Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016

Annex 2: Ministry of Health model of decentralised HIV CST

The Ministry of Health’s model of decentralised care for HIV CST, centred on the role of puskesmas linked to hospitals is outlined in Figure 2. The design of REACH’s CST component is based on this model.

Figure 2: Indonesian Ministry of Health model of decentralised HIV care, support and treatment

Annex 3: Key achievements in CHAI Phase II

Table 12: Summary of key achievements in CHAI Phase II

Project area	Achievements in CHAI Phase II
Care, Support & Treatment	More new patients detected and with early diagnosis, more new patients on treatment at CHAI-supported sites (on treatment before CHAI = 83, after 17 months of CHAI in two sites = 876) Successful decentralization of HIV services / more sites providing ART and/or follow-up services for HIV positive patients: In Jayapura, Yowari hospital and 3 puskesmas are now providing ART, with 5 other puskesmas trained and starting to follow up patients. In Wamena, Wamena hospital and 2 puskesmas are now providing ART, with 4 other puskesmas trained and starting to follow up patients Low rates of Ioss to follow up of patients on ARVs: 20 per cent LTFU cases before CHAI, N=128; 7 per cent after CHAI, N=498 Better rates of care support: 100 per cent of positive patients at both sites receiving care support from health facility or family Increased PMTCT access: Facilitated policy change in Yowari hospital, where pregnant women now have 24 hour access to HIV testing Increased PITC implementation: Facilitated agreement from Yowari and Wamena hospitals on PITC implementation and standard operating procedures; Better program and service coordination: Reactivation of the CST working Group of Papua Province AIDS commision, which had not been active for almost 5 years; Successful TOT implementation leading to GoI-run mentoring plan: Staff mentored and trained local clinicians and public health officers as trainers in Jayapura, resulting in Yowari hospital and District Health Office now conducting regular Puskesmas mentoring visits Introduction of Task-shifting: strong nurse-care models in Kalvari Klinik and Puskesmas (PKM) Kota Wamena Demand creation: many new districts requesting CHAI technical assistance for their HIV-related services
Supply Chain Management	Drastic reductions in stock outs: since the program’s inception in 2009, the number of site level ARV stock outs dropped to 0.9 per cent, with only two sites reporting a stock out in the last six months. Incidence of stock outs reduced from 87% to < 1% Successful decentralization of ARV management: East Java, West Java, Bali, and Papua are now managing ARVs for their provinces, constituting 33 per cent of Indonesia’s patient population Increased number of sites trained on reporting, recording, and inventory management: Cumulatively, CHAI has trained 181 ART sites, representing 60 per cent of the total sites and 69 per cent (16,799 patients) of the total population currently on treatment. This has helped increase the number of ART sites now reporting to 86 per cent Successful launch of a nationally managed HIV rapid test supply chain: 16 pilot sites trained in Central Java and Papua provinces
Policy	Significant technical support on guidelines development and finalization: Staff edited final versions of the ARV and Provider Initiated Testing and Counselling guidelines and provided input on the STI and Prevention of Mother to Child Transmission guidelines Implement Task-shifting at province level: Collaborated with the Papua Provincial Health Office, WHO, and UNICEF to develop and implement institutional and professional task-shifting to ensure accessibility of HIV testing for pregnant mothers and support the prevention of mother to child transmission Successful implementation of national policies to local-level: National policies have facilitated CHAI’s technical assistance in Papua, including Provider Initiated Testing and Counselling Sub Directorate AIDS-endorsed policy review process: CHAI developed with the Australasian Society for HIV Medicine an evidence-based guideline and policy review process initially endorsed by the AIDS Sub Directorate AIDS and the Ministry of Health

Annex 4: Lessons learned from CHAI Papua New Guinea

In PNG, the AusAID funded CHAI Rural Initiative project has been supporting the decentralisation of HIV CST in rural provinces since 2006. While PNG’s overall HIV prevalence is 0.9 per cent, prevalence in the highlands is estimated to be between 2-3 per cent, based on antenatal surveillance.

CHAI has been working with the PNG National Department of Health in development of a model for rural care and treatment that has met with considerable success. When CHAI PNG began their pilot program in late 2007 in the Eastern Highlands Province, access to ART was very limited. As of March 2012, there were over 2,000 registered HIV patients with over 1,200 on ART. These patients were being seen at 10 rural district level facilities (similar to a puskesmas) with rates of lost to follow-up under 10 per cent at 12 and 24 months. CHAI’s approach in PNG is similar to that of REACH in that it works with the government health system to decentralise services by providing technical assistance in key areas such as supply chain management, laboratory, data collection, clinical mentoring and quality assurance.

