STATUS OF TAP IN GHANA- FAMILY HEALTH INTERNATIONAL AS AN IP

1. STATUS OF TAP IN GHANA-FAMILY HEALTH INTERNATIONAL AS AN IP

2. OUTLINE Current status of implementation Challenges Perspectives for the near future The role of operational research within TAP Clinical perspectives and challenges of PMTCT in Ghana

3. Current status of implementation  The Ghana TAP is being implemented by three partners Family Health International (FHI) National Catholic Health Services (NCHS) Private Enterprise Foundation (PEF) FHI and NCS are the main clinical implementers whereas PEF looks at the community arm of TAP and playing advocacy role

4. FHI�s Involvement in TAP June 2005, first trench of monies were deposited into FHI�s accounts July 2005, Sites assessment and accreditation were done June-July 2005, doctors, nurses, pharmacist and adherence counsellors were trained in VCT, PMTCT, OIs and ART for all the four sites

5. FHI Workplan July 2005, FHI presented a programme implementation plan up to December 2005 to the NACP. Excepts include: Sub agreements to be ready by August 2005, Training of Data Entry Clerks and laboratory personnel to be done in September 2005 ART to be started by September-October 2005 Monthly meetings by sites Quarterly reports by FHI QA/QC by Noguchi Memorial Institute for Medical Research

6. Stakeholder meetings Series of meetings were held between key actors in TAP including the NACP between September and October 2005 Discussed the role of PEF, FHI, NCS Discussed issues of cost ($30/month by employees and $5-6 by community people) FHI to support NCS with its HMIS software to make reporting easier and uniform Agreeing on regularity of meetings between IPs (quarterly) PEF and NCHS to finalize their proposals IPs to make request of ARVs on behalf of their sites from NACP Fixing a date for officially launching TAP in Ghana

7. Links with sites FHI TAP coordinator in constant touch with sites addressing issues of slow pace of TAP initiation Agreeing on how start operationalization of TAP in terms of patient flow and service delivery points and other requirements Making arrangements on where specialized services like CD4 cell counts would be done off site

8. Challenges Releasing of key staff to attend capacity building programmes for more than one week was very challenging for private institutions. There is need to always negotiate for dates appropriates for all sites Developing the sub agreements requires intensive imputes from the sites and this takes time as the document will have to travel to and fro before it is finalized Finalizing Sub agreements at FHI Head Quarters to meet all the technical and programme requirements delayed for about 3 months (August- October 2005)

9. Challenges The final document again has to be securitized by site managers before they finally sign and this also takes some time The type of bank account required for the TAP was not what some site presented and they have to open separate accounts for TAP. This also took some time Procurement a per World Bank rules requires about three quotes from sites and some sites are slow on this process

10. Progress so far Monies have been transferred into the accounts of sites Some laboratory equipments have been procured and installed by FHI awaiting other equipments from NACP Computers and accessories have been procured and HMIS has been installed Clinical folders to capture data have been adapted from other FHI sites and modified slightly, printed and supplied to all TAP sites

11. Progress so far In November 2005, All the four sites in the Greater Accra Region and Ashanti Region, have been mentored at the FHI district and Teaching Hospital Sites involving all critical elements of a multidisciplinary team: Doctors, Nurses, Pharmacist, Laboratory Technologist, Adherence counsellors, Data entry clerks, HIV counsellors etc The mentoring as a process will continue through implementation at their sites until sites are confident to managed their own programmes with FHI only playing monitoring and supervisory roles making sure National standards are met

12. Perspectives for the near future Sites to successfully become fully operational before January ending after building a solid system TAP duly launched in Ghana in early January 2005 FHI to use its vast experience in community HIV/AIDS programming to mobilize local communities to increase demand and patronize TAP services by implementing a Strategic Behaviour Communication to complement PEF which deals with advocacy for employers/companies Experience sharing fora by sites and IPs

13. The role of operational research within TAP Looking private-public partnerships in the context of ART Effect of differential pricing in ART services at TAP sites Exit interviews/ surveys to measure service quality and also access adherence of those on ART Review clinical data collected to know the dynamics of the clients we seeing and also have information on how clients are responding to treatment in both adults and children VCT/PMTCT services in the private sector Resistance monitoring of treatment na�ve and treatment experienced patients Other clinical trials of national and global interest

