STI Services

In FY06, the prevention and control of STI was implemented by PEPFAR Ethiopia in collaboration with the MOH and WHO. Some of the major accomplishments during this period include, support to the revision of STI guidelines, development of STI training materials, training of providers and production of job-aids.

During COP07, I-TECH will support expanded access to STI prevention and treatment services and improved quality of STI services at 31 I-TECH supported ART sites in its working regions (Amhara, Tigrai and Afar). Prevention of STI among the general population, most vulnerable groups, and people living with HIV/AIDS is a critical activity in preventing new HIV infections and slowing the pace of the epidemic.

At the regional level, I-TECH will work with Regional Health Bureaus to facilitate and coordinate linkages between STI and HIV/AIDS services, and strengthen external referral linkages between hospitals, health centers, and CSO, FBO and PLWHA Support Groups and Associations. Regional linkages will be supported so that patients who do not respond to syndromic STI management at health center level are referred to hospital care.

At the facility level I-TECH will support provision of quality STI services at 31 public and private hospitals in Amhar, Tigrai and Afar Regions While most people with STI symptoms will seek care at the health center most geographically convenient, there are many who seek all aspects of primary care at hospital level, as they are located in urban areas, and as well, HIV-infected persons receiving palliative care and/or ART at Hospitals are also at risk for STI and require focused STI services at these facilities. Specific activities will include: (1) Needs assessments at all supported hospitals in collaboration with RHB, followed by joint action planning with facility staff to improve STI services and linkages between STI and other services (counseling and testing, care and treatment, ANC, etc.); (2) Provision of on-site technical assistance to improve STI diagnosis and treatment following national syndromic management guidelines; (3) I-TECH will train 200 providers (physicians, nurses etc) on STI prevention, diagnosis, and treatment, with a focus on links between STI and HIV infection, as per national guidelines; (4) Training of facility-based peer educators on STI prevention and treatment for and their partners, as well as community education regarding the STI symptoms and the need to seek care; (5) Linkage with Global Fund and USG-funded partners to ensure adequate supplies of STI drugs at all facilities; (6) Linkages to HIV counseling and testing (C&T) services, promoting a provider-initiated, opt-out approach, for all STI patients, and linkages to care and treatment services for those who are HIV-infected; (7) STI education focused on risk reduction, screening, and treatment for patients enrolled in HIV/AIDS care and treatment at the hospitals, including PMTCT services; (8) Provision of condoms and education on usage, to patients enrolled in care and treatment, with a special focus on most at-risk patients/populations. STI services will also be integrated into antenatal and PMTCT services to ensure that all pregnant women are educated on STI and if necessary treated, and are educated in STI prevention during pregnancy (according to national STI management and antenatal care guidelines); (9) Linkages to community-based organizations that promote risk reduction and HIV/STI prevention and early/complete treatment in communities surrounding I-TECH supported ART sites; and (10) Supportive supervision and mentoring of clinical providers on STI services and STI/HIV linkages by I-TECH Clinical Advisors.

None provided.

Table 3.3.05:

Palliative Care

This is a continuing activity from FY06. This activity is programmatically linked to the following: access to home water treatment and basic hygiene counseling (# 6630), promote positive living and self reliance for HIV/AIDS affected beneficiaries of urban nutritional support program (# 1061), HIV/TB at hospital level (# 5751), regional PMTCT implementation support - hospital level (Amhara, Tigray and Afar # 5639), Technical support for ART scale up (# 5658).

In FY06, I-TECH introduced a basic palliative care approach to the 31 ART facilities it supports. This included initial assessment of the palliative care mechanisms at site, development of training in collaboration with the national lead, and supervision of palliative care activities. Training and supervision focused on identifying pain and discomfort among patients, and ensuring cotrimoxazole prophylaxis, TB screening and targeted elements of the preventive care package such as multivitamin use, nutritional assessments and prevention for positives. This program was introduced to hospitals in Amhara, Tigray and Afar regions (Operational Zone 1).

In FY07, I-TECH will support palliative care activities at 35 hospitals providing HIV/AIDS care and treatment via a multi-disciplinary, family-focused approach to provision of the preventive care package for both adults and children. It will incorporate best practices for the prevention of OI in PLWHA, to slow disease progression, and reduce morbidity and mortality.

