1. Case Study on the Integration of HIV/AIDS Services in Trinidad and Tobago into Maternal, Newborn & Child Health Services, as well as Sexual and Reproductive Health Services, including Family Planning Edwin Bolastig, Yoko Laurence and Karen Pierre Centre for Health Sciences University of Trinidad and Tobago Funded by: Pan American Health Organization/ World Health Organization

2. OBJECTIVES OF CASE STUDY To contribute to the body of work on health services integration To determine: how vertical programs and Global Health Initiatives have impacted on the health system, and affected segmentation/fragmentation 2

3. TRINIDAD AND TOBAGO: Southernmost Caribbean country Independence 1962; Republic 1976 Parliamentary democracy Multi-ethnic population: 1.3M Oil and gas-based economy GNI per capita (09):US$ 17,884 10-year GDP growth(99-08): 7.7% Epidemiologic shift: CNCDs over 60% of deaths 3

4. CONTEXT First HIV case diagnosed in 1983 8 th leading cause of death in 2004 STI-HIV co-infection prevalence rate: 42% (60% M ; 40% F) (Buensuceso, 2008) HIV/AIDS cause enjoys strong political support World Bank loan, EU grant, CARICOM PANCAP, government, private sector funding SOCIAL DRIVERS: Poverty and unemployment Gender inequality/domestic violence High mobility: Caribbean diaspora Stigma and discrimination Multiple sex partners/Early initiation Substance abuse/unprotected sex (UNAIDS, 2005) ECONOMIC DRIVERS: Inequitable income distribution Sex work due to poverty Rapid urbanisation Limited skills and poor socialisation Sex-oriented tourism (Camara, CAREC, 2002) 4

5. BROAD SECTORAL CONTEXT 1986 – National AIDS Programme 1993 – Caribbean Charter on Health Promotion 1996 – Health Sector Reform Programme (HSRP) National Health Promotion Plan 2001 – Health Promotion Council; Directorate of Health Promotion and Public Health 2004 – National AIDS Coordinating Committee (NACC) 2005 – Vision 2020 2006 – MOH Corporate Plan (2006-2009) 5

6. SEGMENTATION/FRAGMENTATION Decentralisation of health service delivery to RHAs with the exception of Vertical Programmes and Services Fragmented human resource management Dual employment system Information and medical records management largely manual Unstructured referral system 6

7. HIV INTEGRATION INITIATIVES Integration with Maternal and Child Health - PMTCT Integration with STI and Family Planning - VCT Integration with Population Programme - PITC Integration with Chronic Disease Care – Tobago Health Promotion Clinic (THPC) Integration of Treatment with Prevention – San Fernando General Hospital Integration of Information Systems for HIV/AIDS – TERIDA Project 7

8. EMERGING MODELS Three (3) Emerging Models of Integration: 1.Standalone outpatient HIV/AIDS clinic integrated with chronic disease care (Tobago Health Promotion Clinic) 2.Hospital-based HIV/AIDS testing and treatment centres – adult & paediatric (San Fernando General Hospital) 3.Satellite network of multi-tiered hospital based and outpatient health facilities 8

9. MODEL 1 – Stand Alone ADVANTAGES/STRENGTHSGAPS/WEAKNESSES By associating HIV/AIDS with other chronic diseases, stigma and discrimination may be minimised Unique branding strategy associating comprehensive approach with quality care Well-organised manual record-keeping transitioning to a paperless information system Multi-tasking of health workers Triaging according to purpose of visit (counselling and testing, pick-up of ARVs, consults, etc.) to avoid long queues and waiting times Community outreach activities (home visits) ensures good follow-up/ return rates Weak linkage with health centres doing counselling and testing Referrals have to be made to the Scarborough General Hospital for treatment of paediatric patients and to the OB/GYN Ward for pregnant women Inconspicuous location – not all potential clients are aware of the clinic site (Conversely, could be an advantage too) 9

10. MODEL 2 – Hospital Based Testing and Treatment ADVANTAGES/STRENGTHSGAPS/WEAKNESSES Simulates one-stop shop for services (STI, HIV/AIDS testing, counselling and treatment, maternal and child care, etc.) in a single health facility/ compound Weak community outreach services Link to family planning services missing Hospital-based care is known to be generally more expensive than out- patient care 10

11. MODEL 3 – Multi-tiered Satellite Network ADVANTAGES/STRENGTHSGAPS/WEAKNESSES Hand-holding approach to referral of patients to other health facilities Assurance of a wide range of services Relatively good feedback being received from facilities where patients were referred to Patients being lost in the process of referring to another health facility Patients being lost to follow-up Longer time spent in securing appointments and attending clinics Travel and opportunity costs of attending multiple clinic schedules 11

12. FINANCING – Total TTD 253.5 million 1 USD = 6.29 TTD 12

13. BENEFITS 1.Programmes – institutionalisation of PMTCT; integration of VCT with SRH; free ARVs 2.Resources - high levels of funding for HIV/AIDS also used for MCH, STIs and FP 3.Processes - shift from a programme approach to institutionalisation of interventions 4.Intermediate products – build capacity of committed health personnel 5.Outcomes – increased HIV testing among mothers; improved efficiency in some areas; community outreach 13

14. Strengthening of services as pre-requisite to integration vs. Integration as means to improve services TWO SCHOOLS OF THOUGHT ON INTEGRATION: 14

15. LESSONS LEARNT Facilitating factors: Role of advocates and champions in the health system Perception of strong political support from government Health promotion (high risk groups and wider population) Service delivery decentralisation (RHAs) Increased resources for HIV/AIDS Expanded role of civil society – knowledge broker 15

16. LESSONS LEARNT Hindering Factors: Structural and support services – inadequate infrastructure, human resource shortages, weak reporting and referral systems Socio-cultural – breach of confidentiality, S&D, territorialism, lack of accountability Policy and legal environment – lacks policy framework for zero tolerance to S&D, non-adherence to protocols/SOPs 16

17. AREAS FOR IMPROVEMENT 1.Socio-cultural 2.Health workforce 3.Service delivery 4.Systems interventions 5.Policy and legal environment 17

18. CONCLUSIONS Resources for HIV/AIDS supported integration of HIV services with other health programmes such as Maternal and Child Health GHIs did not seem to have undermined national planning and policy development process Integration process aligned with national priorities, along existing mechanisms for coordination 18