CD4 Counting in Mozambique s

Transcription

1 Pilot Implementation of Point-Of-Care CD4 Counting in Mozambique s National Health System Ilesh V. Jani Instituto Nacional de Saúde Maputo, Mozambique

2 The National HIV Prevalence in Years Old Individuals is 11.5% (INSIDA 2009) Tete 7.0% Manica 15.3% Sofala 15.5% Niassa 3.7% Cabo Delgado 9.4% Nampula 4.6% Zambézia 12.6% Women Men General Gaza 25.1% Inhambane 8.6% Maputo Província 19.8% Maputo Cidade 16.8%

3 Mozambique s National Health System Adopted a Multi-Step Technology Evaluation Process Technology Selection Technical Evaluation (Laboratory, Field) Pilot Implementation (Site, Province)

4 How to Select Technologies to Evaluate? Description of technology and parameters Type of technology (disposable, handheld, tabletop) Technical Sophistication Mobility & Size Routine Maintenance Requirements Instrument Throughput Power Source Alternate Power Source Availability Capital Cost of Equipment 30 criteria across 4 categories Internal Quality Control External Quality Control Daily Calibration Requirements Number of Steps in Procedure Type of Sample Required Precise Sample Measurement Requirements Batching Result Delivery Result Storage Instrument Connectivity Waste Generation Testing Method & Procedures 40% Technology Attributes 30% Other Company Information 10% Reagents, Consumables & Supplies 20% Heat and Humidity Type of Sample Tubes Need for Centrifuge Reagent & Control Preparation Expiration Period Reagent and Consumable Cost Service and Maintenance Supply Chain and Distribution Timing & Regulatory Status Installation

5 The Matrix Scores Each Technology Based on Criteria Weighted on Importance

6 Nurses in Primary Health Care Clinics Can Accurately Perform CD4 Counts Using Point-Of-Care Devices Alere PIMA (Lab Techs) vs. BD FACSCalibur Alere PIMA (Nurses) vs. BD FACSCalibur Limits of Agreement -314 to +257 Limits of Agreement -249 to +148 But training i on capillary blood collection is critical!

7 Pilot Implementation Was Initially Done in Six Clinics i and One Mobile Team Six primary health care clinics in urban and rural settings One mobile team in a remote rural area in the north of Mozambique Chart review for data collection performed at baseline and post- implementation

8 Point-Of-Care CD4 Counting Improves Patient t Retention ti and ART Initiation Rates p= With POC CD4 Without POC CD4 R d ti i th di ti t l t Reduction in the median time to complete CD4 staging: from 33 days to 3 days

9 The Improvement of Access to CD4 Counting is Not Uniform Across All Clinicsi Matola Clinic 4% 3% CD4 Result on time 24% Machava Clinic No CD4 result 93% Transferred with 76% outdated CD4 result Limiting Factors: - Limited human resources - Change of culture - Patient t overflow - Patient t education - Clinic workflow

10 A Mobile Team Successfully Operates in Northern Lake Niassa, Mozambique Setting: population p ~20,000, area 1,600 km 2. Strategy: Every 2 months, 2 community health workers, with no formal health qualifications, make a round trip of 220 km on foot or kayak, stopping at 8 health posts.

11 A Pilot Implementation in Currently Ongoing in Mozambique s Gaza Province Main Objectives: Test an approach for the implementation of point of care of CD4 counting from a health system perspective. Develop and validate tools to assist provincial authorities in scaling up the implementation of point of care assays.

12 Nov 2010 Dec 2010 Jan 2011 May 2011 Site Matrix Provincial Coordination POC ToT Train Sites Site Introduction Periodic Evaluation Preliminary site list generated from a site selection matrix. Provincial stakeholder meetings. Site list validated. Central level team trains provincial trainers. Provincial trainers train and certify local POC CD4 operators. Sites mentored. New patient flow diagrams implemented. Sites begin to implement POC CD4. Joint Stakeholder evaluation meetings. Discussion of lessons learnt. Road map for continuous improvement. Validation of tools.

13 Quality Assurance Training - Training of provincial trainers - Training of local operators - Validation of local operators Supervision - Laboratories and operators - Clinic flow Quality Control - Proficiency testing (national program)

14 Sites with POC CD4 Perform Well in the National Proficiency i Testing Program CD4 Absoluto CD4 Percentual 0.0 SDI Sites with POC CD4 Sample QC49, average absolute CD4 count=400 cells/mm 3

15 Expected Outputs of the Pilot Implementation ti at the Province Level Site selection tool Implementation process manual Laboratory Clinic Logistics and supply chain Quality assurance Training curriculum Recommendations for division of responsibilities (national, provincial, local)

16 Acknowledgements INS CHAI Provincial Health Authorities in Maputo City, Maputo Province, Gaza, Sofala and Niassa Implementing Health Centres Anglican Church, Niassa Province MSF-Belgium MSF-Switzerland Switzerland ARK UNITAID

17 Ultimately, sucessful implementation of point-of-care diagnostics is about changing health systems, creating a new health care culture and responsibilities shifting to primary health care level. OBRIGADO!