I-TECH will assist 32 hospitals in Operational Zone 1 to provide the preventive care package, complementing Global Fund, MOH, and other PEPFAR Ethiopia activities when possible. I-TECH will focus on provision of the preventive care package, which for adults includes: active TB screening, cotrimoxazole prophylaxis, symptom management, micronutrient (multivitamin) and nutrition supplement and counseling, insecticide coated mosquito nets, positive living strategies, HIV counseling and testing of family members and contacts, and improving safe water usage through provision of safe water vessels at all I-TECH supported hospitals. The preventive care package for children includes: prevention of serious illnesses like PCP, TB and malaria; prevention and treatment of diarrhea; provision of nutrition and micronutrient supplements; and referral to national childhood immunization programs. OVC will be prioritized for palliative care and linked to other OVC care programs to receive a continuum of care.

I-TECH will work closely with other university partners to ensure complementary of activities, with UCSD, for example, on implementation of national pain management guidelines. More details on the delivery of these aspects of the preventive care package are outlined below.

I-TECH support to facilities will be continued or expanded as follows: (1) strengthen the internal and external linkages required to identify HIV+ individuals and provide them with access to care (internal linkages include referrals to the HIV/AIDS/ART clinic from ANC, TB clinic, under-5 clinics, inpatient wards, OPD, and VCT, and external linkages include referrals to and from community-based resources providing counseling, adherence support, home-based care, and financial/livelihood and nutritional support; (2) provide on-site implementation assistance, including staff support, implementation of referral systems and forms, and support for monthly HIV/AIDS team meetings to enhance these linkages; (3) provide training on palliative care and the preventive care package to multi-disciplinary teams; (4) provide clinical mentoring and supervision to multi-disciplinary teams related to the care of PLWHA -- including those who do not qualify for or choose not to be on treatment -- in partnership with RHB in the respective regions; (5) continue to develop and distribute provider job aids and patient education materials related to palliative care and positive living ; (6) identify and sensitize community-based groups on palliative care and the importance of adherence to both care and treatment for PLWHA and the palliative care services available at the facility-level; (7) improve nutrition assessment at health facilities; (8) promote intervention (pharmacologic/opioids and non-pharmacologic) to ease distressing pain or symptoms; (9) continue patient management after hospital discharge if pain or symptoms are chronic; and (10) link patient with community resources after discharge.

I-TECH's activities will promote OI prophylaxis and treatment in accordance with the national guidelines. Appropriate use of cotrimoxazole prophylaxis (pCTX), an essential element of care for HIV+ adults and children, and for HIV-exposed infants, will be an important component of I-TECH's implementation activities, especially at those sites not yet providing ART. I-TECH will ensure that all supported sites have reliable stocks of cotrimoxazole tablets and syrups, and will provide emergency supplies when absolutely necessary to ensure quality and continuity of care. Similarly, TB screening and isoniazid prophylaxis will be promoted and provided for HIV+ adults and children. (See also the section on TB/HIV activities.) Supportive supervision and institution of standard operating procedures will improve the use of cotrimoxazole and INH prophylaxis. Attention will be given to the issue of HIV/malaria co-infection, and to routine provision of impregnated bednets, at minimum, to pregnant patients in HIV/AIDS and PMTCT programs in collaboration with Global Fund.

Health education and behavior change communication for HIV+ individuals will be provided by facility and lay staff, complementing Global Fund and other USG-funded activities. Patients will have access to nutrition counseling and multivitamins. With guidance from JHU, the university lead for hospital-level nutrition, "therapeutic feeding-by-prescription" of patients who qualify based upon criteria agreed with PEPFAR Ethiopia (e.g. HIV+ pregnant or breastfeeding women, HIV exposed or infected infants who are no longer breastfeeding, malnourished patients) will be provided in at least five hospitals. Clear criteria will be established for patient selection, and an exit strategy developed as part of all initiation of therapeutic feeding support. Health education, counseling, and support will encourage positive living to forestall disease progression, promote prevention among positives to prevent further transmission of HIV, and strengthen adherence to both.

