Advanced HIV Disease; Linkages[Uganda ]

Dr. Katureebe CordeliaMinistry of Health, AIDS Control Program CQUIN meeting 28th to 29th July 2020

The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020

• Included within the National Consolidated guidelines for the Prevention and treatment of HIV

• AHD Implementation plan

• AHD tool kit

• Training

AHD Linkage; Policy framework and guidelines

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The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020

• Determine service package by level of facility

• Evidence based situation and gap analysis

• Distribution of commodities/ machines

• HR capacity(knowledge and competencies) by level of facility

• Mapping of facility; skills; commodities; Hubs

• Leveraging on potential support

• Lobbying for resources to cover gaps

• Provider knowledge and skills; Train, SOPs

• Monitoring: Test uptake, stocks

AHD Linkage; Implementation approach

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Some components of AHD package of care will be centralized at all regional referral hospitals and district hospitals with a hub & spoke model to allow effective screening and referrals from lower health facilities

Service delivery packages for different care levels

Laboratory Services: CD4 Testing

• Each district has facility with a CD4 machine

• There are 100 hubs across the country which are accessible through the hub system

• Hubs serve all facilities both public and private labs with in the radius of over 40-50km

The map shows how the Hubs are distributed

across the country.

SOPs for Screening for Advanced HIV Disease

SOP for prophylaxis of opportunistic infections

SOP for referral of PLHIV with AHD

Algorithm for TB screening, diagnosis and management in PLHIV

Algorithm for CCM screening, diagnosis and management in PLHIV

Treatment Protocol for CCM

Treatment Protocol for TB

Management of PJP and severe bacterial infections

Symptom Screening Tool

AHD management toolkit

Algorithm for TB diagnosis in Children

SOP for TB LAM Test

Algorithm for nutrition assessment and care plan of acute malnutrition

SOP for Referral of PLHIV with Advanced HIV Disease

Purpose

To guide site level health care providers on the processes of referring individuals with advanced disease conditions for more specialized management

Target UsersHealth workers at site level: laboratory personnel, clinicians, and nurses

Regional and district mentors

Objectives

To assist proper referral of patients with advanced disease conditions e.g. TB and cryptococcosis

SOP for Referral of PLHIV with Advanced HIV Disease

Applicable scenario:Situations where health facilities lack the capacity to manage PLHIV with AHD due to lack of skills, HR or diagnostic/treatment commodities

Procedure:Situations in which HCW should refer a patient with Advanced HIV Disease:1. Symptomatic patients where diagnostic commodities/ services are not available (TB LAM, CrAg)

For example: To confirm diagnosis of meningitis (Lumbar Puncture) for symptomatic patients whose serum CrAg is positive. Note: Give 1200mg of fluconazole as a stat dose, prior to referral

2. Patients diagnosed with AHD conditions where treatment commodities are not available at siteFor example: For patients with MDR TB, or Cryptococcal Meningitis

3. Patients already being treated for AHD with severe adverse effects/ deteriorating conditionsNote: Refer to ART and TB guidelines for guidance on management of toxicity (pay special attention to scenarios where treatment needs to be stopped immediately/ prior to referral)

4. Patients who have danger signs and symptoms or are critically ill, make appropriate referral to higher level facility after providing emergency care

Note: Once the client is referred, the referring clinician should follow up to ensure the referral was successful

AHD Toolkit: Referral of PLHIV with AHDReferral and linkage points for patients with advanced disease (Cryptococcal Meningitis) within existing networks of district/regional referral hospitals and health centers

Referral and linkage points for patients with advanced disease (TB) within existing networks of district/regional referral hospitals and health centers

The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020

TESTING PERFORMANCE PER LEVEL OF CARE

#Individuals Tested Tested HIV+ New Initiations

No. of HIV+ patients that received CD4 test

No. of patients with CD4<200

No. of patients with CD4<200 that received CrAg test

No. of patients that received TB LAM test

General Hospital 304,660 11,625 12,297 12,166 2,468 1,956 773HC III 517,229 21,103 23,997 12,574 2,207 1,459 445HC IV 461,869 15,935 17,802 8,673 1,750 1,714 625Clinic 76,416 5,081 4,844 6,713 1,371 1,048 962RR Hospital 112,099 4,477 4,354 2,455 572 595 552HC II 34,298 1,806 1,758 875 208 187 77NR Hospital 3,608 146 142 64 14 14 19

Total 1,510,179 60,173 65,194 43,520 8,590 6,973 3,453

% Tested HIV+ New InitiationsNo. of HIV+ patients that received CD4 test

No. of patients with CD4<200

No. of patients with CD4<200 that received CrAg test

No. of patients that received TB LAM test

General Hospital 4% 106% 99% 20% 79% 31%HC III 4% 114% 52% 18% 66% 20%HC IV 3% 112% 49% 20% 98% 36%Clinic 7% 95% 59% 20% 76% 70%RR Hospital 4% 97% 56% 23% 104% 97%HC II 5% 97% 50% 24% 90% 37%NR Hospital 4% 97% 45% 22% 100% 100%

v HC IIIs have more numbers but with only 49% reachv Low hanging fruits form RRH but testing is at 56%

The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020

FACILITY STOCK STATUS FOR CD4 REAGENTS Total CD4 Tests Reported 45,388Expired Stock 5,171Viable Stock 40,217

No. of facilities with these CD4 stock levelsLevel of Care <1 Month 1-2.99 months 3-5.99 months >6 months TotalGen. Hospital 34 16 10 12 72HC III 105 36 19 29 189HC IV 51 31 15 33 130Clinic 23 2 0 1 26RR Hospital 5 4 0 0 9HC II 7 1 2 1 11NR Hospital 0 0 1 0 1Total 225 90 47 76 438

No. of facilities with these CD4 stock levelsOwnership <1 Month 1-2.99 months 3-5.99 months >6 months TotalGovt 161 71 34 63 329PNFP 48 17 11 12 88NGOs 10 2 0 0 12PFP 6 0 2 1 9Total 225 90 47 76 438

The CQUIN Project Virtual Workshop on Advanced HIV Disease July 28-29, 2020

• Data use is critical in • supporting programing related to effective referrals and linkage• Developing QI approaches• Supporting lobbying for resources

• Importance of building capacity for front line providers

• Monitoring is key

Lessons learnt

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