Category Archives: India

I-TECH Network Minimizes Disruptions in Treatment Access for PLHIV During COVID-19

By Chelsea Elkins

Members of a Community Adherence Refill Group in Zimbabwe

In a time of increased barriers, disruptions, and restrictions due to the COVID-19 pandemic, the International Training and Education Center for Health (I-TECH) and its network partners have implemented new approaches and adapted existing programs to support continued access to antiretroviral therapy (ART).

As a result of the pandemic, many organizations and health systems have had to shift to offering virtual care, which allows ART initiation and other HIV services to persist while minimizing patients’ risk of exposure to COVID-19. However, not all patients have access to the technology that makes virtual services possible, and additional approaches are needed to support ART treatment access during this time.

“Globally, the pandemic has generated innovative responses from communities and health systems that are striving to keep people connected to care,” says Dr. Pamela Collins, I-TECH Executive Director. “One challenge is to recognize how (or when) some adaptations increase disparities in access. We’ve learned that the right combinations of technological and no-tech solutions can also be innovative if they help provide the care that’s needed.”

One way I-TECH has helped to provide innovative care during the pandemic is by centering solutions within the affected communities themselves. A few of the community-oriented approaches that the I-TECH network has implemented include decentralized ART centers, community outreach, home delivery, community adherence refill groups (CARGs), and multi-month dispensing (MMD) of antiretroviral (ARV) medication.

Decentralized ART Refill Sites and Community Outreach

Decentralized refill sites have been an essential strategy during lockdown restrictions for I-TECH’s network partners because they allow ART to be distributed at more convenient locations, minimizing travel and treatment interruptions. Some programs have also started providing mobile outreach to improve ART access during the pandemic, at times even providing doorstep delivery to those who are unable to go to a clinic or refill center.

I-TECH’s network partner in India, the UW International Training & Education Centre for Health Private Limited (I-TECH India) launched the ARTMitra helpline in Mumbai, an outreach effort designed to map the location of unreachable PLHIV and aid in planning decentralized ART refill sites. SMS messages were delivered to 13,103 PLHIV who had missed appointments during the pandemic, resulting in the identification of 42 decentralized ART refill centers in Mumbai in 2020. A similar helpline was launched in five districts of the state of Mizoram in partnership with the State AIDS Control Society. In total, I-TECH India, in close coordination with government partners in the PEPFAR states in Northeast India and in Mumbai, has ensured uninterrupted ART delivery through 145 decentralized ART refill sites.

Through outreach efforts, clients were notified about how they could access medication, and which decentralized ART refill site they should visit. Additionally, ART home delivery was provided to 255 PLHIV living in Mumbai who were unable to pick up their medication.

Thank you for calling and informing me about the availability of medicine at the nearby ART Centre, as I had no idea whom to contact and how to collect medicine.

—an ARTMitra client in Mumbai

I-TECH network partner the Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH) has also utilized community outreach to support PLHIV during the pandemic. Zim-TTECH has supported the Zimbabwe Partnership to Accelerate AIDS Control (ZimPAAC) consortium—along with PEPFAR partners, the U.S. Centers for Disease Control and Prevention (CDC) and in close collaboration with national efforts—to provide mobile HIV care, including prevention services and integrated services at ART events. In the Harare District, 8,257 clients were supplied ART during outreach events from 28 March through 17 July 2021.

Community Adherence Refill Groups and Multi-Month ART Dispensing

Through CARGs, a community of PLHIV access treatment more easily by sending a representative to receive ARVs for the entire group. The I-TECH network implements CARGs in a number of countries, using the person-centered approach to simplify HIV care and reduce the need for in-person services. This approach is often used in tandem with MMD, allowing a group to access multiple months of medication at a time.

While ARVs have traditionally been prescribed monthly, MMD allows patients to pick up medication for 2 to 6 months and reduces traditional barriers, such as access to transportation and taking time off work, as well as barriers specific to COVID-19, such as lockdown restrictions and limited capacity of health care facilities. I-TECH and its network partners have scaled up MMD in many programs during the COVID-19 pandemic, effectively minimizing the number of in-person visits and encouraging ART adherence.

In response to COVID-19 and in partnership with CDC, the Ministry of Health and Social Services (MoHSS) in Namibia introduced a new MMD policy in April 2020 for eligible ART patients, making more people eligible for this service than ever before. In addition to policy support, I-TECH Namibia is engaged in technical support to the national HIV/AIDS program through clinical mentors who work in more than half of Namibia’s health districts. This national engagement has contributed to a rapid increase in the number of eligible ART patients who now receive between 2 to 6 months’ supply of ARVs at a time.

‘’As the number of ART patients on MMD increased, waiting areas in Namibia’s health facilities have rapidly decongested, enhancing COVID-19 infection prevention and control measures,” says Dr. Norbert Forster, I-TECH Namibia’s Country Director. “At the same time, our HIV clinicians now have more time to focus their care on patient engagement and on enhancing viral load suppression and other interventions.”