I-TECH operational zones are endemic for Kala Azar, which poses significant challenges to the management of both diseases. Therefore, I-TECH will perform a situation analysis on the extent of Kala Azar infection among patients enrolled in HIV care and treatment, disseminating and using results to improve program strategies and clinical services.

None provided.

Table 3.3.07:

Technical Support for ART Scale-up

This is a continuing activity from FY05 and FY06 and relates to activities in Counseling and Testing (5639), TB/HIV 5751), Palliative Care (1057), PMTCT (5639), STI Services (1035) , laboratory Infrastructure (New) as well as activities implemented through the Twinning Initiative (5678).

I-TECH has played a critical role as the lead for training activities and has supported implementation of ART in Operation Zone 1. It is currently on track in meeting targets for COP06.

Following Ethiopian national guidelines, I-TECH supports development and expansion of full-spectrum, comprehensive hospital-based ART programs. In FY07, at the national level, I-TECH, will continue to work with its USG partners and the MOH in the lead role of ART training activities including curriculum review and development, advanced nurse practice training, and certification. I-TECH will support the Ethiopia Nurses Association (ENA), the universities, schools of nursing and federal and regional hospitals to build the nursing capacity required to provide ART nationwide. In collaboration with partners and building on developments in FY06, I-TECH give to an established advanced nurse practitioner (ARNP) to incorporate specialized HIV/AIDS an ART training in FY07. I-TECH will augment the ARNP faculty by organizing local and international lecturers on HIV/AIDS care and treatment sessions.

I-TECH will train an additional 200 ART HIV/AIDS Nurse Specialists in 2007, working closely with MOH, MOE and HAPCO to certify these nurses for initiating ART hospitals and health centers. It will also alone to have train and certify 40 additional TOT. 374 physicians, nurses and pharmacists will be trained in advanced HIV issues. I-TECH will provide periodic entry level training for the provision of ART, VCT, PMTCT and STI. In addition to this training, ART modules for pre-service training will be prepared in collaboration with major universities sites within the I-TECH region (i.e. Gondar and Mekele) and supported.

Advanced training for ART clinicians will continue through an ongoing relationship with Hadassah Medical Center in Jerusalem, Israel. This advanced training has proven very valuable for Ethiopia ART practice and the development of ART expertise. In addition, multi-disciplinary training will be expand to key programs that have a high level of HIV seroprevalence including the VCT, PMTCT and TB programs. In COP07, the training with Hadassah will target nurses from health centers.

In collaboration with the MOH and PEPFAR Ethiopia partners, I-TECH will develop curricula for refresher courses in ART practice to address major changes in treatment, follow-up and adherence as well as region specific co-morbidities such as Leishmaniaisis in some of the western regions of Amhara and Tigray. It will also develop standardized provider reference tools and patient materials.

In FY07, I-TECH will continue its established partnerships expand to 35 ART sites. I-TECH's priorities will be direct site level support, mentoring, training, quality care, private sector expansion and pediatric care. It will provide intensive technical support to all 35 hospitals in Amhara, Tigray and Afar regions. A team comprised of a physician coordinator, lab technician, program assistant and data manager will be created for each of I-TECH's three regions. These teams will work in close collaboration with the RHB, the I-TECH headquarters in Addis Ababa and its roving clinical support teams.

I-TECH field based teams site mentors (physician and nurse) will regularly visit its regional ART sites to provide guidance to the clinic, laboratory and pharmacy; identify training needs; provide mentoring and case consultation; and address barriers to efficient and effective care. These mentors will be part of a regional ART team for each of the three regions. The ART team will work in close collaboration with the RHB and report to the I-TECH medical and country director.

I-TECH will expand pediatric treatment to Dupti in Afar. I-TECH will provide assistant establish a family-centered treatment and care model. Further it will enhance PMTCT effectiveness, strengthen pediatric case finding and referral to care and treatment

services, promote comprehensive care and treatment services for HIV exposed infants and for HIV+ infants and children, increase access to pediatric ART, and increase availability of infant HIV diagnostics. In short it will advance a comprehensive care package.

