CARE Caring team Acknowledgements The

CARE Caring team. .

Acknowledgements • The people of Rwanda • All the participants • All the organizers and sponsors • The team of rapporteurs • All patients

Outline • Counseling & Testing • Comprehensive care • TB/HIV • Food and Nutrition • OVC

472 U 100 HIV-1/2 CONTROL 7 A Counseling and Testing PATIENT Dat Tran, Kathy Jacquart, Elizabeth Marum

Innovative Approaches to HIV Testing (De. Cock) • <20% of pregnant women get HIV Tested • <13% TB patients tested for HIV • 80% of HIV infected persons do not know their HIV status • Late HIV diagnosis is “bad medicine” – 73% of deaths occur because CD 4 cell <100 when first tested • Ambitious scale-up needed of all models: – Traditional VCT, mobile and outreach VCT – Provider-initiated CT in health facilities • WHO Guidelines now available • Testing for TB patients high priority

It's a Hard Life at WHO

Counseling & Testing in Health Care Facilities • Opt-in testing in TB settings leads to low testing rates (Indonesia Abst 831) • Successful integration in TB settings (Haiti Abst 303, Kenya Abst 678, Uganda Abst 1062) – Over 90% acceptance – More testing of TB patients in PEPFAR focus countries compared to others (Abst 1771) • Many programs for PITC in health facilities (Uganda, Tanzania, Kenya, S Africa)

Counseling & Testing in the Community • Mobile or outreach CT in many countries: ( Rwanda, Kenya, Lesotho, Mozambique, Zambia, Nigeria, Cote d’Ivoire) – Mobile cost effective (Kenya Abst 62) • Home testing increasing: (Uganda, India) – Coverage from 10% to 90% in 2 years – Door to door home testing = early detection of HIV (Mean CD 4 493 in HIV+ in Uganda)

CT for High Risk Groups • Military (mandatory for new recruits in many countries, VCT for soldiers and families) • VCT for drug users in rehab (Vietnam) – HIV+ as high as 60% (Abst 328) • Prisoners (Rwanda) • VCT for truckers in Brazil (Abst 1568) • CT integrated in STI clinics for female CSW (Ghana Abst 1674), for youth (S. Africa Abst 658) • Alcohol counseling important in VCT (Kenya) – Adds 6 min to counseling session (Abst 1580)

Innovative Methods & Partners • Agricultural extension workers (Cote d’Ivoire) • PLWHA for family outreach (Rwanda, Abst 1490) • Hospice program (Zambia) • Task shifting: lay counselors (Ethiopia, Namibia), volunteers (Lesotho) • National Testing Week – Malawi: 97, 000 in one week (Abst 956)

Clients Tested & Counseled in 2006: Impact of National Testing Week in July

Challenges & Questions • Disclosure to HIV infected children remains difficult (Abst 552, 555) • Couple testing and identification of discordant couples high priority for prevention – In mature epidemics, high incidence in married couples (Wilson) – Home testing and testing of spouses of patients may be most effective strategy to identify discordant couples (Uganda) • Policies in some countries do not yet support finger-prick samples, rapid tests, and same day results • How long should pre-test and post-test counseling be? • Stigma remains a barrier to testing in localized epidemics (Indonesia, Abst 831)

Comprehensive Care Ana Bodipo-Memba, Tim Quick, Reson Marima

Integration • Provision of HIV care services within PMTCT clinics • Achieved by training of staff on WHO staging and provision of CD 4 testing at PMTCT clinic • Resulted in more effective and earlier referrals to ART sites Abst 405

Comprehensive Care Packages • Components – – – Prevention Physical -CPT, OI diagnosis and treatment, pain control, nutrition Social Psychological Spiritual • Family centered approach – Track all family members status and continuum of care • • Effective linkages and/or integration of services Community buy in and mobilization Defaulter tracing Remember TB

