Improving Quality of HIV/AIDS Services

The Context

Central Asia is experiencing a concentrated HIV/AIDS epidemic with low HIV prevalence among the general population. Nevertheless, among some vulnerable population groups, estimated HIV prevalence is increasing rapidly and over the next few years, the need for HIV/AIDS care, support, and treatment services will increase. CAR countries will benefit greatly by being prepared for this eventuality and the CAPACITY Project is working to support efforts with special focus on three major areas: linking HIV/AIDS and TB services, ARVT, and voluntary counseling and testing (VCT).

Linking HIV/AIDS and TB Services: Tuberculosis is the most common opportunistic infection and cause of death among PLHIV. While there has been significant improvement in national TB treatment rates, there is significant variability by oblast, which is directly related to the increase in patients with dual HIV and TB infections. Vertical systems of treatement for AIDS and TB have made it difficult for patients with both diseases to be treated effectively. However, there is recognition among national TB and AIDS programs of the necessity to link these services in order to improve patient outcomes.

ARV Therapy: ARVs now exist in four countries of Central Asia, though the scale is still small. Countries have developed protocols based on WHO recommendations. A core group of physicians are trained to provide ARVT, but the numbers will need to increase to accommodate the increasing numbers of eligible patients. However, as these services are very new, little attention has been paid to ensuring that patients who need ARVT accept treatment, remain on treatment, and adhere to treatment. Currently, with small numbers of patients requiring ARVT, ad hoc treatment of patients is somewhat manageable, even if not desirable. However, once the numbers of patients grows, it will be necessary to have systems for patient monitoring and follow-up in place. Current infrastructure and systems are insufficient to ensure that a continuous and uninterrupted supply of quality, cost-effective medicines are available at facilities to treat AIDS and AIDS-related illnesses. Most of the countries have already expressed difficulties in the procurement of ARVs.

VCT: CAR countries each have well developed laboratory services used for HIV testing located throughout the network of AIDS centers, starting with the Republican AIDS Centers and including Oblasts AIDS Centers and some inter-district HIV laboratories. Counseling is available on a limited scale but is not institutionalized or linked appropriately to laboratory services for HIV testing. Where counseling is offered, it often has limited follow-up outside of the AIDS services. Numerous specialists have been trained on HIV counseling by various agencies and the countries have adopted VCT protocols, but counseling has been inadequately implemented. Some NGOs provide HIV-related counseling and are interested in further developing HIV/AIDS care and support services. Generally speaking, however, testing is almost never accompanied by counseling, it is often not voluntary, and patient confidentiality is not always kept.

CAPACITY’s Approach

Because of the current stage of the epidemic, which is in the concentrated stage, the numbers of people with AIDS and requiring treatment and care is relatively small. For this reason, CAPACITY has taken the stance that the most effective use of resources will be in building national and local capacity for HIV prevention among those vulnerable populations at the heart of this concentration of HIV infections. Nevertheless, CAPACITY feels the need to help countries prepare for the certain upcoming need for systems to treat and care for people with AIDS, in addition to assisting countries deal with the relatively smaller number of AIDS patients currently eligible for treatment. Because the a high proportion of AIDS patients will suffer from co-infections with TB, CAPACITY has put a lot of efforts into assisting national programs to build linkages for TB and AIDS service interaction. Models have been established in three countries and are in process in a fourth, to build a system whereby patients with dual infections can receive appropriate treatment.
While ARVT is beginning in Central Asia, there are currently not good systems in place for monitoring and following up with patients. CAPACITY is assisting other stakeholders to develop patient monitoring tools to improve medical practitioners to keep better records of patients. Such a system of patient monitoring will improve the treatment capacity of multiple providers and enable patients to be treated more appropriately. In addition. CAPACITY will study the obstacles to patient enrollment, retention, and adherence to ARVT and make recommendations for improvements. CAPACITY is working with national stewards to improve protocols and government orders for VCT to make counseling an mandatory component of HIV diagnosis. In this process, CAPACITY will provide support to link trained counselors to the existing laboratory system of testing by first helping countries identify the responsible agency within the Ministry of Health for VCT, and second to develop models, where feasible, implementation for VCT. The objective will be to make VCT available to any person requesting the service.

Illustrative Interventions

Linking HIV/AIDS and TB Services:
• Assessing and identifying the opportunities and constraints for linking HIV/AIDS and TB services.
• Work with the MoH, AIDS centers, TB centers, and other stakeholders to develop ideas for linking HIV/AIDS and TB services.
• Develop or adapt protocols for linking the HIV/AIDS services with TB services, and for treating patients with dual HIV/AIDS and TB.
• Support the establishment of referral systems for patients who test positive for HIV to get tested for TB, and for patients who test positive for active TB to go to VCT for HIV testing.
• Support training of medical providers on how to diagnose and treat TB in PLHA, and AIDS in TB patients.
• Support the implementation of models of TB and AIDS service interaction in countries.
• Monitor and evaluate models and advocate for scale-up of successful models.

ARV Therapy:
• Develop or adapt protocols for ARV therapy.
• Assessment of facility readiness and minimum criteria for providing ARV treatment.
• Support the provision of training on the various aspects of AIDS treatment.
• Support linkages between communities and civil society and clinic-based HIV/AIDS services
• Assist national AIDS programs to develop patient monitoring and information systems.
• Assess obstacles and make recommendations for improving ARVT enrollment, retention, and adherence.

VCT:
• Assess and identify opportunities and constraints of current VCT services and identify which categories of institutions should be providing VCT.
• Work with the MoH, AIDS centers, and other stakeholders to develop ideas for expanding access to VCT.
• Legitimize through MoH the participation of identified categories of institutions in VCT.
• Develop A Discussion Paper on expansion of VCT and work with partners to establish models of VCT.
• Identify stakeholders who are currently or have previously trained on VCT or implementing a VCT model.
• Adapt or develop VCT training curriculum and guidelines.
• Support the provision of training of counselors on VCT, and/or link existing counselors to testing sites.
• Support the development of linkages and networks among the institutions working on VCT and ASOs.
• Support implementation of VCT services by identified institutions.

Anticipated Results

• Approach taken to improving VCT that targets specific vulnerable populations and special needs and is sensitive to stigma and confidentiality issues.
• Approach taken for improving and integrating the treatment of AIDS.
• Approach taken for linking treatment and co-managing HIV and TB.

Bulletin

July, 2009
(407 KB)

Partners

www.rcaids.kz
Republican AIDS Center, Kazakhstan

www.ncc.tj
National Coordination Committee, Tajikistan

www.afew.org
AIDS Foundation East-West

www.caap.info
Central Asia AIDS Control Project

www.cdc.gov
Center for Disease Control and Prevention

www.ddrprogram.org
Drug Demand Reduction Project

www.theglobalfund.org
The Global Fund to Fight AIDS, Tuberkulosis and Malaria

www.projecthope.org
Project HOPE/TB

www.soros.org
Soros Foundation

www.undp.org
UNDP

www.unicef.org
United Nations Children's Fund

www.unodc.org
United Nations Office for Drugs and Crime

www.usaid.gov
USAID

www.euro.who.int
World Health Organization

www.zplus.kz
ZdravPlus Project