Challenges in taking Forward ART Program In Pakistan

An Update

Establishment of Treatment Centers:

The Global Fund - Round 2 provided support through the provision of Anti-retroviral therapy for 800 patients. When the project was submitted to The Global Fund it wasconceptualized that the establishment of the Anti-retroviral therapy Treatment Centers in all the provinces will be done through their respective programs supported by the World Bank in their PC-1.The ARV Drug gap identified was covered in the Global Fund Round 2 project.

The Global Fund Round 2 project got approved in 2003 and funding was approved for initial two years. At thesame time all provincial programs were requested to expedite the process of establishment of the treatment centers. The HIV Treatment and CareCenters established under the Enhanced HIV/AIDS (combined initiative of the World Bank and Government of Pakistan) were to be located in tertiary care, public sector teaching hospitals. These centers are to provide comprehensive HIV care services to HIV positive people and their families including free antiretroviral therapy (ART). NACP initiated the process of establishment of thetreatment centres in PIMS and at Mayo Hospital Lahore. The treatment centres became operational in the following order:

  • PIMS Centre in November 2005
  • MayoHospital Centre in December 2005
  • Hayatabad Medical Complex Centre in December 2005
  • Civil Hospital Centre in January 2006
  • BolanHospital Centre in June 2006

Development of guidelines:

With the establishment of the treatment centre the next step was to train Health Care Providers in managing HIV/AIDS patient through the use of ARVs. This was a challenging job as it could not be done without the development of national guidelines and protocols. With this started the tedious and challenging process of development of the guidelines which was done by NACP involving all the stakeholders. The following guidelines were developed and approved:

  • National ARV Guidelines ( regimens and how to use them)
  • National Selection Criteria for ARV management
  • Standard Operating Procedures for The HIV Treatment and CareCenters
  • Center forms

1)Initial visit forms

2)Follow up visit forms

3)Referral forms

4)Counseling forms

5)Consent forms

6)Follow up charts

7)Reporting proforma for ARV utilization and pharmacy inventory

  • National Guidelines for Infection Control
  • Prevention of Parent to child transmission of HIV Clinical guidelines
  • Prevention of Parent to child transmission of HIV Strategic framework

Training of Health care providers:

Whilst the in-country protocols and guidelines were being formulated, 8 weeks training was conducted in Mumbai by the CARAT institute working under TATA institute of social sciences and 15 health care providers were trained to operationalise the treatment centers. Thesepersons were trained as master trainers to further train the health care providers in Pakistan. Training had to be identified keeping in view the specific requirement of the programme and necessary arrangements had to be made to obtain NOC for the participants from their respective departments.

Procurement of ARVs:

In view of the fact that this was the first-ever initiative for Pakistan as well as NACP to be procuring ARVs, necessary processing was required. This included firstly, to register antiretroviral (ARVs) medicines with the drug regulatory body prior to procurement. After which the procurement process of the ARVs was initiated getting all the cost estimates from UNICEF. ARVs became available in July 2005. In terms of country procedure, it is worth mentioning that the entire processing was done in record time.

Operational difficulties:

With centers fully operational and staff in place and ARVs available the access to care and support remained critically low due to the following reasons:

Prevailing stigma and reluctance disclose HIV status

Low numbers of people identified through VCT

Poor referral linkages in the community

Poor utilization by individuals from High Risk Groups

Poor quality of care and judgmental attitudes of health care workers in the HIV care centers

Low motivational level/interest of staff working in the HIV care centers

Lost to follow up

Poor compliance with ART leading to increased mortality/morbidity

Bottle necks on the Achievements in Target Strategies

  1. Expanding Partnerships (Public-private or public-public)
  2. Building Linkages with NGOs
  3. Strengthening of VCT to increase uptake

At that stage new strategies were adopted to increase ARV roll out that included developing partnerships with private hospitals interested in providing HIV care to the more marginalized and impoverished section of the HIV positive population. These private hospitals (i.e ShaukatKhanumMemorialHospital, Lahore and LiaquatNationalHospital, Karachi) are nationally reputable institutions and have trained Infectious Disease and HIV/AIDS specialists working in the HIV care centers. SKMH is providing viral load and CD 4 testing facilities. Similarly MOU was signed with SIUT to providing the testing facilities.

