CASE STUDY OF THE MONTH: Bristol-Myers Squibb Foundation’s SECURE THE FUTURE
INTRODUCTION
This month GBCHealth presents Bristol-Myers Squibb and the Bristol-Myers Squibb Foundation’s SECURE THE FUTURE® program, a $160 million initiative focused on innovative and sustainable solutions to help children, adolescents and families in sub-Saharan Africa who have been infected and affected by HIV/AIDS.
Sub-Saharan Africa, still the most severely affected region, is home to 69 percent of people living with HIV worldwide. Despite a decade of remarkable progress in the prevention and treatment of HIV, in 2011, more than 90 percent of children who acquired HIV and 92 percent of pregnant women living with HIV resided in sub-Saharan Africa.
Established in 1999, SECURE THE FUTURE® has made transformative investments in clinical infrastructure, provider training, electronic medical records, drug procurement, pediatric medicine and comprehensive services to address HIV more effectively across sub-Saharan Africa. The Foundation worked with the Baylor International Pediatrics AIDS Initiative (BIPAI) at the Baylor College of Medicine, governments in sub-Saharan Africa, the Abbott Fund and other funders to provide HIV treatment and care to children.
The Bristol-Myers Squibb Foundation and Baylor established five Children’s Clinical Centers of Excellence in Botswana, Lesotho, Swaziland, Uganda and Tanzania, a network of eight satellite clinics, a Pediatric AIDS Corps of pediatricians and specialists, and supported public-private partnerships (PPPs) to ensure the program’s sustainability. As the program developed, it adapted to the needs of communities by expanding coverage to family members of HIV-positive children and establishing adolescent clinics for children who, having been cared for by the centers, had grown into teens.
The first Children’s Clinical Center of Excellence recently celebrated its 10th anniversary in Botswana in June, and has been replicated across the continent, saving hundreds of thousands of lives. The program in Botswana has been so successful that the foundation and Baylor established a new Botswana-Baylor-Bristol-Myers Squibb Adolescent Center of Excellence, where teenagers can now receive enhanced psychosocial support; and life skills training..
In 2008, SECURE THE FUTURE® entered into a new initiative as a technical assistance and skills transfer program enlisting former grantees and partners in community-based care to provide technical training to other NGOs and governments in eight sub-Saharan countries.
ABOUT Bristol-Myers Squibb and the Bristol-Myers Squibb Foundation
GBCHealth member Bristol-Myers Squibb is a global pharmaceutical company whose mission is to discover, develop and deliver innovative medicines that help patients prevail over serious diseases, including HIV/AIDS. The Bristol-Myers Squibb Foundation (hyperlink to: http://www.bms.com/foundation/Pages/home.aspx) promotes health equity and improves the health outcomes of populations disproportionately affected by serious diseases and conditions, by strengthening community-based health care worker capacity, integrating medical care and community-based supportive services and mobilizing communities in the fight against disease.
ABOUT THE PROGRAM
In 1999, during the early assessment period, Bristol-Myers Squibb and the Bristol-Myers Squibb Foundation, in consultation with local health experts and ministries, recognized there was a lack of groundbreaking ideas to address HIV/AIDS in children. At that time, 1.4 million children were living with HIV in sub-Saharan Africa. Although research showed that without treatment half of HIV-infected infants die by age 2, few received treatment because pediatric AIDS drugs were largely unavailable, and public health systems lacked the facilities and trained health care providers (HCPs) to provide lifesaving care. In response, the foundation reviewed its SECURE THE FUTURE® program and assessed how pediatric HIV/AIDS prevention, treatment and care could be brought to millions of children living with HIV/AIDS in sub-Saharan Africa.
The foundation turned to Dr. Mark Kline, founder of the Baylor International Pediatric AIDS Initiative, to travel to Botswana to speak with the country’s Ministry of Health and pediatric health experts. Botswana was chosen because it had the highest HIV prevalence in sub-Saharan Africa at the time and because of its pioneering efforts to begin widespread distribution of antiretroviral therapy (ART).
The foundation learned that Botswana’s health care system was unprepared to prevent mother-to-child HIV infections or to provide ART to children born HIV positive. Children require different treatment formulations and dosages than adults, and more complex and expensive tests to detect HIV infection.
Though an alarming 36 percent of Botswana’s pregnant women were infected with HIV, leading to a rapid increase in babies born with HIV, few children were receiving antiretroviral therapy because the country’s treatment efforts for mother-to-child transmission of HIV were just getting started. Additionally, there was an acute shortage of equipped community-based clinical facilities and of HCPs trained in pediatric HIV.
The BIPAI Initiative
The Botswana assessment led to the creation of the BIPAI initiative in Africa, a component of SECURE THE FUTURE®, consisting of a three-part approach:
1: Children’s Clinical Centers of Excellence. The Bristol-Myers Squibb Foundation and BIPAI constructed and equipped five tertiary care centers – known as Children’s Clinical Centers of Excellence – in Botswana, Lesotho, Swaziland, Uganda, and Tanzania. These centers, designed to become part of the national health systems and the national rollout of pediatric treatment,, provided emergency and outpatient care, pharmaceutical needs, laboratory services, HIV counseling and testing and psychosocial care. They also offered training for local and visiting HCPs. Electronic medical record systems were used to monitor and evaluate the program. Bristol-Myers Squibb and the foundation funded $18.7 million for these centers; Abbott Fund committed $6.8 million for Malawi and an additional center in Tanzania and $15 million to coordinate and evaluate the network of centers.
