Satellite Roll Out and Lab Capacity Building in Harvard

PEPFAR

Dr. Toyin JolayemiAPIN/Harvard PEPFAR, Nigeria

Over two-thirds of Nigerians live in rural areasProgram focused on tertiary sites at the startGrowing concerns around access, coverage, scale

up etcAvailability of and access to ART improves lives

allowing PLWHAs to live productive livesIssues around inequality and inequity Concepts on “saturation” and “satellite” were

discussed

Context

The satellite and saturation concept was adopted 1. Moving beyond the prime sites to

satellites will expand access to care and treatment and offer greater impact in numbers of people served, geographic areas covered

2. Decongest care and treatment at the prime sites

4 Prime sites to develop 22 satellites sites JUTH Model

Concept

3o LevelJUTH

2o LevelJENGRE

2o LevelVOM

2o LevelPANYAM

Cadillac

Volkswagen

1o LevelPHC

1o LevelPHC

1o LevelPHC Bicycle

Communities CommunitiesDonkey

Homes and Families Homes and FamiliesFoot

3o LevelJUTH

2o LevelVOM

(Gen. Hosp.)

1o LevelPHC

CommunitiesNGOs/CBOs/PLHA/Volunteer

Homes and FamiliesNGOs/CBOs/PLHA/

volunteer

Prev. messageTreatment literacyTreatment support

AdherencePatient tracking

Comm. Based services-IEC-FP

-BCK-Condoms

-DOTSOut reaches

-BCC-Treatment message

-HCT-Advocacy

ReferralsART

PMCTCHCT

Labs – VL, DC4, Genotype, chem, FBC

FPQA/QC/QI

STI

ARTPMTCT

HCTLabs – CD4, FBC, Chemistry

FP, STIQC/QI

HCTPMTCT

STICXTBCK

DOTS?ART refills

FPMultivitamins

HBC-FMCT/DOTS/BCK/CXTPrevention for +veCondoms/STI/FP

MultivitaminsPatient tracking

Infrastructural developmentLab developmentHealth Systems StrengtheningReferral MechanismsTraining and Technical AssistanceMentoringSupervision

Satellite Development Effort

COCIN Health Centre, Panyam: Antenatal Clinic

APIN PlusAPIN PlusLaboratory Infrastructure, EQA

Lab Equipped

Training completed

EQA EQA provider

HIV Screening X X X CAP 2007

HepB & HepC Screening

X X X CAP 2007

CBC X X Ongoing Cross-site

Chemistry X X X CAP 2007

CD4- flow X X X UK-NEQAS2006

Viral Load X X X Harvard2006

Infant PCR X X X CDC/ Harvard2008

Nigeria -Laboratory InfrastructureHIV rapid

tests & immunoblot

CBC Chemistry CD4-flow

Viral load Infant PCR

Resistance

Genotyping

NIMR X X X X X X X

68MH X X X X X X

LUTH X X X X X X X

UCH X X X X X X X

JUTH X X X X X X

UMTH X X X X X X

ABUTH X X X X X X

FMC Benue

X X X X X X

UNTH

Enugu

X X X X X X

ART

satellites

X X X X

Enrollment JUTH JUTH Satellites

Satellite Contribution

New on ART (Apr-Jun 09) 392 203 (34%)

New on Care (Apr-Jun 09) 558 432 (44%)

Current on ART @ June 09 8903 1075 (11%)

Current on Care @ June 09 10672 2349 (18%)

Transfer in of ART patients from JUTH (Apr-June 09)

About 10 * Other issues involved in motivating patient transferTransfer in of Care

patients from JUTH (Apr-June 09)

About 13

Program Output

Enrollment Time period Achievement/Target

New on Care (COP09) Apr-Jun 09 40%

New on ART (COP09) Apr-Jun 09 65%

Program Output

Sites are functional and providing services Community efforts are driving the demand for service Satellites are currently @ 40% of Care target and 65%

of ART targets (3 months) Issues around the supply end Upfront investment has been made Maximizing return on initial investment at the current

output level is an issue Tracking enrollment At a crossroad.

◦ Slow down enrollment…ethical concerns◦ Continue enrollment…finance concerns

◦ Access.

Summary

Thank you!

