreatment seeking

MOMBASA PROJECT: M&E PLAN MOMBASA PROJECT: M&E PLAN SAMPLESAMPLE

Specific Objective 2: To provide ART to 300 patients over a period of five years in accordance with eligibility criteria

Indicators Activities/resources

Outputs

Long term outcomes (impact)

Definition (key indicators)

Sources of data and methods

Periodicity of collection

Responsible

Sub-Objective 2.1: Develop and implement client monitoring system including development of adherence system

Develop clients monitoring system including development of adherence system

Client monitoring and adherence system developed

Forms for clients monitoring

FHI and MOH staff

# and % of clients referred eligible for ART

Numerator: # of HIV + clients who attended the sites and who are eligible according to criteria upon agreed by the steering committee/local guidance

Denominator: total # of HIV+ clients who attending the sites in a given period

Clinic records

Sites monitoring reports

Regular basis

Quarterly reports

Annual reports

Clinic staff

M&E officer Implement client Monitoring system including adherence

# of clients who started ART and adhere to treatment

% of clients who demonstrate 95% adherence to treatment

Numerator: # of clients who show 95% adherence to ARV therapy during the life of the project

Denominator: total # of clients enrolled at the start of the project

Clients records

Sites reports

Regular-basis but to be compiled every quarter

NEXT STEPSNEXT STEPS• Scale-up project at 3 satellite sites in MombasaScale-up project at 3 satellite sites in Mombasa• Progressively develop computer-based data Progressively develop computer-based data

entry system at each siteentry system at each site• November 2003: completion of 6 months of November 2003: completion of 6 months of

ART at CPGHART at CPGH– Collect, analyze and report on key findingsCollect, analyze and report on key findings– Document lessons learned from start-up of Document lessons learned from start-up of

ART projectART project– Disseminate data and conclusions to key Disseminate data and conclusions to key

stakeholders and service providers stakeholders and service providers