Harvard PEPFAR: Six Years of ImplementationMark BarnesDecember 17, 2009mbarnes@hsph.harvard.edu

Harvard PEPFAR: Background in Three CountriesNigeria Gates grant on HIV prevention (Phyllis Kanki)Tanzania NIH-funded HIV and nutrition research (Wafaie Fawzi, Walt Willett)Botswana collaboration with MOH on national HIV laboratory, and NIH-funded research (Max Essex, Ric Marlink)

Harvard PEPFAR in NigeriaAIDS Prevention Initiative in Nigeria (APIN) - established in 2000 with grant from Bill & Melinda Gates Foundation

Harvard PEPFAR(APIN Plus) Program initiated in 2004

APIN, Ltd. - incorporated in October 2007 as a local NGO to assume the functions of Harvard PEPFAR in Nigeria

APIN Ltd and Harvard PEPFAR SitesNigerian states that currently include sites under APIN Ltd & Harvard PEPFAR1

September 2009

Indicator HarvardAPINTotalBC and SCurrentAdultsPeds50,7951,69113,55171664,3462,407Cumulative (Ever) AdultsPeds80,8993,28723,2541,126104,1534,413ARTCurrent AdultsPeds38,1571,72710,16358748,3202,314Cumulative AdultsPeds51,5772,07213,88765665,4642728

Sites by Types

Organizational type #Remarks Primary 1KuramoSecondary 15Includes 5 FBOs and 1 private hospitalTertiary 135 teaching hospitals, 2 FMCs, NIMR, 68 Mil, GHM, GHOnikan, GHOgbom, GHIOdeNGO 4AAN, ARFH, HaltAIDS, MashiahTotal 33

Harvard PEPFAR SitesBenue: Federal Medical Centre MakurdiBornoUniversity of Maiduguri Teaching HospitalState Specialist Hospital MaiduguriNursing Home MaiduguriEbonyi: Widowcare Abakiliki Enugu: University of Nigeria Teaching Hospital Ituku-OzallaKaduna: Ahmadu Bello University Teaching HospitalPlateauJos University Teaching Hospital8 Satellite Hospitals, 44 PHCsOur Lady of Apostles Hospital JosYobe: Federal Medical Centre Nguru

Lagos68 Nigerian Army Reference Hospital Nigerian Institute for Medical Research Military Hospital, Creek Lagos University Teaching HospitalUniversity of Lagos, College of Medicine Mushin General Hospital PHC-Iru Victoria Island Onikan Womens HospitalOgun: Sacred Heart Catholic Hospital LantoroOyoUniversity of Ibadan College of Medicine3 Satellites under UCHAdeoyo Maternity Hospital

Harvard sites transitioning to APINLate 2007-2008Oyo State43 Oyo State DOTS Centres

Lagos StatePHC Iru Victoria IslandOgun StateSacred Heart Catholic Hospital

$1.705m grant

2009Nigerian Institute for Medical Research

Lagos University Teaching Hospital

Mushin General Hospital

Onikan General Hospital

$Budget 12.3mLagos68 Military Hospital, Yaba Military Hospital, Creek OyoUniversity of Ibadan College of MedicineGeneral Hospital Ijebu-OdeGeneral Hospital OgbomoshoSt. Marys Catholic Hospital EletaAdeoyo Maternity Hospital

Proposed for 2010 ???