At 18 months when CCM request for Phase 2 funding was processed the target of number of patients On ARV was increased from 800-1000. By the end of phase 1, 164 patients were on ARV from all over the country. This was an unacceptable situation and thus after in-depth analysis of the situation, NPM- NACP shifted the management of ARTCenters to the PR team. This decision brought a real turnaround as the PR Team devised the enhanced strategy and straight went into implementation at an accelerated pace to increase ARV rollout through involvement of various stakeholders ensuring ownership.

Extended Strategies for ART Program:

In view of the lessons learnt the PR held extensive consultations with various public and private sector stakeholders in formulating the extended strategy for taking forward the ARV Program. Details are as follows;

  1. Decentralization of HIV care and antiretroviral therapy- Increasing the number of treatment centers:

Decentralizing services to district hospitals allows increased access, equity and better support of adherence to care and treatment by providing HIV care and antiretroviral therapy close to the home of the person being treated. This approach relies on all levels of the health care system playing a role in caring for people living with HIV. Decentralizing HIV care and antiretroviral therapy requires simplified treatment guidelines that allow antiretroviral therapy and opportunistic infection management outside specialized referral centers. Effective training and strong follow-up after training are important to ensure the consistent application

of simplified guidelines that will benefit the largest number of people.

In order to decentralize the ARV treatment program extensive efforts are being made which include increasing the geographical accessibility of the HIV care centers. With the collaboration of NWFP AIDS Control program a new centre is being established in Kohat, at KohatDistrictHospital.

  1. Addressing the accessibility issue:

Another centre is planned to be operational with collaboration with Sindh AIDS Control Program at JPMC Karachi to ensure better accessibility. Karachi is a very large metropolitan city with two ports. In view of the present statistic, Karachi has the highest and increasing number of HIV + cases thus it is imperative to address the accessibility issue.

  1. Strengthening existing Centre

The treatment centre at Services Hospital Lahore is being strengthened to be able to work on full potential. This includes provision of staff, equipment furniture and fixtures. It is envisaged that this will increase both in door and outdoor attendance as Services hospital and mayoHospital will offer in-patient facility that is much needed. It is worth mentioning that the private hospitals do not extend any in-patient facility to HIV+ patients. Thus, it is very important to upgrade and refurbish these public sector center to be able to extend full range of services to the patients.

  1. Involving NGOs working with PLWHAs

Formal linkages with NGOs, PLWHA organizations and other potential referral/entry points needs to be strengthened to promote ARV roll out. This linkage/referral chain will to be coordinated and monitored on a regular basis to assess effectiveness and functionality. This will also include sustained follow-up of the patients to ensure compliance and immediate addressal of their health needs in terms any other infections etc or requiring inpatient facility. It is envisaged that this will form the backbone of the entire treatment program.

  1. Linking VCTs and Treatment centers to all service delivery projects

In Pakistan where HIV is still a less common disease but has tremendous stigma, the concept of VCT is difficult to absorb. However, within the broader context of strategic behavior change communications VCT can become a cornerstone for increasing number of people appropriately counseled and tested for HIV. With this view PR has planned to organize a collaborative meeting which shall be used as a forum to officially link the 16 VCT centers and treatment centers under the guidance of the Provincial AIDS Control programs. In this regard consultative meetings are planned for integrating all service delivery projects with the VCT and the treatment centers. The VCT staff through outreach activities will be extending counseling and testing services to the vulnerable groups, i.e., MSMs, IDUs, FSWs, Jail inmates etc through public private and private private partnership.

  1. Private Practitioners

NACP and the PR is making efforts to request Clinton Foundation office in India to facilitate them in taking forward a very innovative project to involve the private practitioners in the overall ARV care and support program. It is worth mentioning that this project is doing well in India thus in view of the cultural similarities will be successful in Pakistan as well. Presently private practitioners are the first point of consultation to almost 70% of population, this making them a very important group of service providers. It is envisaged that this initiative will expand the referral base to a considerable level.

7.Training of Staff & Continuing education

Expansion as well as decentralizing HIV care and antiretroviral therapy requires capacity-building at various health facilities so they can provide services that previously have been restricted to specialized referral centers.

