Programme Area 2: Diagnosis, Treatment and care of PLHIV

Programme Area 2: Diagnosis, Treatment and care of PLHIV

Efforts to strengthening testing, treatment, care and support services over the five years of the NSP were principally led by the MOH National AIDS Programme (NAP) and guided by several key documents. Based on the issues highlighted in the NSP these efforts appear to have been largely effective. Key achievements over the NSP period include: improved access to testing; high Anti-Retroviral (ARVs) coverage; improvements in treatment, pharmacy and laboratory services; the elimination of mother-to-child transmission; high coverage of prevention of mother-to-child transmission (PMTCT) services; and, the use of data and evaluation by MOH to tailor and improve programming. However, there remain opportunities for strengthening testing, treatment, care and support activities that can be pursued in the next iteration of the NSP. These include stronger partnering with strong civil society groups to enhance the psychosocial environment (inclusive of the involvement of groups to support screening and linkages to care, and ensuring a more organised civil society voice within the treatment and support space); improving the partnerships between the ‘health’ and ‘mutli-sectoral’ arms of the response; and, a strengthening of strategic information systems.

1. 
   What steps have been taken to strengthen treatment, care and support services?
   

Figure 5: NSP Intermediate Results and Targets

The MOH response, guided by this more comprehensive plan, appears to have been well structured and organised. This is demonstrated in Figure 6, which outlines the main areas responsible for testing, treatment, care and support services⁶. The use of evaluation to inform programmatic changes (and the development of the new NSP) in areas such as the treatment cascade was also noted by the evaluation team as a good practice that has resulted in programme strengthening.

In addition to the MOH Plan, the ‘Barbados National HIV Policy: A Framework for Action’ was developed by the NHAC in 2008 as a comprehensive policy document on HIV. This document included guidelines to support treatment.

Further direction was also provided through policy documents to guide testing activities and the PMTCT programme, including a ‘Policy Document on the Prevention of Mother-To-Child Transmission of HIV in Barbados’ that was produced by the NAP and standard operating procedures developed for the LRU.

Several strategies for strengthening testing, treatment, care and support services were pursued during the NSP period, based on the Treatment 2.0 framework. The LRU was used as the centrepiece for much of this work. It was fully functionalized in 2002 as a specialised medical facility for HIV, to deliver an array of services through a multi-disciplinary team. The services offered at LRU included ART treatment and monitoring, medical interventions focused on disease management and Highly Active ART, voluntary counselling and testing (VCT), supportive counselling and adherence counselling, in-house pharmacy services, community outreach, management of co-infections and co-morbidities, as well as linkages to nutritional, financial and social support services for PLHIV. Additionally, several CSOs serving a wide range of key populations are also housed at the LRU. As an institution, it has developed the reputation among key populations for being an excellent HIV/STI service provider.

According to some key populations interviewed, the location of the LRU is stigmatized. This was highlighted as a reason for some who refuse to access treatment and for attrition from the ART programme as well as other services offered at the site. Some PLHIV also reported breaches of patient confidentiality.

Testing services at the LRU were available primarily within the laboratory setting. HIV diagnostic testing is available at three rapid testing sites: Winston Scott and Brandford Paitt Polyclinics, as well as the LRU. As per the NSP, the LRU Laboratory improved testing for STI screening during the period within a quality assured laboratory setting. LRU laboratory services were expanded beyond CD4 and viral load testing to offer a range of services including early infant diagnosis, HIV drug resistance testing and molecular diagnosis of tuberculosis (TB) and molecular testing for other STIs thus improving access to services for patients.

Treatment and care services for the period under review remained centralised and offered through the LRU. The LRU did not target any specific sub-population groups but rather treated on an individual basis and addressed the needs of patients in an apparent stigma-free setting. The PLHIV participants of the focus groups noted that the services at the LRU have improved considerably over the past five years. The PHLIV group praised the staff of the LRU, especially the nurses and doctors whom they said were kind, compassionate consultative, professional and highly confidential. One person noted ‘The service is really first class’ another said ‘I love going there’. However, as mentioned, some concerns were also raised about confidentiality of information, especially among the vendors who operate adjacently to the LRU and others visitors to the facility. The PLHIV experiences at the LRU are markedly contrasted with experiences at the Queen Elizabeth Hospital. One of the PLHIV noted ‘The hospital, it can be very hostile; it’s horrible’. It is thus the opinion of the evaluation team the LRU may offer a model for other health providers locally and regionally.

Treatment and care services offered at LRU include partner referrals to testing and counselling, contact tracing, and the follow-up linkage to care where necessary. The clinic also supports post-exposure prophylaxis for those exposed to HIV.

3. 
   Were the approaches to treatment, care, and support effective?
   

The PMTCT programme also appears to be functioning well, with elimination of mother-to-child transmission being achieved and PMTCT coverage remaining high; 99% of pregnant women received screening (2011) and 100% received ARVs (2012). PMTCT coverage was more than 80% with zero percent transmission. This is a solid achievement for the national response.

CSOs were involved in certain aspect of the treatment, care and support response, including representation on the MOH Steering Committee and Audit (Monitoring) Committee and the provision of support for entry into care, linkage and support in care. CSO participation was limited, however due to capacity issues. Additionally, the work of the MOH and NHAC were often ‘siloed’, creating a gap in the national response. This issue was bridged to an extent by CHAA, who worked to connect key populations to MOH services and played an active role engaging in advocacy with the health sector. Their closure has created a void. To address this, the MOH hopes to engage some of the new and developing groups that are showing promise both in terms of treatment and care, and decentralization.

