Aids Care Scheme
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Transcript of Aids Care Scheme
Syndromic approaches for common outpatient conditionsin adults: a priority
revitalising primary careBawoh. M PhD.
Service delivery at primary care
Multi-purpose health worker is expected to:• See all types of clients attending services
– < 5 years, > 5 years, young and old, men and (pregnant) women, HIV(+) and HIV(-)
• Perform all functions– Health promotion, prevention, care and service
management
• Manage all disease types– Acute, chronic, communicable, non-communicable– Irrespective of HIV status
Why syndromic guidelines for primary care?
• Care currently not standardized• Standard practice guidelines are known to improve
process, quality and outcome of care• Majority of patients present first at primary care
level
• Possibilities to confirm diagnoses are very limited• Etiological diagnosis not necessary, as long as
treatment is correct • No knowledge of HIV status• Care as entry point for prevention
Standardised case management:experiences and successes
• Integrated Management of Childhood Illness
• Syndromic Approach to STIs
• DOTS strategy to control tuberculosis
• Practical Approach to Lung health (PAL)
Benefits of standardisedcase management
• Standardisation of diagnosis and treatment• Standardisation of referral
• Case management at appropriate level of care• Rationalisation of drug use• Strengthening primary care to cope with common
outpatient conditions, including HIV and its related diseases
Development of syndromic practice guidelines: a priority
• September 2000: Rockefeller consultation
• Formation of a Syndromic Management Working Group and preparation of background paper
• April 2001: “AIDS care in Africa meeting”
• Development and research on syndromic practice guidelines for high HIV prevalence settings is a priority
Ongoing and planned research• Development by doing
– syndromic guideline development in Zimbabwe and Uganda incorporating existing STI, PAL and IMCI experience
• Strengthening the evidence base– appropriate selection of diseases and interventions to
include in the guideline for high HIV prevalence areas
– closing the guideline - implementation gap
– evaluation of implementation
Deciding on case management priorities for primary care
• General health service attendance (proxy to disease episodes and demand for care of all people attending first level facilities)
• Disease episodes encountered in HIV-infected individuals (proxy to demand for care)
• Cause specific mortality
• Response to treatment
General health service attendance1.5 million OPD visits, 1998, Zimbabwe
1. Acute respiratory infections 27%
2. Malaria 11%
3. STIs 10%
4. Skin disorders 7%
5. Diarrhoea 3%
Adult HIV rate 2000 25%
Disease episodes in Kenyan cohortof HIV-infected people
Disease Incidence1000 prsn-yrs
Frequency ofhealth serviceattendance
Resp tract inf 2382.1 2.4 x /yr
Skin disease 869.8 0.9 x /yr
STI 654.5 0.7 x /yr
Diarrhoea 567.7 0.5 x /yr
Diagram demonstrating CD4 count for different diagnoses
Asy
mp
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Feb
Illn
ess
Upp
er R
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Pne
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Vag
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UT
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ST
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Fol
licul
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Chr
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050
010
0015
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CD
4 C
ount
Diagnoses associated with immunosuppression
Excess mortality in the era of HIV
Age specific mortality rates for diarrhea in 1983 and 1995
Age groups
19831995
Dea
ths
per
1000
po
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tion
Existing evidence that treatment is important
Evidence Response to
treatment in HIVinfected persons
Pelvic inflammatory diseaseCohen, et al. 1997 & Bukusi et al. 1998
Bacterial pneumoniaGilks, et al. 1996
TuberculosisAckah, et al. 1995
Strengthen Health Care System
Mwanza STI study: reduced HIV incidenceGrosskurth, et al. 1995Reduced mortality in
hospitalized HIV patientsArthur, et al. 2000
40% HIV presumably died of 1st OISewankambo, et al. 2000
Survival of cohort in Nairobi who received primary health care, compared by initial CD4 count
Time in Cohort (days)
120010008006004002000
Cu
mu
lative
Su
rviv
al
1.0
.9
.8
.7
.6
.5
.4
Cd4 T-cell Count
> 499
> 499 censored
200-499
200-499 censored
< 200
< 200 censored
Gap: No comparison group
with “usual” access to care
Conclusions
• Frequent disease presentations in early stage HIV infected adults are not different from common outpatient complaints of non-infected adults
• Adequate management of selected conditions reduces case fatality of acute illness and increases quality of life and survival (?) in HIV positive people
Collaborating institutions• Biomedical Research and Training Institute, University of
Zimbabwe, Harare
• Kenya Medical Research Institute, Nairobi
• London School of Hygiene and Tropical Medicine, UK
• Nuffield Institute for Health, Leeds, UK
• University of California San Francisco, USA
• University of Washington, Seattle, USA
• Clinical Research Centre, State Medical Academy, Russia
• World Health Organization
Gaps in knowledge of treatment efficacy
PneumoniaAcute bronchitis
Sinusitis
DermatosesFolliculitis Chronic diarrhea
Research & development of evaluation indicators and process
Clinical outcome
Referral pattern & rate of hospitalization
Cost of care
Incidence of OIs
Survival
Quality of life
Validation indicators