14. Clinical perspectives and challenges of PMTCT in Ghana 

16. AIDS in Ghana The first AIDS cases were reported in Ghana in 1986. New cases 2004 - 14,312 (IDSR) Current estimates put the number of AIDS cases in Ghana to about 200,000. The median HIV prevalence was observed to be 2.4% in 1994 and has increased through 3.6% in 2003 to 3.1%in 2004. The first AIDS cases were reported in Ghana in 1986. By the end of December 2003, a cumulative total of 76,139 AIDS cases had been officially reported. Current estimates, however, put the actual number of AIDS cases in Ghana closer to 200,000. Ghana�s HIV prevalence median HIV prevalence was observed to be 2.4% in 1994 and has increased to 3.6% in 2003. According to the UNAIDS/World Health Organization (WHO), any nation with an adult HIV prevalence of 1% or higher in the general population is characterised as experiencing a generalized epidemic. The first AIDS cases were reported in Ghana in 1986. By the end of December 2003, a cumulative total of 76,139 AIDS cases had been officially reported. Current estimates, however, put the actual number of AIDS cases in Ghana closer to 200,000. Ghana�s HIV prevalence median HIV prevalence was observed to be 2.4% in 1994 and has increased to 3.6% in 2003. According to the UNAIDS/World Health Organization (WHO), any nation with an adult HIV prevalence of 1% or higher in the general population is characterised as experiencing a generalized epidemic.

17. Sites offering Antiretroviral therapy, Public Health sector Manya Krobo -June 2003 St Martin des Porres Hospital, Agomanya Atua Government Hospital Korle Bu� Dec 2003 Komfo Anokye� Feb 2004 Koforidua- August 2005 TAP sites to join very soon as private sector contribution to ART role out

18. VCT services 110 accredited sites in 73 districts GFATM, DFID,, Special support from Dutch Government All 34 sites in Ashanti region 17 in Eastern region

19. PMTCT 103 sites 73 districts Special support from Dutch Government All 34 sites in Ashanti region 17 in Eastern region

20. Voluntary Counselling and Testing

21. VCT services June 2003 to June 2005

22. Prevention of Mother To Child Transmission

23. Key Accomplishments by the START program at Manya and KBTH SITES 5,346 women have received VCT through PMTCT services since 2002 528 nurses and 46 lay people have received PMTCT/VCT counselor training 207 HIV positive women have received NVP during delivery at the PMTCT hospitals 219 babies have received NVP syrup at the hospitals These sites have become sites of excellence and used as learning sites for National Training Programmes

26. Challenges A diminishing number of women seen at each stage (so few of the HIV+ women receiving NVP at delivery and one is uncertain whether or not their babies are not receiving NVP syrup Supervisory and monitoring procedures at clinic Service quality There are no full time counselors in the hospitals except one in Atua. Counselors share their time between their normal duties and VCT service provision.

27. Challenges VCT services are not yet strongly linked to other social services e.g. social welfare and support, legal services, peer group support, PLHA support groups Disclosure and Partner Notification Payment of delivery services by HIV positive mothers at health institutions Infant feeding difficulties leading to babies becoming infected Early diagnosis of HIV infection in children problematic

29. Lessons Learnedso far with pmtct Involvement of key stakeholders both at the national, regional and district levels ensure smooth running of the program as well as help promote the use of services. Due to shortage of staff, all cadres of health care workers need multi-skills to provide range of services. Training all midwives within the facility setting in PMTCT helps minimize disruption of program when staff are transferred out of the district or when they leave the service. This strategy is particularly helpful in settings where shortage of health personnel is a major problem. Frequent updates of knowledge and skills of health workers are necessary to ensure quality of care Health management information system has to be developed at the very onset of the program and staff trained in its use to ensure proper capture of data and timely reports

30. Policy change in the pipeline for PMTCT in Ghana---FHI Senior Clinical Officer Charged with providing evidence (literature review) Sd Nevirapine is still the best option for up-scaling PMTCT services However, we know combination therapy is better than monotherapy ART is being up-scaled and it will be �CRIMINAL� to continue to give monotherapy in centers where full range ART can be or are being delivered