In the lead up to this week’s MDG Summit, health experts discussed integration of HIV/AIDS programs with other health programs at a special event in Washington, DC. David Hoos, MD, of Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP), one of the largest PEPFAR implementers, spoke on the panel, which was sponsored by the Global Health Council and partners, including the IDSA/HIVMA Center for Global Health Policy.
The springboard for the discussion was a showing of an excerpt of a new film by the company Vestergaard-Frandsen, called “The Test.” The film captures a testing campaign they launched in Kenya to massively scale up HIV testing in the Western Kenyan district of Kakamega, in September, 2008. The company stated that, “By conducting an HIV test for more than 49,000 people, the campaign demonstrated that it is possible for Kenya to reach its national goal of having 80 percent of adults know their HIV status.”
The testing services were provided free of charge at 30 community-based delivery sites. Crucial to the success of the program was that all those participating were also provided a CarePack™ containing a bed net, a small water purifier, condoms and educational material for the prevention of malaria, diarrheal disease and HIV respectively. CarePack™ was provided to all regardless of whether they took an HIV test or chose to opt-out.
The showing of the 20-minute film provoked an intense discussion about how best to integrate health programs while also ensuring sustainability and local buy-in.
His Excellency, Ambassador to the U.S. from Kenya Elkanah Odembo, who had worked with the African Medical and Research Foundation (AMREF) in a previous career, said that even in the 1980s there was much discussion about how to achieve an integrated approach, but the question today was how to take such initiatives as portrayed in the film to a much bigger and yet sustainable scale.
Odembo stated that the film should have explained better how the program was integrated with the planning and follow-up capacity of local health officials, taking into account issues such as personnel shortages and the need for a regular supply of medication. He said that sustaining life-long treatment required taking a systems strengthening approach, and he said that “I am also challenging ourselves [Kenyans] to make this commitment.”
Jean Roy, formerly with CDC and the International Red Cross, served as the Chair of the Advisory Group for the Vestergaard-Frandsen campaign. He clarified that Kenyan officials oversaw the entire operation. The campaign took fully into account the fact that “the success of these integrated programs is good planning, all done by national and local health authorities,” Roy said, adding that persons who tested HIV positive during the campaign were immediately linked to an HIV-positive peer educator for support and reassurance and then linked to HIV/AIDS treatment and care programs.
Roy said that what excited him about the campaign was bringing together health objectives, since the tendency was for programs to remain vertical for reasons of competition and turf. He said that the next step is to replicate the program depicted in the film.
But are there already many instances of effective integration of HIV/AIDS programs? Hoos said that while HIV/AIDS care began in specialized clinics, today this is much less the case and that most of ICAP’s activities are focused on working with district health management teams, which integrate HIV/AIDS care into the broad set of health programs. He said the challenge now was how to achieve programmatic impact at the national level, not merely integration at the facility level. He welcomed the initiative from Vestergaard-Frandsen but said the film did not make quite clear how the program would contribute to meeting this broader health challenge.
Paul Jensen of the ACTION Project weighed in on the integration of TB and HIV programs. He said judging from the film that while the campaign was a practical instance of integration, it did not seem to include tuberculosis interventions, such as intensified case finding or awareness-raising about TB and called it a “missed opportunity.” Jensen reminded the audience that when the XDR-TB outbreak took place in South Africa, researchers found that the deadly resistant strain had been spread within an HIV/AIDS support group.
Questions from the audience delved deeper into the issues. One questioner asked about the split within the Kenyan Ministry of Health between curative and preventive medicine, and whether the constitutional reforms recently ratified would address this and allow for a greater decentralization of services. The ambassador indicated that the reforms will indeed allow integration at the ministry level.
Another question was about whether the people who tested HIV positive were effectively linked to care. Roy stated that all follow-up and treatment was being done at the local level, but that the level of this care was “still being evaluated.” The Vestergaard-Frandsen representative at the film showing said that the company worked with the Kenyan government for a year before the campaign to ensure there would be enough resources for testing, counseling and HIV treatment for those who tested positive during the campaign. But it has been difficult to track those individuals to ensure that they are engaged in care. Roy also said that the company built a health clinic in the community to support the effort, and that the full version of the film captures the broader vision of the effort and how sustainability was built into the campaign.
Pediatric HIV/AIDS care was not explored in the film, prompting a pediatrician in the audience to ask if there was any provision for HIV testing of infants by getting a dried blood spot HIV test and sending that for PCR testing and whether there was any nutritional support provided for pregnant and lactating women. Roy stated there was no specific intervention for infants and that only adult tests were performed.
Hoos noted that nutrition is still a problematic area for PEPFAR, but progress has been made by allowing for prescription of therapeutic feeding for a six-month period.