While there are distinct differences between PNG and Indonesia in terms of health systems and operational contexts, there are a number of inherent similarities that result in a high potential for effective cross border sharing of lessons learned. Of particular interest may be cultural approaches to testing in rural areas. For example, through an innovative outreach model, CHAI has tested over 15,000 rural people in clan-based settings and linked those testing HIV positive to care and treatment. The CHAI PNG experience has been that many remote communities are more likely to test en masse than to seek HIV testing services individually. Patient retention activity, through an innovative case management model has sought to address barriers posed by factors such as the rugged terrain in remote areas. Similarly, program implementation has thoughtfully paid attention to the cultural significance of gender relations in terms of the status of highland’s women and issues related to partner disclosure following a positive diagnosis in PMTCT and partner testing. Table 13 below summarizes ways in which CHAI’s efforts in PNG may usefully inform REACH.

Specific PNG program activities which may be applied to REACH will be clearly defined and integrated into REACH annual work plans. The approach to sharing will depend on the task specified and could range from sharing of curricula for expert clients to training of trainers in models of patient retention, targeting clinic based health workers.

As REACH develops, especially with its intensive efforts in operational research, it too will have valuable lessons to share with CHAI’s PNG program. There will be close, on-going collaboration and information sharing between both CHAI teams, facilitated by CHAI’s regional office.

Table 13: Lessons learned from CHAI Papuan New Guinea of relevance to REACH

Component approach	Positive experiences	Challenges	Tools that could be Shared with the Papua Program
Health Systems Strengthening approach to HIV service delivery	Using HIV as a vehicle for HSS couches HIV appropriately within the Health System, thereby building capacity for HIV as well as other services and optimizing investment.	It is best to use this approach from the beginning of an initiative; this is the most demanding approach and therefore can be difficult.	Model to map HIV investment for HSS. Adopting the PIH Four Pillars Approach.
Decentralization of care with centralized coordination	Decentralization of services reaches more patients and builds capacity of more HCWs. Centralized coordination creates a network where resources of all kinds can be pooled and shared. Network of HCWs creates unity and affords opportunity for standard quality assurance that individual clinics could not achieve.	Requires unification by an accepted lead authority of disparate facilities that may or may not be under the same health administration.	Model of functional unit with a referral facility as the hub with higher technical expertise based there to create Centres of Excellence where best practices are modelled. Sharing of experiences of increasing ownership of the program by HCWs and administrators.
Uniform and centralized data collection	Uniform use of job aids-clinical and other patient evaluation forms assists with consistent quality of care. Entry of forms into comprehensive HIV database that includes both clinical and psychosocial data creates electronic medical records to manage missed appointments, drug ordering, as well as program planning for any number of variables, such as access to clean water or food insecurity.	Requires a centralized data manager and solutions for data entry and merging multiple databases into one	Job aids including all clinical and other forms can be adapted for use in Indonesia through translation and other modifications as necessary. The Rural Initiative database is access-based and is easily shared, as is information about networking and generating reports.
Clinical services oriented towards patient retention vs. clinician convenience	Higher patient retention rates Increased clinician satisfaction from more efficient clinics and improved patient outcomes	Patient retention strategies for pre-ART are not the same as for ART patients. Strategies must be reviewed and renewed at least annually based on program evaluation and informed by on the ground experience	Models of patient flow-high throughput and low throughput Task-shifting models SOPs for patient retention
Laboratory strengthening	Centralized coordination of consumables, QA and reporting creates excellent data for the catchment area, accurate consumption rates, and illustrates locations where program is strong or weak. Movement toward point of care technology esp. for antenatal HIV, Hb, Syphilis, HIV, CD4, and TB.	Government involvement and support of POC testing is important for sustainability	Templates for Laboratory record keeping Site Consumption Reports QA for laboratory work done by HCWs Data from study of PIMA CD4 point of care trial in the field in rural PNG (most other validation are laboratory-based) GeneXpert-based algorithm for IPT implementation and SOP for preparation to implement. SOP for one-finger-prick POC antenatal testing
Creation of patient pathways between facilities and clinical areas	Creating linkages between clinical areas and different facilities with SOPs, information sharing, and or capacity-building in clinical areas of greater significance for HIV detection and referral such as STI, TB, peadiatrics and ANC	A patient pathway is only as good as the linkages between the sites; in order for this component to work, personnel understanding and motivation as well as the capacity to follow through has to be assured.	Models of patient pathways used in PNG Rural Initiative
Greater Involvement of PLHA	Using carefully selected trained expert clients in HIV peer counseling, in adult, PPTCT and pediatric settings can increase patient satisfaction and adherence and provide needed assistance to HCWs.	Providers must be involved in developing selection criteria for expert client candidates, and clinic infrastructure must be assessed for implementation. If peer counseling is relegated to outside waiting areas the intervention could have the opposite effect of creating patient loss.	CHAI Expert Client Training Curriculum, TORs, Time and Tally Sheets, and Code of Conduct for Expert Clients.
Appropriate technologies for health			Plans for high through-put, low cost and low operating cost medical waste incinerator, personal rain catchment. Other site appropriate technology, such as headlamps for pelvic exams, container clinics, solar LED lighting for health centres.