International Center for AIDS Care and Treatment Programs

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2007 ICAP Annual Meeting
Providing integrated HIV care at Health
Centre Pietro Di Mattei Mozambique 03/10/2007
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Nampula
Zambezia
Inhambane
Provincial capital
Gaza
Maputo
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Where we work

• National referral hospitals (2)
• Provincial hospitals (4)
• General hospitals (5)
• Rural hospitals (7)
• Health centers (15) 45

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Mozambique National Program

• First ART facility in 2003 - specialized service
  (Day Hospital)
• Revision of national program concepts/approaches.
  
• Expansion and integration
• Rapid expansion of MoH National Program in 2006
  from 47 ART providing facilities in Jan/06 to 179
  in April/2007
• National Policy integration of services
• All criteria for a facility to meet in order to
  provide ART were abandoned
• The provision of ART to one patient equivalent to
  opening of site, objective met

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Rationale for decentralization

• Coverage . Bring service closer to patient
• Integration into PHC system
• Decongestion of oldest major facilities reaching
  capacity limit (hospitals)
• Transition of major facilities to training and
  reference centers

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HIV care integrated at Health Centers - Needs -

• Assessment (Structure, HR, training needs, etc)
• Create an equip, define tasks
• Reorganize the utilization of existing physical
  space
• Add tasks to existing staff/recruit additional
  staff
• Establish a rational flux of patients

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HIV care integrated at Health Centers - Needs -
(2)

• Involve all staff from Health Centre (TB,
  Emergency Room, ANC)
• Train (formal and on the job)
• Supervise regularly

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HIV care integrated at Health Centers -
Challenges -

• Human resources scarce - workload motivation -
  one doctor
• Infrastructure lack of space, privacy
• Poor lab capacity
• Resistance to provision of ART
• Existence of specific HIV ME tools
• Resistance to fill forms/file

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HIV care integrated at Health Centers-
Challenges - (2)

• Different policies in one pharmacy
• Few OI drugs available erratic supply
• Existence of illness management tools not
  including HIV and ART
• National policies on distribution and
  prescription levels
• CD4 emphasis. Final objective ART
• Management of severe toxicities

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Major Urban Areas

• The first-opened Day Hospitals are saturate
• Many patients followed up at this structure do
  not need a specialized service
• The congestion prevents bigger number of patients
  to be enrolled or creates waiting lists
• Need to decentralize selected patients from each
  Hospital to its Health Centers

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Urban area Satellite sites

• Inhaca and Catembe Health Centers under the
  direction of two General Hospital in Maputo
• Special features
• Geographic location (link to Maputo by boat)
• Difficult access to hospital services in Maputo
  City (transport fee and time constraints)
• Comprehensive package of services is offered with
  ICAP support (ART included)
• Easier access
• Less expensive
• Reduce risks for poor adherence

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Urban areas Health Centers in town

• Experience with two health centers in Maputo and
  Quelimane and plans of expansion
• What is the idea
• Health Centers as entry point for HIV patients
• Establishment of criteria for referral/contra-refe
  rral with specialized services (DH)
• Integration of Health Centers in MoH lab/supply
  network
• Decentralization of patients enrolled at DHs
  (patients in care, stable patients on ART)

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HIV care at Health CentersLessons learned

• In a first phase close supervision and support is
  fundamental
• An equip training involving all staff is very
  useful
• Key role of a receptionist
• Space needs to be rearranged/increased to allow
  for counselling activities to be done
• HIV test can be introduced in all consultations
• Introduction of extra forms needs to be limited
• The whole health centre can benefit from
  integration of HIV care

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HIV care at Health CentersLessons learned (2)

• An additional PHC site doesn't mean lot of
  additional patients
• Impact on program
• Need to adapt the support
• Differentiated HR policy for staff attending HIV
  not possible
• Functional integration

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Points for discussion/Future challenges

• What is the lower limit of site support we can
  consider as acceptable?
• Reduce presence vs increase staff
• Targets/Expansion/Quality
• Criteria for graduation
• Graduation and counting patients

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Anchilo Health Center
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Malema Health Center
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THANK YOU