I-TECH’S WORK IN INDIA IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER U91HA06801, THE INTERNATIONAL AIDS EDUCATION AND TRAINING CENTER (IAETC). THE CONTENT OF THIS POST IS THE AUTHOR’S AND SHOULD NOT BE CONSTRUED AS THE OFFICIAL POSITION OR POLICY OF, NOR SHOULD ANY ENDORSEMENTS BE INFERRED BY HRSA, HHS OR THE U.S. GOVERNMENT.

I-TECH Presents Posters at IAS 2021 Conference on HIV Science

The International AIDS Society (IAS) virtually hosted the 11th Conference on HIV Science on 18-21 July 2021. The conference also included a “local partner hub” in Berlin, the original host city, for local experts to gather in person. This biennial conference brings together top HIV researchers, experts, and scientists for presentations and discussions on the latest advances in HIV research and practice.

Representatives from the International Training and Education Center for Health (I-TECH) virtually presented the following posters:

Representatives from I-TECH’s partner network organizations and the Centers for Disease Control and Prevention (CDC) also presented data from I-TECH-supported programs in Malawi, India, and Zimbabwe.

Formulating Guidelines and Operating Procedures in India

I-TECH India PL is part of various national ART and testing guideline groups of NACO in India, including Journey of ART Programme in India; HTS Guidelines; ART Guidelines for HIV-Infected Adults and Adolescents, May 2013; National Guidelines on Second-line and Alternative First-line ART For Adults and Adolescents, May 2013; Operational Guidelines for ART Centers, July 2012; HIV/TB Guidelines, 2015; and National ART Technical Guidelines, October 2018 (http://www.naco.gov.in/care-support-treatment).

The team also assisted NACO in designing standard operating procedures for implementing newer program initiatives such as Treat All, Pre-ART mop-up, co-located ART and OST (Oral Substitution Therapy) Centres, ART through targeted intervention programs, and multi-month dispensation of ART.

Enhancement of Health Information Systems and Data Quality in India

I-TECH India PL has provided national, state, and facility level technical assistance for improving quality, analysis and presentation of ART program data; developed innovative tools for tracking program progress based on data analysis of selected indicators over a period of time and submitted for national scale-up; and provided technical mentoring to improve quality of data collection and reporting by the ART Centers at 48 sites of India in the last three years.

Building the Capacity of the Health Workforce in India

I-TECH India PL has worked with stakeholders to develop national training curricula for health care staff on delivering HIV care and treatment services. In addition, it has:

  • Planned and implemented training programs for various cadres of clinical and program staff;
  • Participated in medical officer training programs at the national level;
  • Designed and conducted five regional continuing medical education (CME) courses in North, South, West and Northeastern regions on “Invigorating HIV Care” for ART center medical officers;
  • Designed and conducted four workshops in two weeks reaching 164 ART counselors for improving care support and treatment services provided to key population clients accessing ART centre services in Maharashtra;
  • Conducted National Distance Learning Seminars (webinars)—an average of 25 sessions per year on clinical- and program-related topics for the past five years reaching over 50% of ART Centers in India, with average participation of 1000 per session. These sessions are recorded and are available on YouTube channel “I-TECH India.”
  • Conducted Regional Distance Learning Seminars (webinars)—an average of 60 sessions per year through 15 HIV/AIDS Centres of Excellence in more than six languages during the last five years reaching over 50 % of ART Centers in India, with average participation of 50 per session; and
  • Coordinated certificate courses from UW on Leadership and Management in Health, Principles of STD (Sexually Transmitted Diseases) and HIV Research, Introduction to Epidemiology for Global Health, Clinical Management of HIV, and Fundamentals of Implementation Science for over 500 individuals during the past five years.

Strengthening Health Service Delivery in India

  • I-TECH India PL has successfully designed and implemented four differentiated ART service delivery models, including models for key population clients, in collaboration with other stakeholders in states of Maharashtra, Nagaland, Manipur and Mizoram to develop a proof of concept for the national level scale up;
  • Improved delivery of health services through onsite technical mentoring and supervison of health care staff in 9% of the ART centers of the country in the last three years;
  • Technically assisted successful implementation of newer initiatives such as treatment of TB through the ART centers, the “Treat All” initiative, and routine viral load monitoring at 48 ART centers; and
  • Conducted/participated in health service delivery assessments of facilities such as the national HIV/AIDS Centers of Excellence, ART Centers, Link ART Centers, and other care and support centers for the NACO.

I-TECH India and Haiti Offices Transition to Local Organizations

I-TECH India will continue to support a complete array of educational services and technical assistance to 17 Centers of Excellence in India.

In spring 2018, the International Training and Education Center for Health (I-TECH) made University of Washington (UW) history when two of its country offices transitioned into independent organizations. I-TECH’s office in India is now the independently run I-TECH India, and its former office in Haiti now operates as CHARESS (Centre Haïtien pour le Renforcement du Système de Santé). Both organizations are sub-contractors on current I-TECH awards.