In FY07, I-TECH will continue to strengthen linkages entry points to among counseling and testing services, ANC and PMTCT programs, TB clinics, under-5 clinics, and adult and pediatric inpatient wards, family planning, TB/HIV, STI, and other palliative care services. On-site assistance will be provided to develop medical records, referral linkages, patient follow-up and adherence support defaulter tracing mechanisms systems. Integration of prevention into care and treatment, involvement of PLWHA will be ongoing commitments. Sites will be supported to establish standardized HMIS, data management, and M&E to guide quality improvement. Site renovations will be the responsibility of RPSO.

I-TECH will assist ART health networks to follow standardized clinical procedures and work with the local universities to establish inter and intra required coordination mechanism. I-TECH will strengthen the two demonstration sites at Gondar and Mekele Universities to be used as a venue for training and clinical apprenticeships for health providers in the Amhara, Tigray and Afar Regions.

In COP07, particular focus will be given to strengthen associations of PLWHA and involve their members in HIV/AIDS program activities. I-TECH will (1) support PLWHA involvement in the Treatment Working Groups, (2) Work closely with the Network Association of Ethiopians Living with HIV/AIDS to foster their greater involvement, (3) build the capacity of NEP+ in program management and implementation, (4) hold a national PLWHA involvement workshop and national peer educators review meeting, (5) expand to IZ hospital networks, the peer educator program piloted in four ART Hospitals in COP06 and (6) provide assistance in Oromia, Somali, Dire Dawa, and Harari to involve PLWHA as case managers and peer educators.

HIV Treatment and outreach needs of young married women

A very small proportion of the pregnant women offered HIV counseling and testing in hospital-based PMTCT settings in Ethiopia in FY 2005 accepted the service, resulting in a significant missed opportunity for HIV prevention. Informal polling of PMTCT clinicians suggests that clients' fear of stigmatization if identified HIV-positive and misunderstanding regarding the potential for prevention of HIV transmission are important reasons for low uptake. Qualitative data solicited from focus groups could uncover reasons for low PMTCT uptake not previously considered as well as suggestions for framing the messages given to clients by PMTCT counselors.

The evaluation question will be: What are the reasons for low uptake of HIV counseling and testing in hospital-based PMTCT sites in I-TECH's focus regions of Tigray, Amhara, and Afar?

Two hospital-based antenatal care clinics offering PMTCT service in I-TECH's focus regions will be selected on the basis of a history of low PMTCT uptake and high HIV seroprevalence among antenatal care attendees. Pregnant women seeking antenatal care at these two sites will be recruited to participate in focus groups. Focus group discussions will solicit opinions about HIV testing, potential reasons for refusal and acceptance, and other themes that might have bearing on the reluctance to accept HIV counseling and testing. Key themes from these focus groups will be identified and conveyed to PMTCT counselors in the form of suggested themes to highlight when discussing HIV testing with their clients. Participation in focus groups will be voluntary, and take place in private settings where they cannot be overheard. No names or identifying information on any of the participants or participant records will be recorded to assure confidentiality.

The population of interest will be pregnant women seeking antenatal care at hospital-based PMTCT sites in Tigray, Amhara, and Afar.

Funding will be for salaries and training for 2 field-based evaluation coordinators/focus group leaders; regional travel to sites for recruitment activities and conducting focus groups; participant stipends; technical assistance from Addis-based I-TECH Ethiopia and I-TECH/University of Washington staff; miscellaneous supplies.

