Track E Implementation Science, Health Systems and Economics

Abstract

Due to Lesotho's high adult HIV prevalence (23%), considerable resources have been allocated to the HIV/AIDS response, while resources for non‐communicable diseases have lagged. Since November 2011, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has supported Lesotho Ministry of Health to roll out Family Health Days (FHDs), an innovative strategy to increase community access to integrated health services, with a focus on hard‐to‐reach areas where immunization coverage, HIV service uptake, and screening and treatment for chronic diseases are low. Services were provided at mobile service delivery points from 17th October to 25th November 2011. Delivery points located in rural setting were staffed by multi‐disciplinary teams of doctors, nurses, community workers, nutritionists, AIDS officers, and pharmacists (30‐40 health professionals present). During this campaign, 8,396 adults were tested for HIV (67.3% female; 32.6% male). In all, 588 (7%) tested HIV‐positive (6.7% female; 7.1% male). Among those testing HIV‐positive, 68.5% (403) received CD4 testing and 36.6% were enrolled into HIV care at their nearest clinics. A total of 324 ART defaulters were identified and linked back to care. Follow‐up with referral facilities showed 100% of patients (defaulters and newly enrolled) linked to care were enrolled at a facility. Standard immunizations were administered to 990 children. 4,454 adults (24.7% male; 75.3% female) were screened for hypertension, and of those screened, 24.2% had elevated blood pressure and were linked to care centers. Addtitionally, 3,045 adults had blood sugar tests (27.0% males; 73.0% females); 3.1% had elevated blood sugar and were linked to care facilities. Offering integrated services within hard‐to‐reach communities can increase access to a variety of critical health services, including those for non‐communicable diseases, and can link ART clients lost to follow‐up back to facilities. This approach will be scaled up throughout Lesotho as a strategy to reach all populations in the country. The high burden of undiagnosed HIV in sub‐Saharan Africa limits treatment and prevention efforts. Community‐based HIV testing campaigns can address this challenge and provide an untapped opportunity to identify non‐communicable diseases (NCDs). We tested the feasibility and diagnostic yield of integrating NCD and communicable diseases into a rapid HIV testing and referral campaign for all residents of a rural Ugandan parish. A five‐day, multi‐disease campaign, offering diagnostic, preventive, treatment and referral services, was performed in May 2011. Services included point‐of‐care screening for HIV, malaria, TB, hypertension and diabetes. Finger‐prick diagnostics eliminated the need for phlebotomy. HIV‐infected adults met clinic staff and peer counselors on‐site; those with CD4≤100/µL underwent intensive counseling and rapid referral for antiretroviral therapy (ART). Community participation, case‐finding yield, and linkage to care three months post‐campaign were analyzed. Of 6,300 residents, 2,323/3,150 (74%) adults and 2,020/3,150 (69%) children participated. An estimated 95% and 52% of adult female and male residents participated respectively. Adult HIV prevalence was 7.8%, with 46% of HIV‐infected adults newly diagnosed. Thirty‐nine percent of new HIV diagnoses linked to care. In a pilot subgroup with CD4≤100, 83% linked and started ART within 10 days. Malaria was identified in 10% of children, and hypertension and diabetes in 28% and 3.5% of adults screened, respectively. Sixty‐five percent of hypertensives and 23% of diabetics were new diagnoses, of which 43% and 61% linked to care, respectively. Screening identified suspected TB in 87% of HIV‐infected and 19% of HIV‐uninfected adults; 52% percent of HIV‐uninfected TB suspects linked to care. In an integrated campaign engaging 74% of adult residents, we identified a high burden of undiagnosed HIV, hypertension and diabetes. Improving male attendance and optimizing linkage to care require new approaches. The campaign demonstrates the feasibility of integrating hypertension, diabetes and communicable diseases into HIV initiatives. Planned Parenthood Federation of Nigeria (PPFN) is implementing the Global Fund Round 9 project as Principal Recipient. In 2011, PPFN was challenged with lack of HCT RTK, FP and STI commodities resulting in poor performance. In creating change to optimise PPFN performance, the Rapid Emergency Scale Up Plan was developed to meet the backlog of unmet targets in three weeks; the Kotter's 8 step change mode as theoretical model. The plan addresses HCT and provision of integrated SRH/HIV services through FP/STI services to capture HCT missed opportunities. This abstract therefore seeks to document lesson learnt through the plan surpassing PPFN HCT services. PPFN designed a plan showing targets linked to each clinic. A cumulative target for all clinics within a cluster was assigned to