Deliveri ntiretroviral Therang A g ppyy in Resource-Constrained Settings LESSONS FROM GHANA, KENYA AND RWANDA Robert Ritzenthaler© 2005 Family Health International (FHI). All rights reserved. This book may be freely reviewed, quoted, reproduced or translated, in full or in part, provided the source is acknowledged. This document has been funded by the U.S. Agency for International Development (USAID) through the Implementing AIDS Prevention and Care (IMPACT) Project (Cooperative Agreement HRN-A-00-97-00017-00), which is managed by FHI.Delivering Antiretroviral Therapy in Resource-Constrained Settings LESSONS FROM GHANA, KENYA AND RWANDA Robert RitzenthalerACKNOWLEDGMENTS Family Health International (FHI) is proud to present Delivering Antiretroviral Therapy in Resource-Constrained Settings: Lessons from Ghana, Kenya and Rwanda. This document is intended for governments, development partners and public and private health facilities seeking to provide ART as part of comprehensive care and support for people living with HIV/AIDS. Robert Ritzenthaler developed the document with other FHI staff members and partners at Management Sciences for Health and the Population Council. Leine Stuart, PhD, ACRN, and Judith Harkins, MSN, MPH, made significant contributions to the text. The publication was designed by Jimmy Bishara. Other contributors at FHI include: John Adungosi, MBChB, MSc, MRIT Deborah Murray, MBA Martin Ngabonziza, MD, MPH Kwasi Torpey, MBChB, MPH Margaret Dadian, MJ Mary Lyn Field-Nguer, RN, FNP, MSN Peter R. Lamptey, MD, DrPH Ya Diul Mukadi, MD, MPH Dimitri Prybylski, PhD, MPH Kathleen Henry Shears, MS Steve Taravella Eric van Praag, MD, MPH Helena Walkowiak, MSc (Rational Pharmaceutical Management Plus) contributed her expertise and insights on commodity issues and laboratory and pharmacy strengthening. Horizons staff Susan Kaai, MSc, Avina Sarna, MD, MPH, and Johannes van Dam, MD, MS, contributed the chapter on operations research with Mark Hawken, MD, then with the International Centre for Reproductive Health. Our deepest gratitude goes to the patients and health staff at the ART sites profiled in this document: Atua Gov-ernment Hospital and St. Martins de Porres Hospital in Ghana; Coast Provincial General Hospital in Kenya; and Biryogo Medical and Social Center and Kabgayi District Hospital in Rwanda. Their willingness to confront the myriad challenges and complexities that attend HIV treatment in resource-constrained settings is an inspiration. We also recognize the deep commitment of the ministries of health in Ghana, Kenya and Rwanda. To obtain additional information about ART sites in Africa and other regions, please contact: Ya Diul Mukadi, MD, MPH, Director, Care and Treatment Division Institute for HIV/AIDS, Family Health International, 2101 Wilson Boulevard, Suite 700, Arlington, VA 22201 USA, Tel: 703.516.9779, Fax: 703.516.9781, Email: [email protected] Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Introduction ............................................ 11 Chapter 1. Country Preparedness .................................. 17 Commitment and Participation ................................. 18 National ART Guidelines and Drug Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Roles and Mechanisms for Participation and Feedback . . . . . . . . . . . . . . . . . . . . . . . 25 Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Chapter 2. Community Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Formative Research in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Stakeholder Involvement, Including PLHA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Community Education ..................................... 39 Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Chapter 3. Site Preparedness .................................... 47 Site Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Site Assessments ........................................ 50 Site Preparedness: Clinical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Lessons Learned: Clinical Services ................................ 54 Site Preparedness: Laboratory Services .............................. 55 Lessons Learned: Laboratory Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Site Preparedness: Pharmacy Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Lessons Learned: Pharmacy Services ............................... 63 Chapter 4. Referral Systems and Linkages .............................. 67 Essential Services for PLHA ................................... 67 Referrals and Linkages within Communities and Health Facilities. . . . . . . . . . . . . . . . . . 68 Lesson Learned ......................................... 69 Chapter 5. Patient Preparation and Adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 EligibilityCriteriaandPatientSelection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Pre-treatment Counseling, Ongoing Adherence Counseling and Adherence Monitoring . . . . . . . 75 Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 12 Chapter 6. Health Management Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . 81 Key Considerations ....................................... 82 HMISDevelopmentandIntegration . . . . . . . . . . . . . . . . . . . . . . . …