Community Systems Strengthening for Improved HIV Care: The Uganda Experience

1. Dr. Ario Alex Riolexus, STD/ACP – Ministry of Health, Uganda 24th July 2014 TASO Satellite Meeting, 20th International AIDS Conference, Melbourne – Australia Community Systems Strengthening for Improved HIV Care: The Uganda Experience

2. Uganda HIV Context • After over a quarter century, HIV epidemic in Uganda is still severe and generalized. • Current estimates of HIV prevalence is at 7.3% in adults but with marked geographical, socio-demographic and socio-economic heterogeneity. • Burden: About 1.5 million adults and children in a population of 35 million. • New infections:124,000 in 2009, 130,000 in 2010, 145,000 in 2011, 130,000 in 2013 • 60,000 annual mortality

3. Uganda HIV Context Cont: • Scale up of ART using a public health approach in 2004 • Number in need of ART at 500 CD4 – 1,405,000 (1,207,000 adults and 193,000 children) • Current No. on treatment – 600,000 • Retention after 12 months of ART initiation – 86% • Adherence to ART at 95% and above - 91%, • LTFU – 18.5% • 96.8% are on 1st line ARV regimen; 3% are on 2nd line; a small percentage is on 3rd line

4. The National HIV Response • Appropriate policies • Multi-sectoral response with broad based stakeholder involvement • NSP • Decentralisation policy • MoH Sectoral Policies and Guidelines • National Health policy • HSSIP • The Client Charter • Public Private Partnership Policy • ART , eMTCT, HCT, HBC Policies, Adherence Strategy etc • National Prevention Policy

5. The National HIV Response Cont: • National Development Policy • Financing ARV procurement • Decentralisation of ART to lower level HF • Political commitment • eMTCT campaign – 1st Lady is Champion • The President and 1st Lady openly undergoing HIV Testing • HIV Trust Fund

6. What is Community Systems Strengthening? • An approach that promotes the development and sustainability of communities and community organizations and actors, and enables them to contribute to the long term sustainability of health and other interventions at community level.

7. Background to Community Strengthening - 1 • Experience from community based organisations and lessons learnt • The rapid scale up of ART using a public health approach posed health systems challenges • The medical paradigm for control of the HIV epidemic was stretched to the limit in Uganda, where institutional and human resources were inadequate for the large numbers seeking care. • This called for task sharing and skills transfer

8. Background to Community Strengthening - 2 • NHP and HSSIP recognises the role community plays in health delivery but notes its current weaknesses • Understanding the cause of weakness in a system is the first step towards recognising the solution • HSR of the HIV national response revealed serious gaps in all health systems building blocks

9. Background to Community Strengthening - 3 • Recognition of the role of community systems in the whole HIV treatment cascade • Strengthening the community system and using PLHIV as part of the solution to the workforce needs to bridge the gap for a better national response • Grant proposal funding requirements

10. Institutions with improved Community – Facility Linkage • Infectious Diseases Institute (IDI) • The AIDS Support Organization (TASO) • Joint Clinical Research Centre (JCRC) • Mildmay Uganda • Reach Out Mbuya • Northern Uganda Health Integration to Enhance Services (NUHITES) and STARs • EGPAF • SUSTAIN • Uganda Cares, Mama’s Club, M2M etc • VHTs in Public and PNFP Facilities

11. Program approaches to Strengthening Communities A- Family-Centered Care: offering care and support to meet the needs of the entire family • Using the Chronic Care Model • Using Mother Baby Care Point • Using the Male Involvement Strategy

13. The Chronic Care Model • The Chronic Care Model, depicted above emphasizes a patient-centred approach to handling chronic conditions, with the Community, Family, Health System and favourable policies all contributing to a patent’s wellbeing and health. • The core triad of Patients and Families, Community Partners, and the Health Care Team is the cornerstone of chronic care.

14. The Chronic Care Model • The three-tiered Uganda Chronic Care Model encompasses Patients and Family, Community Partners and Health Care Teams and focuses on a patient-centred approach helps programs control costs by enabling appropriate use of self-care and low-cost services based in the family and community. • The model also emphasizes a proactive approach to anticipated care needs.

