Service Integration

in the Contextof PEPFAR

Programming

David HoosSeptember 2010

3841238777391423950839873402380

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

0

100

HIV Care ART

Continued increase in number of ICAP-supported facilities and enrollment in HIV care and treatment

Ethiopia

Lesotho, Rwanda,S. Africa, Tanzania

Mozambique

Zambia Nigeria, Kenya

Cote d’Ivoire

652 facilities

861,280 ever enrolled in

care

Num

ber o

f pati

ents

Num

ber of facilities

430,876 ever initiated ART

Swaziland

Demand and Uptake of HIV care and treatment continues to increase

Num

ber o

f new

pati

ents

Note: *New enrollment includes transfers

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

6,078

17,875

29,032

37,193

52,471 52,846

60,440

73,566 72,580

84,28090,326

2,1075,457

12,42716,639

24,091 26,25729,484

36,838 36,032

45,891

52,684

New care enrollment New ART enrollment

Can Efforts Related to Millennium Development Goal 6 Support MDG 4 and 5

to eradicate extreme poverty and hunger;

to achieve universal primary education;

to promote gender equality and empower women;

to reduce child mortality;

to improve maternal health;

to combat HIV/AIDS, malaria, and other diseases;

to ensure environmental sustainability; and

to develop a global partnership for development

MDG-1:

MDG-2:

MDG-3:

MDG-4:

MDG-5:

MDG-6:

MDG-7:

MDG-8:

PEPFAR implementing partners work throughout the health facility

Num

ber o

f site

s

Note: Some sites offer more than one activity

Total d

istin

ct site

s

Care &

treatm

ent

TB scre

ening fo

r HIV

pts

HIV te

sting fo

r TB p

ts

PMTCT

Early in

fant d

iagnosis

PICT/V

CTLab

0

200

400

600

800

1,000

1,200

1,400

1037

507 474310

879

451676

385

182

180 147

101

43

12414

69

Non-MCAP

MCAP

39142 39326 39508 39692 39873 40057 402380%

50%

100%

0

50

100

150

200

250

300

350

400

450

78%

66%

79%

88%

79%

88% 90% 90% 93% 94%

85% 85% 83%

Proportion # facilities

Service Integration: HIV testing continues to increase in TB clinics Pe

rcen

t of p

atien

ts

n=5,992 n=6,397 n=8,416 n=8,750 n=8,907 n=10,003 n=7,613TB patients with

unknown HIV status

Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-100%

10%

20%

30%

40%

50%

60%

70%

0

100

200

300

400

500

600

40%

48%52%

57%55%

57% 56%59%

62% 61%65%

Proportion # facilities

Service Integration: TB testing continues to increase in HIV clinicsPe

rcen

t of p

atien

ts

n=22,037New HIV patients n=28,630 n=37,234 n=38,025 n=38,379 n=44,612

PHC: HIV care is not a vertical program: care provided by same staff for same patients leads to increased retention (an opportunity for

MDG 4 and 5)

Systems for HIV Care and other Health Issues Face Common Barriers and Challenges

Maternal health Child health TB Diabetes HIV/AIDSBarriers and challenges:• Demand-side barriers • Inequitable availability• Human resources• Lack of adherence support• Infrastructure, equipment• Program management• Drug supply / procurement• Referral and linkages• Community involvement

√√√√√√√√√

√√√√√√√√√

√√√√√√√√√

√√√√√√√√√

√√√√√√√√√

Adapted from Travis, Bennett, et al. Lancet 2004

Establishment of HIV-related support services offers opportunity for generalization of essential services

Perc

ent o

f fac

ilitie

s

Adherence counseling

Outreach Peer educators Nutritional treatment for

adults

Nutritional treatment for in-

fants/children

Food security support for adults

or children

0%

50%

100% 96%

59%

31%26%

21%

98%

65%

54%

25%

41%

N/A

99%

82%

74%

41%

66%

35%

Jul-07 Jan-08 Jul-09

Continued ART* 354557

82%

Discontinued ART 76,319

18%

33%

64%

9.1% per year on

ART

PEPFAR reporting requires HMIS: an opportunity to support an overall chronic care model

.44% per year on

ART

4.7% per year on

ART

Lost to Follow-up

Reported Dead

Reported stopped ART 3%

Source: ICAP URS March 2010Notes: *Includes patients who transferred out while on ART.

Rates

Mapping can assist in utilization of PEPFAR supported HIV care sites for other public health needs

Interrelationship of MDGs 4, 5 and 6

• HIV and maternal conditions are the two leading causes of mortality in women age 20-59 in low income countries and worldwide*

– 17.7+ million women and girls living with HIV worldwide

– Over 530,000 women die in pregnancy or childbirth yearly

– An estimated 200 million women in the developing world want to space or limit childbearing but are not using family planning, which contributes to 25% of maternal and child deaths

– Women who are HIV-infected have rates of maternal mortality up to 5-times that of uninfected women

*Women and health: today's evidence tomorrow's agenda, WHO, 2009

Effect of HIV Treatment on Incidence of Malaria in HIV-infected Patients

Uganda & Zimbabwe

Year 1 Year 2 Year 3 Year 40

100

200

300

400

500

600

700

591

476

259

153

Rate

of M

alar

ia p

er 1

,000

pys

Kasirye et al, IAS 2009

Effect of PMTCT Programs on Quality of Overall Antenatal Care and Delivery - Cote D’Ivoire

Delvaux et al, IAS 2009

Potential Impact on < 2 Child Mortality Kwa Zulu Natal, South Africa

Ndirangu et al. AIDS 2010

PEPFAR-2 Offers Opportunity for Service Integration Guidance on PMTCT/MCH/FP Integration

Where feasible and appropriate to the epidemic support should be provided for:

Integrating PMTCT with MCH services as an entry point to other HIV services.

Linkages and wrap around with family planning services

e.g., co-locating and linking PMTCT and family planning services , training FP clinical providers on PMTCT, counseling HIV+ women in PMTCT

Safe Motherhood and child survival interventions :

Emergency Obstetric Care and neonatal resuscitation could be integrated into PMTCT training where feasible.

Linkages should be strengthened between key initiatives such as PEPFAR and PMI, which focus on pregnant women and children

Causes of Maternal Deaths• Direct (69%)

– Obstructed/prolonged labor=21%– Ruptured uterus =22%– Severe pre-eclampsia =20%– Abortion= 10%– PPH= 10%– APH=9%

• Indirect causes (21%)– Malaria 35%– Anemia 25%– HIV/AIDS related 21%– Other 19%

• Unknown (10%)

19

But WHY Do These Women Die?• Delay in decision to seek care – increased uptake of PMTCT may

impact– Poor uptake of ANC– Lack of understanding of complications that can be prevented

by facility-based births• Delay in reaching care – expansion of level of HIV care at PHC

may improve access for other diseases– Transport – PHC not equipped to handle complications

• Inadequate /unskilled care at facilities – Training opportunities funded through PEPFAR may support– Shortages of supplies and staff– Inadequately trained staff– Finances

Three Delays Model

Challenges

• Perception that treatment and prevention are dichotomous choices

• How to identify efficiencies within development funding?

• Flat or decreased funding will limit options• Perception that disease specific funding will

cannot strengthen health systems