Country Presentation Nigeria

1
Country Presentation Nigeria
International Center for AIDS Care and Treatment
Programs Annual Meeting, March 2006 Dar Es
Salaam, Tanzania

• Dayo Adedoyin
• Bola Oyeledun
• Austin Ndulue

2
Country Profile-Nigeria

• Current population estimated to be 116.9 million
  (NPC).
• Made up of 36 states including a federal capital
  territory
• Has 774 Local Government Areas (LGA).
• Sates grouped into 6 geopolitical zones NW, NC,
  NE, SS, SW SE
• Two-thirds of the gross domestic product (GDP)
  from oil production.

3
EPIDEMIOLOGY OF HIV IN NIGERIA

• HIV prevalence increased from 1.8 in 1991 to 5
  in 2003
• 10 of the world HIV burden in Nigeria with
  3.2-3.6 million PLWHA (adults and children)
• 2.4 million are women
• over 270,000 paediatric HIV cases

4
ISSUES

• Basic issues driving the Nigerian epidemic
  include
• Poverty
• Stigma and discrimination
• Socio cultural and economic issues
• Inequitable distribution of services HIV
  services started in tertiary level of health care
• Urbanization of care and treatment services
• Initial denial
• Less than 1 of facilities nationwide provide
  PMTCT services

5
Country Targets

• Comprehensive AIDS care and treatment and
  expansion of pMTCT now national priorities
• Government targets increased from 10,000 to
  250,000 on treatment by June 2006.

6
OVERVIEW OF ICAP IN NIGERIA - 1

• Two Sites identified after long and high level
  advocacy and consultations with major
  stakeholders in September 2005
• Multiple sources of funding
• Track1 with CDC
• Cooperative agreement for MTCTPlus with the
  United States Agency for International
  Development (USAID)
• Funds from MTCTPlus Initiative

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OVERVIEW OF ICAP IN NIGERIA - 2
Map of Nigeria

• ICAP provides support in
• two states in Nigeria
• Kaduna State, in the North Central zone
• ? Population5,917,812
• ? HIV prevalence (2003) was 6.0
  (Kafanchan9.6)
• Cross River State, in the South South Zone.
• ? Population 2,873,930
• ? HIV Prevalence (2003) was 12

8
OVERVIEW OF ICAP IN NIGERIA - 3

• Goal of ICAP program in Nigeria is to
• Decrease pediatric infections
• Reduce morbidity and mortality in pregnant women,
  and household members
• Increase access to comprehensive HIV care and
  treatment in peri urban and rural areas

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OVERVIEW OF ICAP IN NIGERIA - 4

• Strategies
• Family centered approach
• Provider initiated testing
• Multidisciplinary teams
• Focus Families and households
• Entry points Multiple

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UNIQUENESS OF COUNTRY PROGRAM

• Integrated comprehensive care and treatment
  services including
• Provider Initiated Testing
• Prevention of mother to child transmission plus
• Pediatric HIV care and treatment
• Care and treatment of adults and other household
  members
• TB/HIV integration
• Comprehensive lab support
• Adherence, psychosocial support
• Procurement and distribution of drugs and
  supplies
• Community linkages and support

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OVERVIEW OF ICAP IN NIGERIA - 5

• Targets

Based on current ANC attendance Targets
under review upwards
12
How we work

• Collaboration with
• GON at all levels
• Other USG( especially UMD and APIN/HSPH) and Non
  USG teams especially UNICEF
• Community and Faith based organizations
• Work within the National Strategic Framework and
  Health Sector Plan for HIV/AIDS (broad frameworks
  to guide all HIV programs in Nigeria)

13
WHERE WE WORK General Hospital, Kafanchan - 1

• Bed Capacity 250
• Basic services provided
• Challenges
• - FP (skeletal)
• Nutrition (skeletal)
• pMTCT (no NVP, counseling only)
• No ART
• No potable water
• Less than eight hours daily electricity supply

