1. Satellite Roll Out and Lab Capacity Building in Harvard PEPFAR Dr. Toyin Jolayemi APIN/Harvard PEPFAR, Nigeria

2. Over two-thirds of Nigerians live in rural areas Program focused on tertiary sites at the start Growing concerns around access, coverage, scale up etc Availability of and access to ART improves lives allowing PLWHAs to live productive lives Issues around inequality and inequity Concepts on “saturation” and “satellite” were discussed Context

3. The satellite and saturation concept was adopted 1. Moving beyond the prime sites to satellites will expand access to care and treatment and offer greater impact in numbers of people served, geographic areas covered 2. Decongest care and treatment at the prime sites 4 Prime sites to develop 22 satellites sites JUTH Model Concept

4. 3 o Level JUTH 2 o Level JENGRE 2 o Level VOM 2 o Level PANYAM Cadillac Volkswagen 1 o Level PHC 1 o Level PHC 1 o Level PHC Bicycle Communities Donkey Homes and Families Foot

5. 3 o Level JUTH 2 o Level VOM (Gen. Hosp.) 1 o Level PHC Communities NGOs/CBOs/PLHA/Volunteer Homes and Families NGOs/CBOs/PLHA/ volunteer Prev. message Treatment literacy Treatment support Adherence Patient tracking Comm. Based services -IEC -FP -BCK -Condoms -DOTS Out reaches -BCC -Treatment message -HCT -Advocacy Referrals ART PMCTC HCT Labs – VL, DC4, Genotype, chem, FBC FP QA/QC/QI STI ART PMTCT HCT Labs – CD4, FBC, Chemistry FP, STI QC/QI HCT PMTCT STI CXT BCK DOTS ?ART refills FP Multivitamins HBC-FMCT/DOTS/BCK/CXT Prevention for +ve Condoms/STI/FP Multivitamins Patient tracking

6. Infrastructural development Lab development Health Systems Strengthening Referral Mechanisms Training and Technical Assistance Mentoring Supervision Satellite Development Effort

7. COCIN Health Centre, Panyam: Antenatal Clinic

8. APIN Plus Laboratory Infrastructure, EQA Lab Equipped Training completed EQAEQA provider HIV ScreeningXXXCAP 2007 HepB & HepC Screening XXXCAP 2007 CBCXXOngoingCross-site ChemistryXXXCAP 2007 CD4- flowXXXUK-NEQAS 2006 Viral LoadXXXHarvard 2006 Infant PCRXXXCDC/ Harvard 2008

9. Nigeria -Laboratory Infrastructure HIV rapid tests & immunoblot CBCChemistryCD4- flow Viral loadInfant PCR Resistance Genotyping NIMRXXXXXXX 68MHXXXXXX LUTHXXXXXXX UCHXXXXXXX JUTHXXXXXX UMTHXXXXXX ABUTHXXXXXX FMC Benue XXXXXX UNTH Enugu XXXXXX ART satellites XXXX

10. EnrollmentJUTHJUTH Satellites Satellite Contribution New on ART (Apr-Jun 09)392203(34%) New on Care (Apr-Jun 09)558432(44%) Current on ART @ June 0989031075(11%) Current on Care @ June 09106722349(18%) Transfer in of ART patients from JUTH (Apr-June 09) About 10* Other issues involved in motivating patient transfer Transfer in of Care patients from JUTH (Apr-June 09) About 13 Program Output

11. EnrollmentTime periodAchievement/Target New on Care (COP09)Apr-Jun 0940% New on ART (COP09)Apr-Jun 0965% Program Output

12.  Sites are functional and providing services  Community efforts are driving the demand for service  Satellites are currently @ 40% of Care target and 65% of ART targets (3 months)  Issues around the supply end  Upfront investment has been made  Maximizing return on initial investment at the current output level is an issue  Tracking enrollment  At a crossroad. ◦ Slow down enrollment…ethical concerns ◦ Continue enrollment…finance concerns ◦ Access. Summary