Furthermore, have a system of continuing education is yet another important area that needs to be addressed. Usually, once trained there is very little follow-up with trainees after initial training. In addition, recently trained providers usually have little access to experienced providers to call upon for consulting, reviewing cases, solving problems and reinforcing clinical decisions and diagnoses. Staff reeducation and ongoing clinical training must be strongly emphasized to ensure high-quality care and addresses the public health concern of the spread of HIV drug resistance in the setting of rapid enrolment and scale-up. In order to address this, provision has been made in the proposed budget for continued education.

  1. HIV/TB

The management of patients co-infected with HIV and TB is complicated clinically and programmatically. Trained staff can play an important role in improving the quality of care of HIV/TB co-infected patients of both of these aspects. Close coordination with the TB control programme is necessary, but integrated training activities are natural at the district and facility level.

In this context, NACP is going to work closely with the national TB Control Program as well as the NGOs working in TB service delivery such as Pakistan Anti TB Association.

Clinical aspects will include:

  • diagnosing TB among people living with HIV;
  • initiating and managing antiretroviral therapy among patients receiving anti-TB treatment, including managing drug side effects;
  • managing TB reconstitution syndrome among patients starting antiretroviral therapy
  • offering HIV testing to people suspected of having or definitely having TB.

Supervisory aspects will be:

  • HIV testing and counselling of everyone suspected of having TB;
  • prompt referral from the TB programme to the HIV care team and vice versa
  • co-treatment support for TB treatment and antiretroviral therapy, including directly observed antiretroviral therapy in certain cases.

9.PPTCT Program

NACP is in the process of establishing 5 PPTCT sites in the Obstetric wards of PIMS-Islamabad and 4 provincial capital hospitals. All protocols and guidelines have been made. It is envisaged that once these are operational it will also contribute considerably towards identification of HIV+ women.

The PR Team also conducted an in-depth analysis of the current scenario related to slow progress of the ART Program. Based on the analysis undertaken by the PR, certain facts became evident that included:

  • Provincial Programs need to have a more proactive role
  • VCT centers lacked linkages with the Treatment Centers
  • VCT centers often lost clients during referrals
  • Testing facilities required improvement through outreach services
  • PLWHA associations needs to be involved more
  • NGOs working with PLWHA also need to be more involved
  • ARV roll out was slow and needs immediate measure to step up

In light of the above findings, it seems imperative to bring all the stakeholders on one forum to discuss the above issues to improve coordination and outline best possible collaborative interventions. It is in this context that a two-day coordination meeting is being scheduled in all the provinces. The objective of the meeting is to develop strong linkages between the Provincial AIDS Control Programs, MSS-VCT centres, NGOs/PLWHA groups and HIV/AIDS Treatment Centers for better coordination leading to optimum performance. Thus provincial Coordination Meeting were held with a wide range of public/private sector stakeholders in association with Provincial AIDS Control programs. A total of approx 550 participants participated nationwide.

Along the way, the Provincial Program Managers were involved for better performance and ownership, the PR Team also scheduled specific meeting with the Project Managers of Provincial AIDS Control program and explained the revised strategy for up-scaling and strengthening the Treatment program. Based on lessons learnt from the previous years of treatment program it was decided that to increase ARV roll out and ensure sustainability it was necessary that the provincial programs give leadership to the treatment program. Various strategies were discussed in length e.g. to avoid loss of patients during referrals, it was decided to open new centers and strengthen the existing ones; develop linkages between treatment centers and VCT centers; Involvement of PLWHA groups and civil society was also emphasized. The revised strategy was prepared in light of the discussions held with the PPMs. Under the new strategy in order to ensure patient compliance and follow up, new HIV centres have to be opened, meetings were held with the respective Program Managers to discuss necessary details.