15. Mother Baby Care Point • The mother baby care point is an improved service delivery model to optimize retention and adherence, EID uptake, and appropriate transitions for mothers and exposed infants • Keeps mother-infant pairs together at one "care point" through 18 months post-partum and beyond • Minimizes the number of transfers for the pair

16. MBC Service Delivery Model Community Systems: FSG, Peer Mothers, Community Follow up MCH Service Point HIV Negative Infants at 18 months Negative infant discharged Antenatal Care for Mother Mother - Baby Care point (post natal) Mother referred to treatment clinic • Routine ANC care • HTC, risk reduction counseling, condoms, & couples HTC • ART initiation & management for HIV+ pregnant women • ART for already enrolled HIV+ Postnatal mothers • ART for newly diagnosed HIV+ postnatal mothers • Family planning • Routine PNC including Immunization, well child services, EID & care for HEI up to 18 months • ART for all HIV+ infants through 18 months HIV Infected infants at 18 months Positive infant and mother referred to treatment clinic HIV Treatment Clinic Pregnancy Postpartum / Breastfeeding Period 18 months postpartum Ongoing care & support

17. Program approaches to Strengthening Communities B- Comprehensive Care: providing holistic care for people living with HIV/AIDS, TB, sexually transmitted infections, and other opportunistic infections. • National Adherence Strategy • Treatment Supporters • Expert Clients

18. Program approaches to Strengthening Communities C- Service Linkages: leveraging locally available existing resources, training health workers and improved reporting. • Linkage Facilitators • Peer Mothers/Fathers • PLHIV Networks • Village Health Teams (VHT) • Family Support Groups (FSG) • Home Visiting by Health workers • Effective referral system • mTRAC, DHIS2 • MARPs strategy

19. Program approaches to Strengthening Communities D- Sustainable Approaches: strengthening existing CSOs and increasing their capacity to mobilize and manage resources. • Civil Society Fund • Enhanced planning capacity of CSOs • Local generation of revenue by CSOs • Increased support to CSOs by government • Encouragement of formation of indigenous NGOs – TASO, Baylor Uganda, IDI, Mildmay, Mama’s Club etc

20. Program approaches to Strengthening Communities E- Fostering Partnerships: promoting partnerships at all levels—local, regional, national, and international. • Representation of CSO and ADP in TWGs, PC, HPAC • Partnership Committee • East African Community • Partnership Frameworks with International Agencies • JRM, JAR, NHA • GIPA • MoU with Implementing Partners

21. Otherapproaches to Strengthening Communities 1- Demand Creation and Advocacy: promoting uptake of services and improved lobbying for service provision and allocation of resources and accountability. • Consumer advocates – CHAIN, PLHIV Networks • CSOs – ICWEA, UGANET, NAFOPHANU, UDN etc • Parliamentary Committee on HIV/AIDS • Tailored campaigns – eMTCT, HTC, WAD etc

22. eMTCT Campaign

23. Other approaches to Strengthening Communities 2- Improved Communication: promoting uptake of services, linkage and referral. • Mobile phone text messaging as a reminder tool for promoting adherence to ART • Availability of many telecommunication companies – MTN, Airtel, Orange, etc • Booklets on HIV for political and cultural leaders • Use of local FM radios

24. Other approaches to Strengthening Communities 3- Capacity Building: improving the capacity of the community to respond and participate meaningfully in HIV care. • Mentorship programs for service providers at all levels • Leadership and technical training of CSOs and service providers • Fellowship Program at MUSPH • CSS Activity funding – GF, PEPFAR, Irish AID etc

25. Other approaches to Strengthening Communities 4- Quality Improvement: improving the quality of HIV care using simple proven quality improvement models. • National Quality Improvement Framework • Formation of Quality Improvement Teams in all health facilities • Inclusion of Expert Clients and CSO representatives at Health Facility Quality Improvement Teams

27. I Thank you