WHO Analgesic Ladder • Accessibility & affordability • Training/ sensitisation

Cotrimoxazole • CTX and ITNs in children (Abst 1031) – CTX alone beneficial – Combination of CTX prophylaxis and ITN associated with 97% reduction in malaria in HIV positive children – No severe malaria cases seen in HIV infected kids • Malawi CTX (Abst 1668) – Among patients starting ART 40% reduction in mortality for patients on CTX – CTX should be given to all symptomatic adults • WHO guidelines issued in 2005 – All HIV exposed children until confirmed negative – All HIV positive children

Where are the Children ? • Identification of children – Need clear policy on counseling and testing, care and treatment for children • Provider initiated – Need to educate the community on the CT for children and adolescents, their rights • Health care workers need to be trained in pediatric ART and other issues • Youth involvement and support

Let Us Not Forget Children…

Innovations • Mothers 2 Mothers in PMTCT: – empowerment of women and increasing uptake in PMTCT + by using existing services

Effect of HIV Funding on Health Services (Abst 250) • General health has benefited from HIV funding – 21 of 22 services improved – 16 statistically significant, 7 attributable to HIV service • HIV services should be implemented within existing frameworks

Mukoma Health Center Patient Waiting Area Before HIV renovation work October 2006 After renovations May 2007

Rutobwe Primary Health Center Lab Before HIV renovation work October 2006 After HIV renovation work April 2007

TB/HIV Amy Bloom, Anand Date

WHO Global TB Report for 2005 (abst 1771) • 7% TB patients tested for HIV • <0. 5% of all PLHAs screened for TB

National HIV testing among TB Patients – Kenya (Chakaya) N=115, 000 in 2006

Integrated TB/HIV Hospital-Based Clinics HIV testing among TB patients • Uganda (abst 831) – 96% of TB patients tested for HIV; 33% were HIV+ – 37% of patients started ART • Kenya (abst 678) – 94% of TB patients tested for HIV; 45% were HIV+. – 100% of eligible patients started ART – 100% started on CPT (national level 87%)

Integrated TB/HIV Hospital-Based Clinics TB screening in HIV patients • In Uganda, 4835 HIV clinic patients were screened for TB; 17% had active TB (Abst 831) • In Haiti, 9% VCT clients had active TB (Abst 303) • In Rwanda, a five question symptom screening tool was developed – Of 8121 ART enrolled pts, 76% were screened – 8% had active TB Intensified case finding is key!

Improving Diagnosis of TB Among HIV-infected Individuals • Improve technical capacity (training, QA/QC) • Explore more sensitive, high volume techniques (FM) • Expand access to culture and new diagnostic methods • Consider CXR, other procedures as appropriate • Expand availability & use of sensitivity testing

MDR/XDR TB • A consequence of suboptimal TB control (service coverage, case detection, low cure rates, high rates of unfavorable outcomes) • HIV infected individuals with their increased tendency to utilize health services at risk of acquiring TB including MDR and XDR TB in health care settings • When HIV infected persons acquire XDRTB the outcomes are very poor • Inadequate Infection Control Practices encourage the transmission of TB including MDR and XDRTB

TB Infection control not happening!

Five Steps to TB Infection Control in HIV Care Setting • Step I: Screen – early recognition of cases or suspects • Step II: Educate – cough hygiene • Step III: Separate – cases or suspects in OPDs & wards • Step IV: Provide HIV/AIDS services – prompt services to reduce exposure • Step V: Investigate for TB or refer – TB diagnosis on site or prompt referral

Caring for Carers Tiffany Hamm

Innovations • Botswana has developed of a comprehensive wellness program with HIV/AIDS mainstreamed as part of a holistic approach • Training package includes: Stress management, Team building, Death and dying and Occupational health • Alternative testing approaches for HCW: – One rapid test project starting in Kenya – Pop Service International engaged for outreach VCT in Zimbabwe for HCWs • Development of a 30 minute documentary about five HIV+ health workers