ARV Pick-up data for assessment of ARVregimen and adherence in evaluation of treatment failureTranscription error ofDrug name(ciprofloxacin) inPharmacy DB

The Treatment Utility Graph very useful for adherence and clinical progress

NameTitle

NameTitle

NameTitle

NameTitle

NameTitle

NameTitle

Team Title

NameTitle

Company Name

Company NameDepartment Name

Country Director/Chief Executive Officer

Chief Financial Officer

Human Resource & Benefits Manager

Chief Clinical Director

Quality AssuranceCoordinator

Program Director

PMTCT Coordinator

Program Associate

Cleaners (Lagos)

Satellite Coordinators(North&South)

Snr. Finance Officer (Lagos Office)

TB/Palliative Care Coordinator

Program Associate

I.T. Specialist

Prev. & Lab.Coordinator

Database Specialists North&South)

Chief Pharmacist

Senior Admin Officer

Logistics Officer

Cleaners (Abuja)

Pharmacist

Admin Assistant

Finance Officer

Admin Associate

Front Desk Officer

Finance Officer

Office Assistant

Office Assistants (Lagos)

Drivers (Abuja)

Drivers (Lagos)

Office Assistant (Abuja)

Store Assistants

HR Specialist

Snr. Finance Officer (Abuja Office)

Snr. Admin Associate

APIN Board

Program Associate

AIDS Prevention Initiative In Nigeria Organization Chart

Procurement Specialist

Internal Auditor

Cashier

M & E Officers (North & South)

Snr. Finance Officers (North & South Sites)

Laboratory Officer

Prevention Officer

Care & Support Officer

I.T.Associate

Systems DevelopmentStrategic InformationHuman ResourcesFinance and AdministrationPharmacy/LogisticsQI/QAProcurementAudits

Challenges Stakeholders skepticism about formation of APINOverlapping Harvard/APIN responsibilitiesDifferent funding cycles anticipated gap for each year of transitionAPINs lack of working capital

ChallengesDrug warehouse fire- April 26, 2008Space constraints- regulations on constructionLoss of trained personnel to other PEPFAR partners and international NGOsLack of institutional support at some sites

Harvard PEPFAR in Tanzania

Tanzania Country Profile

HIV/AIDS in Tanzania

SOURCE: THIMS, 2007/8

The National Care and Treatment Program Launched in 2004

Government Commitment to provide free ARVs to all PEPFAR and Global Fund are among major supporting partners

Harvard- PEPFAR ProgramCollaborating institutions (MDH)Muhimbili University College of Health & Allied Sciences (MUHAS)Dar es Salaam City CouncilHarvard School of Public Health

Total ever enrolled75,198

Active on ARVs30,884

Ever initiated ARVs47,221Harvard PEPFAR in Tanzania:Sept. 2009 September, 2009

29 sites Public1 faith-based 18 sites Private

Urgent Need to initiate Care and Treatment in 2004

2004-2009 PrioritiesCreate more clinic space to accommodate increasing patients Emergency staff hiring to meet increasing demandImprove capacity of existing laboratories/establish new ones for patients monitoringTraining of service providers on HIV care

Addressing human resource problemThrough PEPFAR funding, we engaged more than 600 local staff to work with the programHired about 450 more staff Provided incentives to ensure staff retention (training, good working environment, professional recognition)Program paid staff are now being absorbed in the government system by phases

TrainingMDH Program provided routine basic ART training according to national curriculum for the core and back up teams1 month practical trainingOngoing mentorship/preceptorshipVideo conferencingLater introduced other essential related training according to needsTreatment adherenceNutrition

Strengthening of Laboratory ComponentHuge investment in renovation to create space and meet standards (10 labs)Procurement of equipmentsProcurement of reagentsTraining in GLPQuality assurance and quality controlPutting in place supply chain management

2009-2012 Priorities

System strengtheningQuality Improvement ProgramData management for decision makingTransition Harvard core business to local entity for sustainability

Quality Improvement (QI)Building the culture of QI: regarding quality improvement program as important as meeting targets in numbersDevelopment of indicatorsRegular assessmentFeedback and strategies for improvement Focusing on all 3 domains Quality of care providedEase of access to service Patient satisfaction

Example: Addressing quality issuesPatients are less likely to stay in care if provided by overwhelmed health workers, at clinics far awayInnovationsSize and proximity of services addressed by scaling up and decentralizationProlonged working hoursVisits scheduled by date and time block