There were a number of different providers involved in delivering social services for PLHIV, including social workers at the LRU, who linked people to social assistance. The available social assistance available to PLHIV and other affected by HIV included a food bank, welfare, and housing support. Prior to 2011 there was also a hostel, but it has been closed due to lack of demand. Some key informants suggested that the hostel is not needed anymore because of improvements in stigma and discrimination and medical care.

While many of these interventions are promising, data to allow a deeper analysis of their performance was not made available to the evaluation team. Further, it appears that there have been limited assessments of these services. It is the opinion of the evaluation team that this was a missed opportunity for the national response to demonstrate success and learn from past experiences. For example, despite general goodwill among service providers, issues of stigma (including self-stigmatization) appear to be limiting the uptake of welfare services. Without data, the extent to which this is occurring is difficult to assess.

The HIV/AIDS Food Bank operates under the MOH, who support the cost of staffing the operations of the Food Bank. The role of the Food Bank is succinctly described on the MOH website⁷ which states ‘The Food Bank is committed to providing nutritional care and support for persons living with HIV and AIDS, while helping them to achieve optimal nutritional status. The Food Bank distributes nutritionally balanced food hampers and liquid supplements, provides nutritional counselling on healthy eating habits and provides education on food preparation among other things.’ The PLHIV in the focus groups highlighted positive experiences accessing social services at the Food Bank and the Vashti Inniss Empowerment Centre.

Food packages for PLHIV and others affected by the disease are generated based on donations from the private sector and individuals, and thus are offered at a minimal cost to MOH. Consequently, the Food Bank offers a sustainable model of supporting PLHIV, especially since it involves volunteerism of persons in various Ministries and the private sector based on a cooperate social responsibility model. This type of model could be explored for greater engagement of the private sector in other areas of the response, especially in the provision of other social services.

Housing support for PLHIV was led by the HIV/AIDS Coordinator in National Housing Corporation based in the Ministry of Housing, Lands, Urban and Rural Development, using an interagency team approach that places PLHIV most in need into free public housing. While the limited number of public houses has meant that, only a small number of PHLIV have benefited from this programme, the team approach to supporting PLHIV is commendable. This approach could be further strengthened by giving consideration to a programme that helps to empower persons and transition them to full independence.

The evolution of the social support approaches was interpreted by the evaluation team to suggest that the programme was adapting to meet the needs of patients over time. For example, in 2002 a domiciliary care program was initiated to focus on housing, but has since been expanded to include a wide range of social services. It was also noted that there was limited ongoing engagement of key populations in these programmes that have resulted in substantial unmet support, especially in the terms of psychological and social support. The exception to this though is CHAA’s prevention with positives work. As mentioned, there was also limited information on the reach and coverage of the housing and social service programmes.

The evaluation team also noted that there was evidence of evolution in the treatment approach. Combination pills were made available to clients to address compliance and updates to recommended treatment therapies; discussions took place with the aim of improving access to treatment services through the decentralization of services; and, the guidelines and standard operating procedures for treatment were updated. Adherence interventions were also implemented to sustain patients on medication, and there is documentation of interventions within the supply chain management being reviewed to reduce costs. The continuous evaluation and improvement highlighted here is a strength that should be carried into the implementation of the next NSP.

In terms of exploring the strategic information systems that support treatment, care and support programming, it was observed that the LRU had a functional database in place. This database captured all laboratory data and was being used to generate surveillance reports. To support this system, a network of persons were in place to collect data and staff were assigned to assist in collation and management of data quality. For example, positive cases tracked and the data compiled by nurses and counsellors at the health centres. This was then reviewed and analysed by the Surveillance Officer and Data Analyst. While data from all clinics and health centres on the PMTCT Programme was compiled by the Public Health Nurse at LRU. It was unclear how much of this strategic information was being generated.

In addition to the routine data collected through the database, two studies were completed during the life of the NSP in an attempt to collect more information on MSM and sex workers and to use this information to improve programming. The treatment, care and support response, therefore, appears to have been data-informed, at least internally.

There is room for greater strengthening of strategic information, especially in terms of measuring performance against the NSP and in the sharing of information with stakeholders outside of the health sector. Despite the broad range of priorities and strategies for treatment, care and support articulated in the NSP and supporting documents, there is only one outcome indicator for care and support in the National Monitoring and Evaluation Framework (NHAC, 2008). That indicator is ‘Existence of comprehensive HIV/AIDS care and support policies, strategies and guidelines’ (p.16). This indicator does not reflect the NSP priority.

4. 
   Was there efficient use of resources to respond to the treatment, care and support needs of key populations?
   

1. 
   Establish stronger partnerships between MOH, NHAC, CSOs and HIV/AIDS Coordinators to provide feedback to guide programming. This interaction is critical to being able to enhance the support environment in a more meaningful way. This could be achieved through quarterly strategic meetings that incorporate agendas and minutes.
   
2. 
   Critical is the strategic sharing of information between the leadership of the MOH and the NHAC to support the targeted prevention and treatment based activities with key populations. This needs to be enhanced.
   
3. 
   Enhance psychosocial support to empower key populations – Positive Health Dignity and Prevention programme needs to be established (see CDC best practices).
   
4. 
   Continued use of data to address quality management is an implementation strategy that should be maintained and used with other groups outside of the MOH.
   
5. 
   Facilitate targeted prevention activities with key populations to capture PLHIV earlier.
   
6. 
   Develop the capacity of HIV/AIDS Coordinators and other public health stakeholders (training, mentoring etc.) to establish stronger linkages to support prevention and treatment aspects of the HIV response.