Satellite Roll-out, Task Shifting, and

Laboratory Capacity Building

Botswana Harvard PEPFARClinical Master Trainer (CMT), Lab Master Trainer (LMT), and

Monitoring & Evaluation Unit of Ministry of Health (M&E)

15

Master Trainer/ARV Site Support Program

Clinical Laboratory

Monitoring & Evaluation Unit (within DHAPC):

Linked to:• All ARV sites

• Other MOH programs

Masa

BHP-PEPFAR ARV Site Support Program

Three Objectives of Master Trainer and Site Support Program

1) Capacity Building through Clinical Mentoring, Training and Overall Site support

2) Decentralization of laboratories

3) Support development of the Monitoring and Evaluation of the National ARV Program - Masa

Capacity-building:Commitment to use in-country experts

All but two are Batswana or African expats who had already been working in-country

Initial criticism of hiring most experienced doctors, nurses, lab staff, and pharmacists from the National Program

Current appreciation of results:More than 150 HCWs mentored by each of

the above expertsIncreased labs and capacityAdditional ARV sites staffed by fully trained

HCWs

ARV Site Roll Out Process:Clinical Master Trainers

Site and pharmacy readiness assessmentsAssistance with all aspects and systems to

set up a new siteTraining, mentoring, and on-site support – 2

weeksTelephone site supportQuality Improvement:

QI training at site levelDevelopment of QI teams at all ARV sitesImplementation of chart reviews and other

evaluation toolsFeedback and QI planning with site QAI team

Clinical Master Trainer Program : ARV Sites Assessed and Supported

Mother Sites Supported

MiddlepitBokspit

Goodhope

Palapye

Masunga

Werda

Kalkfontein

Newxade

Each Mother Site has 3-4 Clinics (only some shown)

Why Task Shifting?

To date no Medical School in BotswanaApproximately 400 doctors in

BotswanaMore than 4,000 Batswana nurses in-

countryMinimal number of pharmacy staff

How will the new ARV sites and their pharmacies be staffed?

Task Shifting

Nurse Prescriber & Dispenser Training to Date - 170 nurses trained in prescribing and dispensing

ARVs - 379 nurses trained in ARV dispensing only

Nurse training for Rapid HIV testing and Dried Blood Spot in collaboration with PMTCT38 trained to date

Roll-out of Nurse Prescribers and Dispensers to Clinics

65 clinics - stand alone clinics with full prescribing and dispensing capability

64 prescribe and dispense on an outreach basis - the doctor and pharmacist or pharmacy technician travel to and from the facility on the ARV clinic day.

7 facilities initiate and prescribe but drugs are collected from another facility within the site (a site is defined as a mother site/hospital and its satellite ARV clinics)

The Impact of the Nurse Prescriber

PFM

Comparison of the numbers of patients reviewed by doctors and

nurses per month at a major facilityDoctors,

1800Nurses,

1200

0

500

1000

1500

2000

Doctors Nurses

No

. of

pa

tie

nts

2323

Satellite Clinic Roll-out

• At start of PEPFAR in 2004– 32 hospital ‘Mother Sites’

• Currently – 29 District Hospitals– 2 Botswana Defence Force Hospitals– 1 Mine Hospital– 136 ARV Clinics (satellite facilities)

• This last month, 68.7% of new patients were initiated on ARVs at satellite clinics, rather than hospital clinics.

WHY Task Shifting for Labs?

2 Reference Labs21 decentralized labs for CD4 testing8 decentralized labs for VL testingNeed for Rapid Testing and Dried

Blood Spot testing at all ARV sites

Process of Laboratory Decentralization

Laboratory Master TrainersSite assessmentCentralized training at Botswana National

LaboratorySite training and equipment set-upReagent supply managementAcceptable Internal Quality Control

testingFollow-up site supportTelephone site support

Laboratory Capacity Building

At start of PEPFAR - 20042 hospital reference labs capable of

performing 100% of CD4 and Viral Load testing

Currently the Botswana Lab Master Trainers have trained and supported ALL decentralized labs and private sector labs which run Public Private Partnership (PPP) specimensCD4s - 21 decentralized labs performing

59% VL – 8 decentralized labs performing 30%

27

CD4 Testing Comparison: 2004 – 2nd Qtr. 2009

Viral Load Testing Comparison: 2004 – 2nd Qtr. 2009