Site-level laboratory Support

In 2007 I-TECH will assume the responsibility of supporting laboratories at all hospitals, health centers and regional labs to provide technical assistance, and refresher trainings for all staff. This approach will consist of problem-solving for the various issues that hamper capacity development and quality assurance in all 131 hospitals and additional regional laboratory sites. To accomplish this charge I-TECH will add a laboratory expert to each of its three Regional ART teams to work in collaboration with the primary laboratory expert who was employed in 2006 and works at the main offices of I-TECH. Duties of these new staff positions would include: (1) Assess the level of training needs for each laboratory for both primary and update training; (2) Provide routine instruction for specific testing required for ART implementation and monitoring (i.e. CD4; chemistry; hematology; liver function) as well as more regionally required testing such as viral load; (3) Complement the expertise and capacity building by the PEPFAR Ethiopia and EHNRI (4) Identify and address issues that create barriers to providing ART care and follow up of treatment such as periodic CD4 testing. (5) Troubleshoot laboratory problems such as maintenance of equipment, supplies of reagents, handling and transportation of specimens; routine reporting; adherence to laboratory quality assurance protocols; addressing bio-safety issues; staff turnover for needed training; develop the proper liaison with the key laboratory experts at the regional and national levels (MOH; EHNRI); and to notify the central I-TECH offices in situations where additional national or international expertise might be required (such as the American Society of Clinical Pathologists) (6) Visit and provide technical assistance to site laboratories. The support will also include laboratory management, internal re-organizational lab set up, specimen management, test procedures, documentation, reporting, and inventory management. The services will also support inventory and stock management of laboratory supplies at each health facility (7) Understand the laboratory testing and training needs of those ART and ancillary programs such as TB, STI and HIV testing in order to identify, supply and advocate for the technical assistance needed within those laboratory components (8) Support regional laboratory trainings including HIV serology-rapid test, CD4, hematology/chemistry, TB smear microscopy and OI diagnosis. A total of 100 laboratory personnel will be trained in collaboration with regional laboratories.

These responsibilities will expand I-TECH's capacity to provide a much more site-specific approach to all of its 35 hospital networks in its three regions. These additional staff positions also fit in to the model of the regular physician/nurse clinical teams that will routinely (at least twice a month) visit the hospital sites in each region. In addition the lab technical expert will be expected to work as a liaison with the newly initiated health center staff that are, or will be, initiating ART treatment.

I-TECH will technically assist in referral laboratory services; specimen collection at health centers or peripheral hospitals and transport to next hospital laboratory and/or regional laboratory for diagnosis and monitoring ART. Technical support will be provided in specimen collection, transportation, patient sample tracking, reporting of results and implementing standard guidelines/procedures are followed.

This expanded laboratory expertise will strengthen the public health laboratory system within each region as well as assist in the overall ART scale up by reducing the barriers found some laboratory sites.

Site Level Data Support

This is a new activity for FY07. This activity relates and linked to other program areas including Counseling and Testing, TB/HIV, palliative care, PMTCT in addition to ART services in Amhara, Tigray and Afar regions. This activity will also be strengthening the implementation of the national HMIS.

The MOH has established a chronic disease record-keeping system for the national ART program. Standardized tools include intake and follow up forms, pre-ART and ART registers, monthly cohort analysis and reporting forms among others. The national ART monitoring and evaluation system provides the means to collect data in a standardized manner. However, data at site level is currently under-utilized.

The ART program would be strengthened further by increasing the capacity of treatment-providing hospitals, RHB and regional universities to collect, manage, analyze and utilize ART-related data generated at site level for decision making to improve clinical and program management.

PEPFAR Ethiopia will expand provision of comprehensive HIV/AIDS services to 131 hospital networks in FY07. Despite the rapid expansion of HIV/AIDS services all over the country very little attention was given to systematically analyzing, documenting and sharing the information by and with stakeholders at all levels (i.e. health care personnel at facilities, health managers at the zonal and regional levels). Consequently, limited information is available on the quality of services, barriers to utilization of services, and best practices in PMTCT, HCT, TB/HIV, palliative care and ART services.

UW/I-TECH will support Tigray, Amhara, and Afar to assess and monitor HIV/AIDS services coverage, quality and supporting processes. In addition, I-TECH will support development of data collection systems streamlined to capture required data for calculation of standard indicators.

Institutions will be supported to fully and effectively manage and use the data. Sites will be assisted in appropriate ways to tabulate and visualize their data such as through the use of GIS, tables, charts, line and bar graphs and other standard methods. Appropriate options for tabulation include aggregation of data by patient, clinic and regional levels.

Specific activities include training of health care providers at facilities in basic computer skills and data management which includes data entry, data analysis, technical paper writing and presentations, and the provision of technical support. The support will include bi-annual regional review meetings which will serve as a forum where facilities will present their data and share experience. The support to the sites will strengthen the national M&E system the MOH/HAPCO and regions are developing with other PEPFAR Ethiopia funds.

I-TECH will also support documentation of best practices from sites and presentations of findings and experience both at local and international scientific and programmatic forums.

Implementation mechanisms for this activity will include providing the necessary modeling at site and RHB levels within I-TECH regions.