Task ShiftingInadequate human resourcesInnovations to make use of available resourcesTask shiftingNurses dispensing drugsPLWHAs providing group counselling, tracking of missing patientsUsing community lay workers to promote adherenceIntegration of HIV care into general health services (ANC, TB)

Patient retention a major challengeAt least 20% of patients are lost to follow and are rarely tracedPatients not on ARVs are more likely to be lost to follow up40% of lost to follow up patients are missed within their first 30 days of enrollmentLost to follow up is often likely due to deathLTFU has major public health implications

Patient tracking Established a close monitoring system using available resourcesAt every visit, nurse/counselor updates map cue (phone number, physical address)Patients are traced through mobile phones, or/and physical home visitCommunity-Based Health Workers & volunteer PLWHAs follow-up patients withmissed visitsabnormal lab results that need immediate attentionHIV exposed infants

Transitioning to Local OwnershipPlan is to transition the Harvard role to a local entity (MDH) by phasesDuring the process Harvard will continue providing TA and capacity building to the local entityLocal entity will continue to collaborate with Harvard in TA, training, research

Harvard PEPFAR in Botswana:Supporting the National ARV Therapy Programme (Masa)

Masa: Botswana National ARV ProgramTotal Population of Botswana 1.8 millionStarted in 2002 first African country to give free ARVs to all citizensNovember 2009110,000 on ARV treatment in Public Sector61.8% female6.8% children < 13131,444 - Total on Treatment (public and private)

**Monitoring & Evaluation Unit (within DHAPC):Linked to: All ARV sites Other MOH programs

Mother Sites SupportedBokspitGoodhopePalapyeMasungaWerdaNewxadeEach Mother Site has 3-4 Clinics

*CMT Cumulative Progress To Date

Originally 32 mother sites in regional hospitalsDirect support to:29 District Hospitals2 Botswana Defence Force Hospitals138 Satellite Clinics CMTs started and support60% of new patients initiated at new clinicsTraining (4,000 in formal training)Nurse Prescriber & Dispenser Nurse DispenserKITSO Introduction to AIDS Clinical CareKITSO AIDS Clinical Care FundamentalsQuality Assurance and Improvement (QAI)Other topics as requested by MoH

*

*LMT Cumulative Progress to Date:Decentralized Labs: Set-up, Training and Support of 100% of labsCD4s - 21 labsVL 8 labsPCR 1 lab

Formal Lab Training (125 Lab Staff)CD4Viral LoadTraining ManualSample Collection and ProcessingRapid Testing for Nurses and Dried Blood Spot Collection for Lay Counselors at sites without labs

*

LMT Cumulative Progress to Date:

60% of CD4s now performed at decentralized labs

29% Viral Loads now performed at decentralized labs

Harvard PEPFAR in Botswana:2009-2012Chartering of BHP, new not-for-profit entity in Botswana, with Harvard-MOH board of directorsBHP will become the prime recipient of PEPFAR funds in 2010PEPFAR is only 20% of BHP activities

Thank You

20/5/2008*11 states in Nigeria20/5/2008*This table shows the transition of our patients and activities by year and annual budget for APIN, Ltd20/5/2008**Successfully applied for CDC RFA 07 - 730 as a PEPFAR care and treatment partner$1.705m grant to implement Comprehensive HIV/AIDS care at SHCH, VI-Iru and 43 DOTS Centers in Oyo StateIn COP 09, APIN assuming the responsibility of 4 more Harvard Sites with a budget of $12.3m. Notification of this award was received in July.There is uncertainty about the next set of sites that would transit to APIN. Presently, there are different scenarios being mentioned. One is the possibility of regionalization where implementing partners are made to work in certain regions of the country. This would not be a favorable option for our program as we have some large sites in parts of the country.**The treatment Utility Graph remains one very potent instrument to monitor patients adherence to treatment as well as clinical progress.APIN Ltd has 65 employees

20/5/2008*20/5/2008*20/5/2008*What date (so far?)Sites of whatPut in same font*