Background

In September 2006 MJAP received a grant from the US President’s Emergency Plan for AIDS Relief (PEPFAR) to strengthen the care and management capacity of KCC clinics to deliver comprehensive HIV prevention, care and treatment services. MJAP, in partnership with IDI, has supported KCC to roll out services at eight of its ten clinics. IDI is supporting six KCC clinics through this initiative: Kiswa, Kiruddu, Kisenyi, Kawaala, Kitebi, and Komamboga.  

Areas of IDI support to KCC include:

• Pharmacy management and technical skills
• Data management
• Procurement
• Laboratory management
• Palliative care
• Counseling and testing
• ART delivery
• Combined HIV/TB care
• Prevention
• Strengthening general management systems
  

The aim of all activities has been to strengthen the KCC clinics in order to support the development of sustainable and comprehensive HIV/AIDS programmes (including ART), that can serve increasing numbers of HIV positive patients and their families.  

Approaches Used and Key Accomplishments

HIV Counseling and Testing, and Related Training:  By August 2009 49,716 individuals in the six KCC clinics had received HIV counseling and testing (with test kits supplied by MOH; although the project has maintained a buffer stock for use during stock outs).
The project has conducted Voluntary Counseling and Testing (VCT) outreach activities, through which a number of individuals have been tested for HIV in the areas served by the six health centers. The project also carries out Routine HIV Counseling and Testing (RCT).
The project has ensured that counseling and testing is always available, and that patients always receive their results. This has been achieved through coordination with MJAP and other partners to ensure that a broad base of staff at targeted clinics have been trained in provision of counseling and testing; providing test kits when none are available from other sources; and scaling up numbers of people being tested and counseled.
The community outreach activities facilitated by this project have ensured that there is a steady flow of people from surrounding communities who are interested in receiving counseling and testing.  There has also been a strong focus on identifying, testing and counseling discordant couples and family members of those already identified as HIV positive. 

HIV/AIDS Basic Care:  All six KCC clinics supported by IDI receive basic care kits through a Memorandum of Understanding signed with the Programme for Accessible Health Communication and Education (PACE; formerly Population Services International).  Palliative care has included Cotrimoxazole prophylaxis, safe water vessels and insecticide treated bed nets; as well as treatment for opportunistic infections.  A total of 9,672 cumulative clients (as of 30th August, 2009) are receiving care through the project.  

TB Screening, Care and Treatment for HIV/TB Co-Infected Patients:  A total of 9,692 patients have been screened and/or investigated for TB; and a total of 1,021 TB/HIV co-infected clients have received care and treatment across the six clinics.  X-rays are freely available to all patients who need them as part of investigative support.

Provision of ARVs:  A total of 3,572 clients (cumulative as of August 2009) have been initiated on ART (both MOH and PEPFAR funded). The following graph shows active clients by antiretroviral status as of June, 2009:

In addition, 543 clients (included above) on ART have been transferred from the IDI clinic to the KCC clinics for continuation of care.

Laboratory Support:  The project bought HIV/AIDS diagnostic laboratory equipment for Kiswa Health Centre, including CD4 and Humalyte Count Machines. These were installed, and the laboratory was launched on March 25th 2009. The project has also remodeled the laboratories in Kisenyi, Kawaala and Kiruddu clinics by expanding them and equipping them with basic equipment such as centrifuges, refrigerators, testing kits and some reagents.

The project has consistently supported all KCC clinics by providing lab consumables and equipment for routine tests. Supplies procured and distributed to the six KCC clinics supported by IDI have included HIV test kits, TPHA (Syphilis) kits, pregnancy rapid test kits, microscope slides, haemacues for hemoglobin estimation, vacutainer tubes, needles and other consumables.

Infrastructure Upgrades:  Space at health facilities has remained a challenge—particularly in the drug stores, patients waiting areas and drug dispensing areas. Interventions have included expanding usable space and installing shelves at Kisenyi, Kawaala and Kiruddu health centers. Patient waiting areas were constructed in Kisenyi, Komamboga and Kawaala. At Kiswa, Kitebi and Kiruddu, shaded waiting areas were put up in partnership with Baylor College of Medicine Children’s Foundation-Uganda (Baylor–Uganda).

Human Resource Capacity Building:  The project has carried out a range of trainings which have increased the clinical and management skills of KCC health care workers. There have been over 500 participants in a range of courses (with some participants taking more than one course).  Training (mostly at IDI) has covered areas such as HIV/AIDS management, TB/HIV co-infection, counseling and testing, pharmacy strengthening, data management, palliative care, and laboratory skills and management.  General management training has been conducted by various partners including the Uganda Management Institute.

A key challenge is that there is an insufficient number of staff to meet the needs at the busy KCC clinics (which provide many services other than those related to HIV/AIDS). In order to supplement the existing staff, the project has recruited a total of 30 contract staff including eight medical officers, six nurse counselors, seven data clerks and some administrative staff. These contract staff members have been supporting the six KCC clinics and the project office, in addition to training the KCC health workers.

Provision of Drugs and Consumable Supplies:  Most of the HIV-related drugs (e.g. cotrimoxazole [septrin]) used in the project have been procured using PEPFAR funding.  The project has also introduced a reliable supply system that has eliminated stock outs.  In addition the project has enhanced the capacity of KCC clinics to access drugs and supplies through the MOH procurement system. The project now efficiently manages the stocks of drugs and other consumables; and ordering, receiving, recording and disbursements are being handled in a timely manner.

Data Management:  At the start of the project the data management systems were paper-based, weak and unreliable—with poor storage and retrieval arrangements. The project has improved the paper-based data systems at six KCC clinics and recruited a data clerk for each clinic.
In addition, the project has been piloting the Open MRS (Medical Records System)  in Kiswa; and the roll out of this programme to other centers is starting soon. The forms for use will be based on MOH-Health Management Information System registers, the MOH HIV Blue Chart, and supplementary forms that will support reporting requirements for KCC clinics.  The system will enable the KCC clinics to generate monthly clinic reports, MOH reports, and CDC reports.

Prevention:  Creating a warm and welcoming environment is an important part of the IDI/KCC project clinical approach. Prevention with Positives at KCC clinics is also important—as a key aspect of prevention. Interventions include training “expert clients” to facilitate this endeavor, and designing means for routinely evaluating the effectiveness of the intervention with regard to improved prevention, adherence, and healthy living.   Clients are engaged in determining how to best communicate the factors that enable them to live healthy and productive lives, which include taking ARVs as prescribed; practicing other approaches to healthy living (cotrimoxazole, safe drinking water, use of bed nets, condom use, etc.); and helping others to find the social and psychological support to sustain difficult drug regimens over a lifetime. Fifty trained clients are reaching out to individuals through community outreach to:

• Promote HIV/AIDS prevention through, abstinence and behavior change
• Reduce HIV-related stigma and discrimination
• Mobilize the community to seek HIV/AIDS prevention, care and treatment services
  

A focus on prevention is an important part of all clinical activities at KCC clinics:

• Through counseling and personal testimonies, clients are trained on how to avoid transmitting the virus to others
• Clients receive free condoms
• PMTCT is supported through effective use of ARVs among pregnant women 
• HIV-discordant couples are identified and counseled on how to prevent transmission
• The project has also generated and distributed IEC material for patients to take home
  

Challenges and Opportunities

Funding for the current KCC capacity building project will end in March 2010, and efforts are currently being made to identify long-term approaches for IDI to continue partnering with, and supporting, KCC clinics in a sustainable way.