1. Dr Rochelle Adams ACC Project Manager On behalf of the ACC team AWACC 2015 19 November 2015 Health systems Strengthening for Success and Sustainability

2. Presentation Outline Background Objectives of ACC Proposed Approach Aim Methods Progress Capacity Building and Sustainability Conclusion

3. Background KZN has close to 1 000 000 patients on ART. *Only 40% of adult ART patients receive12 monthly VL testing  *20-25% of these patients have unsuppressed viral loads  *25% of patients who begin ART are lost to follow-up by 12 months Source: Massyn N, Day C, Peer N, Padarath A, Barron P, English R, editors. District Health Barometer 2013/14. Durban: Health Systems Trust; October 2014. ( *SANAC Report Nov 2014) TB & HIV account for a third of all premature causes of death in eThekwini district

4. 4 Courtesy of H. Ngobese - KZN HAST Manager 17 April 2014 Mortality in HIV positive: 33% in patients not on ART 5% in patients on ART 44.2% of all in hospital deaths 60% TB /EPTB Critical Issues that Undermine the Success and Sustainability of the ART rollout Current DHIS/TIER.NET/NHLS limited in understanding gaps in care or in informing HSS interventions

5. Improve management of complicated HIV, TB and DR TB patients through  Training and mentorship of frontline HCW’s to increase capacity for identification and management of complex medical problems  strengthening of referral pathways,  improvement in understanding of clinical guidelines, algorithms  Improve systems and procedures for effective triage  Improve capacity for specialized clinical, laboratory and pharmaceutical support services Establish systems and capacity to identify and manage viraemia on ART and manage 2nd and 3rd line ART and TB drug failure Collect strategic information to track patient and program outcomes Transition to KZN DoH 5 Objectives of the ACC programme

6. The Proposed Approach (1) Training and capacity building in complex patient management Work with DSP’s and DMT’s in identifying gaps in access to care, in service delivery and guideline implementation that contribute to: –Poor clinical outcomes –Failure to detect and manage patients failing ART –Ineffective triage within referral pathways –Provide a better understanding of “why are patients dying” Evaluate findings and develop an intervention plan targeting improved management of complex TB, HIV and DR TB, including management of treatment failure 6

7. Aim To ascertain patient and health systems factors that contribute to poor TB and HIV outcomes and provide recommendations for targeted Health Systems strengthening activities aimed at improving outcomes

8. Methods (1) Devise systems for evaluating coverage and quality of services for complex patient management and care of patients failing ART Located within the QI department in the District Process and Tools for evaluation defined over several months with multiple stakeholder input including:  DCST and Technical Advisor  Quality Assurance Manager  HAST Manager and TB Cluster Manager  Academics incl Departments of Infectious Diseases, Public Health, Family Medicine, Virology  District Support Partner

9. Methods (2) Evaluate high burden facilities with > 2500 patients on ART Facilities will be chosen to get an adequate representation of the level of services by facility type  Hospital  Community Health Centre  Primary Health Care Clinics.

10. Progress Data tools and systems finalised Review of 3 facilities completed Generate report highlighting trends Review findings with the DMT Develop targeted recommendations for HSS for each facility type Develop final report by end Jan 2016 Take this process to each District in KZN

11. Capacity Building and sustainability Training of EThekwini District staff teams  Quality Improvement  How to conduct facility and file audits Collaborate with the district to select key indicators and variables to monitor programme outcomes Provision of tablets for electronic database collection Assist the district with in implementing first facility and file review

12. Conclusion UNAIDS 90-90-90 Strategy is an ambitious target to help end the AIDS Epidemic  Aims to ensure that 90 % of ALL people with HIV are on ART and are virologically suppressed Use of data feedback loops to understand and improve HIV and TB service delivery is an important step in ensuring that we are responsive to this strategy High quality services necessary for sustaining a successful ART rollout, and in reducing morbidity and mortality

13. Acknowledgements This training was supported by the Grant or Cooperative Agreement Number U2G GH001142, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the presenters and do not necessarily represent the official views of the U.S. Centers for Disease Control and Prevention or the U.S. Department of Health and Human Services