Integrating Food & Nutritional Support within HIV programs Tim Quick

Country Experiences • Western Kenya ( $ 9. 9/month) – the Food by Prescription Program is providing fortified blended flour supplement ($. 30/d) and household water Tx to PLHIV patients with BMI<18. 5, PMTCT women & OVC at clinics – Nutritional assessment & counseling by trained lay workers relieves medical staff • Malawi – RUTF- Ready to use Therapeutic Food – 1 in 5 adult patients are eligible for RUTF at ART initiation, response 4 -6 weeks • Mozambique ($ 10. 8/month) – Plumpy. Nut malnourished children and for weaning – Exit at 45 days

• WHO has developed and field tested “Guidelines for an Integrated Approach to the Nutritional Care of HIV-Infected Children (6 months – 14 years)” to be integrated within IMCI and other clinical guidelines for pediatric care & Tx. – Guidelines and job aids must be adapted and integrated within country guidelines for IMCI and pediatric care. – Similar guidelines for nutritional care within IMAI to be developed for adults & adolescents

Comprehensive Care of Orphans & Vulnerable Children Teri Wingate

Key Observations Critical for understanding context of scaling up OVC support: Sub-saharan Africa is only region with increasing numbers of orphans projected through 2010. Intro for Session E 3 Source: Africa’s Orphaned and Vulnerable Generations: Children Affected by AIDS, UNICEF, 2006

Key Observations • Coordinating systems strengthening at different levels to promote awareness and strategies for action to assess and meet the needs of OVCs – International and national leadership to foster understanding of the situation of orphans and vulnerable children and mobilize action – PEPFAR-funded programs contribute to comprehensive National Plans for OVC care e. g. Uganda and Mozambique – Strengthening government partners, coordinating bodies and district level implementation is critical in providing a platform for local capacity building of organizations, community workers and volunteers supporting OVC

Key Observations – Family centered programs provide synergies and use consistent referrals to enhance continuum of care • Identify vulnerable children and provide psychosocial support to families. (abst 782 Africare East Africa), Support Groups, Sensitization, Parenting Training, Links to IGA (ANCHOR Initiative) – Volunteers need support: • RAPIDS (abst 581 Zambia) leverages significant public/private partnerships to provide transportation and “working tools” to help Volunteers deliver services. • In CORE Uganda, Volunteers coordinate services for 3 vulnerable households with an average 4 OVC each

Innovations & New Tools • New tools have been developed or adapted to assess the needs and track status and services for orphans and vulnerable children – Child Status Index (piloted Tanzania & Kenya) – Quality Assessment and Improvement tools (piloted Ethiopia) – Pictoral guides for Monitoring OVC services with non-literate people (Mozambique) – Training modules for OVC Psychosocial Support (ANCHOR) – OVC organizational capacity assessment tools (Uganda) – Mapping OVC needs & services Poster Abstract 1735 on Mapping OVC Data: (Measure Evaluation, USAID, OGAC)

Lessons Learned: Scaling Up – Extensive strengthening of communities to lead delivery and coordinating care for vulnerable children • OVC Care Committees (782 COPE project Eastern Africa) • Community Care Committees (Mozambique) • Neighborhood Care Points, Grandmothers’ Houses and Chief’s Fields (568 Swaziland) • Most Vulnerable Children Committees (629 Tanzania) • Adult mentors providing home visitation to child headed households (647 Rwanda) – Cash transfers are promising family-focused programs for OVC (1468 & 726 – Kenya, Malawi, South Africa, Zambia) • Targeting extremely poor families also reaches high percentages of HIV-affected households • No early evidence of misusing funds

IMAI • Easy, effective model for introducing HIV/AIDS treatment and care • A clinical team approach maximizing the strengths of all cadre of health care providers • Adaptation, training and roll out in Tanzania and Ethiopia • Modules need evaluation

We cannot always cure but we can always care