1

Partnering to Strengthen Local Efforts Can Help Us Get to Six Million on ART

Anja Giphart, MD MPHVice President, Program Implementation

Elizabeth Glaser Pediatric AIDS Foundation

July 25, 2012

Project HEART Countries and Number of Sites

Project HEART Care and Treatment Results, 2004-2011

Eligible Women for PMTCT ser-

vices

Women Received HIV Test Results

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

Num

ber o

f wom

en

N= 2.9m

N= 2.6m

Total HIV+ Pregnant W

omen

Women Rece

iving ARV Prophylaxis

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Zambia South Africa Mozambique Cote d'Ivoire

N= 369,197N= 326,728

Project HEART PMTCT Results 2005-201162,000 pediatric

infections averted

Local Capacity Building Approach #1: District Approach to Expansion

of Services

District Approach

• An effective approach to rapidly scaling-up HIV services while building local financial, technical and management capacity

• Working “through” the districts: – Districts are responsible and accountable for

implementation, quality and scale-up of HIV services in their location

– EGPAF provided technical assistance and direct funding via subgrants

• EGPAF worked with a total of 159 districts across 5 countries

• In the final project year 96% of subaward funds were awarded to local partners, the majority being districts and community organizations

Tanzania Care and Treatment Scale-up

2004

Q4

2005

Q1

2005

Q2

2005

Q3

2005

Q4

2006

Q1

2006

Q2

2006

Q3

2006

Q4

2007

Q1

2007

Q2

2007

Q3

2007

Q4

2008

Q1

2008

Q2

2008

Q3

2008

Q4

2009

Q1

2009

Q2

2009

Q3

2009

Q4

2010

Q1

2010

Q2

2010

Q3

2010

Q4

2011

Q1

2011

Q2

2011

Q3

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

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Cumulative number of patients ever enrolled in HIV careCumulative number of patients ever started on ARTNumber of reporting sites

Num

ber o

f pati

ents

Num

ber o

f rep

ortin

g si

tesDistrict

Approach Expanded in

2007

Directly and Indirectly Supported Care and Treatment Sites, Tanzania

N=260

ART results for 5 Regions as of March, 2012

N=6,016 N=56,486

Sites New on ART Current on ART0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

37%29%

8%

IndirectDirect

Mozambique Subgrant Burn Rates Improvements over

Time

Maputo Gaza Nampula Cabo-Delgado Total

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0tan14a566014

0tan24a5660240tan24a566024

0tan5a566050tan26a566026

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Percent of Budget Spent by Subgrantees in 4 provinces

2008 -2011

July- December 2009 January-June 2010 July- December 2011

Local Capacity Building Approach #2: Decentralizing Training

Traditional In-Service Training

COUNTRY NAME

Physicians Trained: ART

Nurses Trained: ART

Other HCW Trained: ART

Côte d’Ivoire 3,069 2,571 655

Mozambique 278 916 687

South Africa 932 1,868 1,868

Tanzania 1,712 1,861 1,214

Zambia 926 4,047 2,638

TOTAL 6,917 11,724 6,962

Over 25,000 Healthcare Workers Trained in the provision of comprehensive HIV care and

treatment

Pre-Service Training in Cote d’Ivoire

Medicine69 doctors trained in care and treatment of HIV/AIDS, TB, and

malaria

* 12 employed by program site

* 14 awaiting assignment as civil servants

* 42 writing thesis* 1 working outside CI

Pharmacy25 pharmacists

trained in lab and strategic supply

management

* 4 employed by program site

* 19 writing thesis* 2 working outside CI

Social work151 social workers trained to provide

support and follow-up to PLWHA

* 131 employed as civil servants, mostly

in program sites* 20 awaiting assignment

245 health professionals trained, 2007-2011

Pre-Service Training in Mozambique

By June 2011, Project HEART supported a total of 9 courses for 259 medical officers, nurses, pharmacy agents, and assistant health officers.

Targeted Mentoring for Pediatric TreatmentCase Review of 348 Pediatric Patients

in 3 Referral Hospitals in Tanzania

Site# of records reviewed

# of children on ART

# eligible but not on ART

% eligible but not on ART

Maswa District

154 38 57 37%

Shinyanga Regional

130 49 47 36%

Bukombe District

64 41 18 28%

TOTALS 348 128 122 35%

“Systematic analysis of EID cascade and implementation of specific interventions: Lessons from Tanzania.” Schimana, W et al. IAS, 2011

Targeted mentoring to improve pediatric ART initiation -

Tanzania*

Eligible children not on ART

0%10%20%30%40%50%60%70%80%90%

100%

Baseline

Eligible children not on ART

0%10%20%30%40%50%60%70%80%90%

100%

After mentoring

* Data are from three referral hospitals in Tanzania

Local Capacity Building Approach #3: Transition

Services to Local Partners

Two Phases of Project HEART

Phase I: Emergency scale-up, 2004-2009

Phase II: Sustain & Transition, 2009-2012

Two Program Phases

Project HEART Transition Approach

Sustainable Health Outcomes: Clients have continuous high quality

HIV care and treatment delivered by local partners

Health Service Provision

(Quality & Access)

Management Capacity of

Government, NGOs & Private Sector managing health

system

Client and Community Engagement

(active civil society, high demand)

Enabling Environment Policies, political stability, human rights, gender equality, etc.

Transition Monitoring ToolsArea of

MeasurementDescription Monitoring Tool

Capacity Assess existence and scope of organizational systems and processes

H-CAT (for MOH Districts and Regions)

Organizational Capacity and Viability Assessment Tool (OCVAT)

Site Capacity Assessment Tool Affiliate Accreditation Tool

Transition Outcome indicators demonstrating an incremental increase in responsibility and ownership

Benchmark Matrix OCVAT Project workplans & budgets

Sustainability Performance indicators demonstrating sustained ownership and quality

Benchmark Matrix Affiliate Accreditation Tool Project workplans & budgets

Country Transition Approaches

• Health Systems Strengthening, capacity building and transition to local authorities -2 Provinces Directly Funded by CDC in Mozambique

• Transition to Existing NGO– Zambia: CIDRZ– South Africa: McCord Hospital and Health

Systems Trust, Aurum Institute• Enhanced health systems strengthening and

transition to a new independent NGO (EGPAF Affiliate) in– Cote d’Ivoire– Mozambique– Tanzania

Getting to Six Million: Our Future Depends on It

Acknowledgements

• PEPFAR and the US Government• Ministries of Health and the National, Regional and

Local Governments in Cote d’Ivoire, Mozambique, South Africa, Tanzania and Zambia

• International and local partners• CDC/Atlanta (from GH, PGO, Budget Office and ADS)• CDC in Cote d’Ivoire, Mozambique, South Africa,

Tanzania and Zambia• EGPAF staff in LA, DC and Cote d’Ivoire, Mozambique,

South Africa, Tanzania and Zambia• Other Track 1.0 partners for their collaboration• The patients, providers and communities for their

participation, engagement and courage