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WHERE WE WORK , Kafanchan - 2

• Staff strength
• Doctors 12
• Pharmacists 4
• Registered nurse only 4
• Registered midwife only3
• Registered nurse/midwife 123
• Lab scientist 6
• Lab technicians 5
• Lab assistants 3
• Nutritionist 1
• Medical records officer 2
• Account staff 5
• Ward aides/assistants 76
• Hospital assistants 7
• Card issuers 14
• CHEWs 2
• Auxiliary nurses 5

• Referrals
• PLWHA referred to Abuja, JUTH, ABUTH for ART
• Currently referral is not formalised
• Referral form not available
• Referral directory not available
• No system to track referred clients

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WHERE WE WORK , Kafanchan - 3

• Coverage More than 500,000 in 8 LGAs
• Quality of service
• No SOP seen for any service (HCW rely on school
  notes training materials)
• Guidelines available for
• PMTCT
• TB
• CT
• Patient mgt flowchart available only for TB
• No monitoring checklist
• The manuals accompanying various test kits are
  the only guidelines/SOPs available for laboratory
  tests

• Electricity
• From national grid
• Highly erratic
• A functional 500kva diesel gen available
• 2 other 5kva petrol gen available

16
WHERE WE WORK , Kafanchan - 4
17
WHERE WE WORK General Hospital, Ogoja, Cross
River state

• Coverage 650,000, in 6 LGAs (1/3 of the state
  pop)
• Bed Capacity 138
• Basic Services provided
• Stand alone VCT center
• Challenges
• No pMTCT
• No ART
• FP (skeletal)
• Nutrition (skeletal)
• No potable water
• Less than eight hours daily electricity supply
• Low current electricity

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WHERE WE WORK , Ogoja - 2

• Staff strength
• Doctors 6
• Pharmacists 1
• Registered nurse only 29
• Registered nurse/midwife 105
• Lab scientist 1
• Lab technicians 2
• Lab assistants 7
• Medical records officer 14
• Account staff 6
• Ward aides/maids 31
• Cleaners 2
• Security 6

• Referrals
• PLWHA referred to GH Calabar, UCTH (6 hrs drive)
• Currently referral is not formalised
• Referral form not available
• Referral directory not available
• No system to track referred clients

19
WHERE WE WORK , Ogoja - 3

• Quality of service
• No SOP seen for any service (HCW rely on school
  notes training materials)
• Guidelines, Patient mgt flowchart and monitoring
  checklist not available
• Manuals accompanying various test kits are the
  only guidelines/SOPs available for laboratory
  tests
• No ME unit, Basic data collection is by MROs

20
WHERE WE WORK , Ogoja - 4

• Lab services
• No external or internal QA or QC procedure
• No test kits
• No functional biochemistry equipment
• Sahle method for Hb

21
Achievements so far - 1

• MOU signed at national and state levels

22
Achievements so far - 2

• In-country office set up in Abuja
• Recruitment of staff on going, 12 staff currently
  on board ART/ME/Lab advisors, Site
  coordinators, admin and finance staff, support
  staff

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Achievements so far - 3

• National Level
• Established strong working relationship with GON
  through NASCP and NACA
• Provided technical assistance in the
  development/finalization/reviews and adaptation
  of various tools e.g. National PMTCT Training
  curriculum, IEC materials on Infant feeding ,
  palliative care guidelines, QA for lab
  activities, TB/HIV integration
• Development of minimum package for pMTCT care
• Standing member of the PAC, Expanded Theme Group

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Achievements so far - 4

• Site level
• Conducted site assessments in consultation with
• CDC and the USG in country coordinating team
• Draft site readiness reports available
• Draft detailed implementation plans/scope of work
  for rapid initiation of rapid scale up of HIV
  care and ART activities developed