Some of the revised strategies included:

Increasing the geographic accessibility of the HIV care centers

Improving access through enhanced partnerships with private hospitals:

Enhancing quality of care to increase HIV care utilization

Strengthening community linkages with broader range of NGOs

Scaling up VCT

In order to make these collaboration meetings a success, it was envisaged that this tripartite activity between The Global Fund, NACP/PACPs and NGOs will be an experience to remember in exhibiting public-private partnership in taking forward HIV/AIDS Treatment Program in Pakistan. The agenda for this two day activity was formulated in a way that first day focussed on reviewing the component of Treatment Program with respect to VCT; developing linkages and identifying roles /responsibilities of various stakeholders and the second day towards VCT Review Meeting for revised strategies and enhanced role of persons of the Treatment Centers; NGOs; vulnerable groups and of PACP

It is worth mentioning that the HIV/AIDS epidemic is relatively new to Pakistan particularly the complex aspects of treatment and care. We are currently undergoing the normal learning curve for both health care providers and PLWHA. Learning from the experience of other developing countries and realizing that there is no clear cut “easy solution”, Pakistan is trying out different approaches in rolling out ART. With enhanced strategy and involvement of the district government the number of patients on ARVs is showing an upward trend and with the current pace the target of 1000 patients on ARV shall be successfully achieved.

Challenges in implementation: Lessons Learnt

  • Some of the early experience of rolling out ART in Pakistan highlighted the logistical and health infrastructure problems inherent to many developing countries. Pakistan was no exception. Located in public sector hospitals these HIV Treatment and Care Centers faced issues of insufficient linkages and referral systems with non-governmental organizations (NGOs) and PLWHA, unrealistic patient expectations of HIV infection and ART, strong mistrust of the public sector health system, poor concept of continuity of care, and unfriendly attitudes of health care providers. These in turn lead to sub-optimal treatment adherence with risk of developing drug resistance, low patient satisfaction and poor quality of care.
  • It took NACP some time to develop treatment guidelines and protocols which had to be adhered. Secondly, when it came to giving out ARVs, a need was felt to disseminate the message that not every positive patient requires ARV and the selection criteria had to be strictly followed. Some NGOs misunderstood/misinterpreted this message and started advocating that ARVs are available in Pakistan they are not being given to the patients. At this stage a need was felt to focus on the following areas to ensure long term sustainability and success of HIV treatment and care centers including effective delivery of ART in a consultative way through an integrated multi-pronged approach.
  • Promoting ART literacy-when to start, who will benefit most, treatment adherence, better understanding of side effects, resistance risks.
  • Building linkages-from the community to facility to community and greater involvement of civil society and ownership of the Provincial AIDS Control Programs
  • Improving attitudes of health care providers-reducing stigma, dispelling myths, promoting ethics and patient confidentiality.
  • Trainings in HIV/AIDS and ARV management for care providers at large to promote non-judgmental attitude towards HIV+ patients.
  • In view of the limited movement of the people especially women, to increase the number of treatment centers to facilitate accessibility. Establishing the treatment centers within tertiary hospital to ensure one window service approach.
  • Provision of in-patient facility for HIV+ patients as and when required in wards and training of the wards staff in non-discriminatory behaviour.
  • Provision of diagnostic services for CD4 and Viral load test. There is only one such facility available in public sector i.e., in PIMS-Islamabad. This facility is catering to entire province of NWFP and northern Punjab. For the rest of the country such facilities are sought through private sector i.e., ShaukatKhanumHospital for central and southern Punjab from Sindh institute of urology and transplant-Karachi for entire province of Sindh and Balouchistan. This is a very limiting factor in the overall treatment program because as per protocol all patients need to have their CD4 and vial load levels done prior to be put on ART. Recently, ShaukatKhanumHospital has started charging for the CD4 and viral load and thus the burden for entire Punjab province has also come on the PIMSCenter. (These issues are being addressed through The Global Fund Round 7 proposal)
  • To establish GF funded centers to ensure smooth and standardized services for an initial period that can be taken over by respective provincial AIDS Control Program. This is important as in order to exhibit a cost-effective efficient model of services and referral for sensitive diseases such as AIDS, initially it should be funded by a single source to identify the most appropriate strategies and best practices. Once the model is successful it ca then be part of the mainstream of services and can be replicated.
  • PHLA need logistic support for travel and lodging facilities when they come for initial diagnosis and then for treatment. Unfortunately such much needed support is not extended by any organization and additionally will be difficult for any donor to pick this sort of cost. Thus, a gap remains between provision of services and accessibility by the patients. Todate these costs have been met by adhoc arrangements on case to case basis.

Strategies to Address Barriers/Challenges