PPFN staff in each of the 35 states. This was replicated by region. To determine if each staff would meet its targets, Kotter's 8 step models was applied. PPFN had the following targets for 2011: provide service in 486 health facilities and ensure that and 225,800 HCT clients were provided with FP and STI services. By using FP/STIs services as entry point, PPFN met its target by 110% for HCT services, 213% for FP/STIs services with 88% of facilities providing services The paper indicates integration of services as a way to meet client's needs in a challenging environment and therefore increases performance while optimizing resources. While policy and implementation support for SRHR/HIV integration is increasing, significant questions and uncertainties remain about what such programming means in practice. This is particularly the case in concentrated HIV epidemics, where little is still known about what integration should look like for key populations, including sex workers, men who have sex with men (MSM), transgenders, injection drug users (IDUs) and people living with HIV (PLHIV). While integration is a desirable goal in the long‐run particularly for clinical services, joining programs and systems that are not ready could compromise quality and access for these groups that already face difficulty in obtaining appropriate services for both HIV and SRH needs. India HIV/AIDS Alliance undertook a global review of over 160 resources available on the websites of selected national and international organisations, including NGOs, technical support agencies and UN agencies. The resources included case studies, mappings, toolkits, policy briefings and program reports. The review identified the most common challenges in designing and implementing SRH/HIV integrated programs for key populations. These included stigma and discrimination, low levels of demand, lack of rights‐based approaches, low attention to gender inequality, low understanding of key populations' specific SRH needs, lack of capacity and sensitivity among service providers, lack of strong referral systems and inadequate resources for additional interventions. The review highlighted key steps that organisations can take to successfully integrate SRHR and HIV in their responses for key populations. While SRH/HIV integrated programs present an important opportunity to respond to the unmet needs of key populations, integration that is premature, overly rapid or too large‐scale risks compromising rather than enhancing key populations' access to high quality HIV and SRH services. Good practice principles, including gender equality, human rights‐based approaches, meaningful involvement of communities, for work with key populations are particularly critical in effective HIV/SRHR integration. The Systematic Monitoring of the Male Circumcision Scale‐up (SYMMACS) is designed to track voluntary male circumcision (VMMC) service delivery in Kenya, South Africa, Tanzania, and Zimbabwe. The study measured adoption of six elements to increase efficiency in the delivery of clinical VMMC services, including: Data collection took place at 14‐30 VMMC sites per country (73 sites total) from April‐December 2011. It included observation of the clinical facilities, observation of VMMC procedures, interviews with VMMC providers and the in‐charge officer, and compilation of service statistics. Surgical method Task shifting (allowing non‐physicians to perform VMMC) Task‐sharing (allowing non‐physicians to conduct aspects of VMMC) Rotation among multiple bays in the operating theater Bundling of supplies and tools Use of electrocautery instead of ligating sutures Surgical method Task shifting (allowing non‐physicians to perform VMMC) Task‐sharing (allowing non‐physicians to conduct aspects of VMMC) Rotation among multiple bays in the operating theater Bundling of supplies and tools Use of electrocautery instead of ligating sutures The results are useful for monitoring service delivery in each country and conducting cross country comparisons. The data shows considerable variation by country on 5 of the 6 elements, the exception being nearly universal use of the forceps‐guided method (see Table 1). The study revealed stark differences on task‐shifting, both in terms of actual practice and provider attitudes toward it. For example, in Zimbabwe, while no providers report using task‐shifting, 86.5% say they would implement the practice given the choice. Countries also differed in the use of multiple beds per provider (rotation) during VMMC, with100% of providers in Zimbabwe reported using multiple beds, compared to 38% percent in Kenya, reflecting a different service delivery model. Provider reported use of electrocautery ranged from 5.4% in Tanzania to 88.6% in South Africa. Kenya (n = 85) South Africa (n = 95) Tanzania (n = 93) Zimbabwe (n = 74) If given the choice, providers reported that they would apply the following efficiency measures at their MC clinic: Already do (%) Yes (%) Already do (%) Yes (%) Already do (