25
Achievements so far - 5

• Increase human resource capacity
• Multi disciplinary committees operational
• Staff trainings conducted on pMTCT and HCT
• Good lab practices, HIV serology and CD4
• ART clinic sites identified
• Renovations plans completed
• Renovations on-going
• Interim plans (especially for lab support)
  developed to jumpstart activities

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Achievements so far - 6

• Trainings
• In Kafanchan, Kaduna state
• PMTCT training conducted
• for 31 HCWs
• Sponsored 4 lab scientists for
• training in HIV serology, virology,
• CD4/8, Good lab practice, etc

CT training conducted for another 31HCWs
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Achievements so far - 7

• Trainings
• In Ogoja, Cross river state
• 32 HCW being currently trained in CT

All trainings are handled by national trainers
using the national curriculum/guidelines
Other trainings such as Adult ART, ME,
multidisciplinary sensitization, paediatric ART,
Adherence counseling, pharmacy/logistics, BCC,
Palliative care (facility and community based)
will also follow in March/April
28
Achievements so far - 8

• Establishment of community networks
• 31 HCW provided with first set of lectures on
  referral
• A referral directory is being compiled
• About 4 organizations identified for community
  based activities (SWAAN, CACA, WCH, MWG)
• Behavior change communication activities
• A BCC consultant engaged to assist with BCC
  activities
• BCC materials are being adapted
• Advocacy conducted in Kwoi and
• Kafanchan, Kaduna state

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Achievements so far - 9

• Community activities (advocacy/sensitization) in
  Kwoi and Kafanchan, Kaduna state

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Achievements so far - 10

• Clinical support
• Checklist for monitoring being collated for
  review
• Procurement and infrastructure support
• Plans for physical infrastructure finalised
  site plans and estimates for refurbishing being
  reviewed
• An inventory management system being adapted for
  use for drug/supplies/kits orders and prevent
  stock-outs
• List of required lab equipments compiled and
  process of issuing LPOs on-going
• Request for rapid test kits made to CDC
• Columbia University NY has placed orders for ARVs

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Achievements so far - 11

• Monitoring and evaluation
• Compiled all indicators (GON, USAID, CU) for
  reporting
• Developed
• results framework for USAID
• draft comprehensive ME workplan
• Adapted and updated all required data collection
  tools
• Working with sites to
• identify site level ME staff
• develop efficient patient tracking system

32
Challenges - 1

• Staff recruitment
• Recruitment of highly competent staff is a time
  consuming activity
• Site level staff issues - ?hiring of
  supernumerary vs. paid staff (national issue)
• Infrastructure
• Sites need extensive renovations to provide HIV
  treatment
• A lot of basic equipments are needed for the labs
  to start

33
Challenges - 2

• Project implementation
• Ensuring that pregnant women come for ANC early
  instead of the current trend
• Development of a scheme to follow up positive
  mothers and their babies up to 18 months
• Facility for testing of children before 18 months
• Developing modalities for community based
  recruitment and testing of children, pregnant
  women, their partners and household members men
  in the community

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Challenges - 3

• Procurement and infrastructure support
• Maintenance of cold chain for reagents
• Maintenance of ambient temperature for drugs
• Ensuring constant supply of electricity
• Facilities currently receives lt 6hours daily
• Most times the voltage is less than 150V (220V is
  the standard rate in Nigeria)
• No potable water
• Infrastructure renovation, procurement and supply
  of equipments usually takes time to be completed
  (long procurement process)

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Way forward

• Catholic Maternity Center identified in Ogoja to
  provide interim lab support services
• Loan immediate lab materials from collaborating
  partner (UMD)
• Install boreholes and back up generators asap
• Purchase no break power inverters
• Complete ART, lab and other trainings
• Promote active enrollment of patients in both
  sites
• Commence outreach activities to increase
  enrollment (e.g. Catholic Maternity Center)
• Strengthen record keeping and data use processes
• Address urgent staffing needs at site elvel

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CONCLUSION
ENORMOUS CHALLENGES

DETERMINATION

OUTSTANDING SUCCESS!