2: Pediatric AIDS Corps. In response to the shortage of local HCPs, the foundation and Baylor created a program that recruited physicians, mostly from the United States, to work in the tertiary care centers but more importantly in remote and rural regions to provide training to local health providers in primary health centers. All were board-eligible or board-certified in pediatrics, family medicine or internal medicine, and 80 percent were specialist pediatricians. After four weeks of training at the Baylor College of Medicine, the Pediatric AIDS Corps physicians stayed at their African posts for 12 months. Beyond that, 37 percent stayed a second year, and of those, 33 percent stayed even longer. The goal was to stay until in-country physicians and other health care providers could be trained. The foundation funded $22.5 million for salaries, administrative costs, training, living and travel expenses for the Pediatric AIDS Corps for up to 260 AIDS Corps doctors over five years. The Baylor College of Medicine provided loan repayment for the doctors of up to $40,000 a year for each year of in-country service.
3: Public-Private Partnerships. In each country of operation, Baylor created NGOs to negotiate and coordinate the program’s contributions and the nature of its collaboration in Memoranda of Understanding (MoUs) with the ministries of health. The ministries agreed to provide the land for the centers, to integrate the centers into their countries’ public health systems, to provide operating costs for the centers and to provide medications delivered through national treatment programs. SECURE THE FUTURE® provided the funding to build and equip the centers and to monitor and evaluate progress.
Reach
As of June 2013, more than 170,000 children and family members are being treated in the centers. About 40 percent are now teenagers, most whom have grown up because the program saved their lives.
CRITICAL SUCCESS FACTORS
Including whole families and communities, not just individuals: As the centers matured, the range of services expanded to provide ART to teens and adult family members, as well as integrated TB/HIV services. Centers now also treat malaria and sickle cell anemia.
Providing on-going training opportunities: More than 700 HCPs per month attended educational lectures at the Children’s Clinical Centers of Excellence and more than 500 HCPs per quarter were spending at least one week under direct supervision of the center’s staff. Originally, pediatric HIV training and ongoing mentoring were conducted by the Pediatric AIDS Corps physicians; however, those functions are now fulfilled by local physicians recruited at the Centers of Excellence and a new Global Health Corps helps address gaps in care.
Working in partnership with national health systems and ensuring sustainability: When the Baylor initiative started, the Children’s Clinical Centers of Excellence were the only place providing complete care for children living with HIV/AIDS. As district hospitals and primary health centers received training from Pediatric AIDS Corps physicians, these facilities were able to treat pediatric AIDS. The centers, fully integrated into the national health care systems, now treat the most serious cases, while district hospitals and health centers manage the rest.
Integrating into national policies: The program contributed to the development of national guidelines on HIV issues, including treatment, prevention of mother-to-child transmission and the care of infants born HIV-positive and exposed to HIV through breastfeeding.
Adapting to a changing climate: When the first center in Botswana opened in 2003, the average age of an infected child was 5 years. In 2013, the average age is 14, due in large part to the Botswanan Government’s success in preventing mother-to-child transmission and ensuring that perinatally-infected children survived to adolescence and beyond. Since adolescents require different services and approaches than younger children, the centers expanded their services to include Teen Clubs that offer psychosocial support and help adolescents living with HIV to adhere to their treatment regimens. In 2013, Botswana opened a newly built Adolescent Centre of Excellence.
Engaging Bristol-Myers Squibb employees: Employees donated money for part of the construction of the new adolescent center in Botswana. Their contributions were matched one-to-one by the Foundation and their names are displayed in the facility.
“After 10 years working on pediatrics in partnership with BIPAI we can see the benefits from our investments,” says John Damonti, President, Bristol-Myers Squibb Foundation. “Children are thriving, treatment and care has been rolled out to remote areas and our center networks are all supported through the national government and other external funding sources. The work is far from over but there is a solid and well-managed foundation to work from.”
“We may be able to go out of business in the pediatric HIV arena. That would make us the happiest unemployed folks in the world.” – Michael Mizwa, COO and Senior Vice President, Baylor College of Medicine’s International Pediatric AIDS Initiative.
Lessons Learned
Diversified funding is key to sustainability. Initial funding for the Children’s Clinical Centers of Excellence came from the Bristol-Myers Squibb Foundation, Abbott Fund, Texas Children’s Hospital and Baylor College of Medicine. However, the long-term sustainability of a program of this scope required multiple sources. The centers now receive annual cash subsidies and provision of medicines from local ministries of health, and funding from international donors such as USAID, PEPFAR, CDC and UNICEF.
Work earlier with ministries of health to recruit and train local health workers. It was difficult to replace the Pediatric AIDS Corps with local physicians, who were in short supply, and to provide care and training. Over time, physicians were recruited locally and from neighboring African countries—but recruitment should have begun earlier, when the first center opened. Additionally, the program could have worked earlier to train nurse practitioners to treat and care for patients in the many sites without physicians, a practice called “task-shifting.”
Community outreach plays a key role. During the course of the program, the foundation and Baylor realized the difficulties in getting people living with HIV to adhere to their HIV treatment and to keep clinic visits. Special counselors were assigned to assist patients and their caregivers to make sure that they stuck with their medical regimens once they left the clinic While the Children’s Clinical Centers of Excellence still lost some patients to follow up, having members of the community reach out to patients at their homes greatly improved retention.
LEARN MORE
http://www.bms.com/news/features/2013/Pages/TeenagersLivingwithHIVAIDS.aspx
http://www.securethefuture.com/our_experience/funding/STF_SEC.pdf