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The Project HEART Experience:
Assessment of an HIV Care and
Treatment Program
Amanda D. Castel, MD, MPH
Assistant Research Professor
Michelle Gill, MPH
EGPAF/GWU Partnership Executive Coordinator
Department of Epidemiology and Biostatistics
The George Washington University School of Public Health
and Health Services
EGPAF/GWU Partnership
April 30, 2009
Assessment Goals
 Examine different models of service delivery
for care and treatment scale up in 3 of 5 PH
countries
 Examine different approaches to providing
technical and programmatic support for care
and treatment (not PMTCT focused)
 Identify best practices, challenges,
solutions, and obtain recommendations from
the field
 Identify ways to further support and
integrate care and treatment in PH countries
Assessment Team Members
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GWU Faculty and Staff
– Amanda D. Castel, MD, MPH (Overall Assessment Team Leader)
– Michelle Gill, MPH (Zambia, TZ)
– Irene Kuo, PhD, MPH (Team Leader for Zambia trip)
– Jennifer Skillicorn, MPH (Cote d’Ivoire)
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External Consultants
– George Beatty, MD, MPH (UCSF) (TZ, Cote d’Ivoire)
– Judith Justice, PhD, MPH (UCSF)( TZ, Zambia, Cote d’Ivoire)
– Maureen Shannon, CNM, FNP, PhD (Univ. of HI)(Zambia, TZ)
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EGPAF Staff
– Lindsay Bonanno (Tanzania)
– Nicole Buono, MPH (Cote d’Ivoire)
– Stephen Lee, MD (Zambia)
– Ric Marlink, MD
– Rose McCullough, PhD (Tanzania)
Focus Areas
Management
Models of Service Delivery
Quality of Care/Continuum of Care
Community Linkages
Policy Analysis and Influence
Training/Mentoring/Supportive
Supervision and Capacity Building
 Quantitative Evaluation Systems
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Assessment Methods
 Developed quantitative and
qualitative tools
 Conducted document review and
desk audit of relevant program
information
 Conducted site visits
 Conducted in-depth interviews
 Wrote country level reports and
global report
Country-Level Interviews
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EGPAF U.S. and country staff
Centers for Disease Control and Prevention
Other PEPFAR funded Track 1.0 Partners
MOH programs: e.g., National AIDS Control
Program, TB/HIV, M & E, District or Regional
AIDS Coordinator
Supply chain and drug procurement
organizations/agencies
NGOs, CBOs, FBOs
Sub-grantees
Staff at clinical sites, N=49 sites
Country Visits
 Teams:
– 5-6 members for each trip
– EGPAF, GW faculty and staff and external
consultants
 Zambia- June 2008
– 18 sites visited
– Range: 494 - 7,453 patients per month*
 Cote d’Ivoire-July 2008
– 16 sites visited
– Range: 43 - 3,026 patients per month
 Tanzania- September 2008
– 15 sites visited
– Range: 123 - 3,997 patients per month
*Data not available for 2 sites
Sites Visited, N=49
Characteristic
Number
Setting
Capital city
13
Other Urban
17
Peri- Urban
8
Rural
11
Public
30
Private/FBO
19
C and T/PMTCT
33
Primary
31
Secondary
10
Tertiary
5
Peripheral
3
Site Type
Service Provided
Site Level
Summary Findings by
Focus Area
Management
 Strong and responsive U.S. and
country management teams
 Opening of sub-offices in some
countries
 Addressing challenges related to
financial and contract management
 Need for regular communication
between U.S. and country offices
Policy Analysis and Influence
 EGPAF or sub-partner playing major role in
development of key policies related to C & T
 Provide substantial technical assistance and
guidance on development of guidelines and
regulations
 Recognized as a leader in area of HIV C & T
 Working to influence task-shifting in
response to healthcare worker shortages
 Coordination with other treatment partners
could be improved
Models of Service Delivery
 Various partners and approaches used based
on host country’s needs
 District approach allows for sustainability and
“standard” approach to C & T service delivery
 Working with the public sector reaches the
most people and solidifies EGPAF’s
relationship with host MOH
 Single-service sub-grantee may present
challenges with regard to sustainability
 Performance-based financing preliminary
results are encouraging
Quality of Care/Continuum of Care
 Clinical care that is generally based on WHO or
national guidelines and standards
 Beginning of task-shifting activities at a limited
number of sites
 Limited access to viral loads, RNA and DNA PCR
and second line regimens
 Healthcare worker shortages require creative
solutions – use of PLWHAs, overtime allowances,
task shifting
 Variable linkages and integration of C & T with TB
and PMTCT
 Pediatric C & T lagging behind that of adults
 Need systematic mechanisms to track patients lost
to follow-up
Community Linkages
 Community linkages were not consistently
integrated into continuum of care
 EGPAF U.S. and country offices beginning to
recognize the importance of community and
linkages
 Varied approaches to implementation of
community linkages programs and services
 Creative use of PLWHA and expert patients
 Lack of nutritional support and transport identified
as barriers to continuity of care
 Limited coordination of referral systems between
community-related groups and C & T sites
Training/Mentoring/ Supportive
Supervision/Capacity Building
 Successful leveraging of available incountry expertise as a resource for training
and guidelines development
 High quality initial training in adult and
pediatric ART
 Methods to measure retention and
application of knowledge still need to be
determined
 Health care worker shortages and rapid
turnover of staff
Quantitative Evaluation Systems
 Dedicated U.S. support staff to focus on
programmatic, technical and M&E issues
 Existence of electronic databases in
countries which improve patient tracking
and efficiency of data management
 Attempts to harmonize indicators and
develop standard reporting forms
 Recognition of the importance of QI
mechanisms to improve patient services
 Limited feedback and use of data to
improve programs
Major Recommendations
Major Recommendations
 Continue to take a leadership role in formulating
and advocating for policies related to the delivery
of C & T, including task-shifting, transportation
and supply chain management
 Strengthen achievements in pediatric C & T
 Address issues related to quality of care such as
pediatric enrollment, TB, PMTCT and RCH linkages,
health care worker shortages, community linkages
and involvement including nutritional support
 Develop EGPAF organizational and country specific
guidelines and strategic plans for community
linkages to ensure that community linkages are
integrated into the continuum of care
Major Recommendations (2)
 Create additional opportunities for
technical discussions and sharing of
experiences
– Across the PH country office staff
– With other treatment partners
 Consider collecting indicators that may be
more reflective of quality of care outcomes
such as improved cohort reporting,
additional treatment outcome measures
and effectiveness of community linkages
 Conduct regular review and assessment of
PH programs
Limitations of Assessment
 Limited time in clinics
 Chart audits, clinical observations or
patient interviews not conducted
 Did not assess PMTCT
 Did not have opportunity to meet
with non-PEPFAR partners
 Non-random sample of clinics
 Language barriers
 EGPAF staff as part of assessment
team
Next Steps
 Share findings with:
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EGPAF staff
Project HEART countries
CDC Atlanta and country offices
International conferences
Peer-reviewed literature
 Used findings in PY6 applications
 Incorporate information and
recommendations into program activities
Acknowledgements
EGPAF U.S. Staff
 US EGPAF Interviewees
EGPAF Country Office Staff
 Tanzania
 Cote d’Ivoire
 Zambia
GWU SPHHS
 Alan Greenberg
 Manya Magnus
 James Peterson
A special thanks to all those who were interviewed as part of
the assessment