13. Thank you!

14. Satellite Roll-out, Task Shifting, and Laboratory Capacity Building Botswana Harvard PEPFAR Clinical Master Trainer (CMT), Lab Master Trainer (LMT), and Monitoring & Evaluation Unit of Ministry of Health (M&E)

15. 15 Master Trainer/ARV Site Support Program ClinicalLaboratory Monitoring & Evaluation Unit (within DHAPC): Linked to: All ARV sites Other MOH programs Masa BHP-PEPFAR ARV Site Support Program

16. Three Objectives of Master Trainer and Site Support Program 1) Capacity Building through Clinical Mentoring, Training and Overall Site support 2) Decentralization of laboratories 3) Support development of the Monitoring and Evaluation of the National ARV Program - Masa

17. Capacity-building: Commitment to use in-country experts All but two are Batswana or African expats who had already been working in-country Initial criticism of hiring most experienced doctors, nurses, lab staff, and pharmacists from the National Program Current appreciation of results: More than 150 HCWs mentored by each of the above experts Increased labs and capacity Additional ARV sites staffed by fully trained HCWs

18. ARV Site Roll Out Process: Clinical Master Trainers Site and pharmacy readiness assessments Assistance with all aspects and systems to set up a new site Training, mentoring, and on-site support – 2 weeks Telephone site support Quality Improvement: QI training at site level Development of QI teams at all ARV sites Implementation of chart reviews and other evaluation tools Feedback and QI planning with site QAI team

19. Clinical Master Trainer Program : ARV Sites Assessed and Supported Mother Sites Supported Middlepit Bokspit Goodhope Palapye Masunga Werda Kalkfontein Newxade Each Mother Site has 3-4 Clinics (only some shown)

20. Why Task Shifting? To date no Medical School in Botswana Approximately 400 doctors in Botswana More than 4,000 Batswana nurses in-country Minimal number of pharmacy staff How will the new ARV sites and their pharmacies be staffed?

21. Task Shifting Nurse Prescriber & Dispenser Training to Date - 170 nurses trained in prescribing and dispensing ARVs - 379 nurses trained in ARV dispensing only Nurse training for Rapid HIV testing and Dried Blood Spot in collaboration with PMTCT 38 trained to date

22. Roll-out of Nurse Prescribers and Dispensers to Clinics 65 clinics - stand alone clinics with full prescribing and dispensing capability 64 prescribe and dispense on an outreach basis - the doctor and pharmacist or pharmacy technician travel to and from the facility on the ARV clinic day. 7 facilities initiate and prescribe but drugs are collected from another facility within the site (a site is defined as a mother site/hospital and its satellite ARV clinics)

23. The Impact of the Nurse Prescriber PFM 23

24. Satellite Clinic Roll-out At start of PEPFAR in 2004 – 32 hospital ‘Mother Sites’ Currently – 29 District Hospitals – 2 Botswana Defence Force Hospitals – 1 Mine Hospital – 136 ARV Clinics (satellite facilities) This last month, 68.7% of new patients were initiated on ARVs at satellite clinics, rather than hospital clinics.

25. WHY Task Shifting for Labs? 2 Reference Labs 21 decentralized labs for CD4 testing 8 decentralized labs for VL testing Need for Rapid Testing and Dried Blood Spot testing at all ARV sites

26. Process of Laboratory Decentralization Laboratory Master Trainers Site assessment Centralized training at Botswana National Laboratory Site training and equipment set-up Reagent supply management Acceptable Internal Quality Control testing Follow-up site support Telephone site support

27. Laboratory Capacity Building At start of PEPFAR - 2004 2 hospital reference labs capable of performing 100% of CD4 and Viral Load testing Currently the Botswana Lab Master Trainers have trained and supported ALL decentralized labs and private sector labs which run Public Private Partnership (PPP) specimens CD4s - 21 decentralized labs performing 59% VL – 8 decentralized labs performing 30% 27

28. CD4 Testing Comparison: 2004 – 2 nd Qtr. 2009

29. Viral Load Testing Comparison: 2004 – 2 nd Qtr. 2009