“With the India and Haiti I-TECH office transition to a local identity, we are applying what we already know about transition to creating new relationships with these independent entities,” says Dr. Ann Downer, I-TECH Executive Director and Professor in the UW Department of Global Health. “To help ensure long-term sustainability, we are working together on business plans and mapping out strategic priorities and mutual interests. This transition has intensified our partnership rather than creating distance.”

A roadmap for the university

I-TECH has worked closely with UW Global Operations Support over the past decade to inform the internal procedures and structures necessary for international office registrations. According to Doug Divine, Director of UW Global Operations Support, this work has promoted operational effectiveness by enabling a safe, compliant, and legal environment for conducting international work.

“I-TECH has been our key partner in the justification and implementation of these registrations, establishing 11 of the 15 entities registered abroad,” says Divine. “It has been so rewarding to have partnered with I-TECH on such an innovative administrative approach. Seeing these registrations become fully functioning independent entities not only fulfills a key mission of I-TECH to help establish sustained capacity where it is needed most, but also reflects the commitment of the UW community toward international engagement.

I-TECH’s close work with Global Operations Support has also prepared I-TECH India and CHARESS for success, helping to create the administrative and policy structures necessary for them to more easily fledge.

New opportunities

The team at CHARESS will continue to oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population and other implementing partners in Haiti.

The transition of the India and Haiti offices marks new territory in I-TECH’s move toward country ownership, allowing in-country teams to simplify administration and explore funding opportunities that weren’t available to them as UW entities.

The I-TECH India team looks forward to these new opportunities. “This really opens doors to new things,” says Dr. Anwar Parvez Sayed, Clinical Programs Director for I-TECH India. “We were previously looked at as a foreign entity, and we can now apply for local grants.”

I-TECH India has provided technical assistance to 10 Indian Centers of Excellence (CoE) on HIV/AIDS since 2003. In the years ahead, it will continue to support a complete array of educational services and technical assistance to the CoE network in India, plus an additional seven pediatric sites, called pCoE.

“We will now be complying with local Indian regulations, which simplifies things,” says Madhuri Mukherjee, Country Representative of I-TECH India. “Though we no longer have the layer of Washington State and federal compliance, we will remain closely aligned with I-TECH’s and UW’s missions. It’s beneficial from both sides to maintain a close relationship.”

In fact, I-TECH India and CHARESS will each have a memorandum of understanding (MOU) with I-TECH/University of Washington. Each MOU will underscore the organization’s shared history with I-TECH and outline elements of an ongoing commitment — including being preferred partners on new funding opportunities.

In Haiti, CHARESS will continue to maintain, train, and deploy health information systems (HIS) such as iSantéPlus and the Système d’Echange d’Information de Santé d’Haïti (SEDISH), a national health information exchange. It will also ensure that the national sites for both receive on-site and remote technical assistance. In addition, the team will oversee clinical mentoring activities at 20 sites and provide technical assistance to the Ministry of Public Health and Population and other implementing partners in Haiti.

“As CHARESS, we look forward to continuing the programming that we have been so proud of,” remarks Dr. Jean-Guy Honoré, CHARESS Executive Director. “Our HIS work, in particular, has had a real impact in Haiti, and our new local status will allow CHARESS to pursue even more opportunities to become a global leader.”

An updated vision of sustainability

In its 16 years of operation, I-TECH’s ultimate goal has always been to strengthen local capacity and to help build sustainable health systems. To that end, I-TECH’s direct service and technical assistance programs are tailored from the initial planning stage to produce projects that can be successfully absorbed into national systems. Its main partner in this endeavor is always the local Ministry of Health.

At the International AIDS Society conference this year in Amsterdam, Dr. Downer presented recently completed research on six transitioned I-TECH programs (of more than 350 that have transitioned), exploring the degree to which investments had been sustained by local partners, as well as identifying the key elements of successful transition.

I-TECH’s experience with transition to local ownership and long-term sustainability of interventions aligns with those presented by Vogus and Graff (PEPFAR Transitions to Country Ownership, June 2015), including the need to plan for:

  • Communication of transition strategies through high level diplomacy;
  • Stakeholder participation in transition planning;
  • Government support of the plan, including alignment with local government policies, practices, and salaries;
  • Use of planning tools (i.e., a roadmap); and
  • Adapting approaches to the local context during transition.

“In addition to the known characteristics of successful transition of projects to local ownership, I-TECH has found that we also need to identify a champion within local government to advocate long-term for the adopted interventions,” says Dr. Downer. “We also need to plan intentionally for how much and what type of technical assistance or short-term funding will be needed in order to ensure sustainability.”

Doug Divine sees massive benefits at each stage of I-TECH’s country office relationships, from registration to independence. “Without I-TECH and the projects it has spearheaded, I’m not sure UW would have made the advancements it has made on the international front,” he says. “I-TECH had the vision, the infrastructure need, and the boots on the ground — which gave us impetus to set up structures for the rest of the university. Other departments can now leverage those resources, and now the spin-off offices fulfill our commitment to allow these structures to grow in their own context.”

Leadership and Management in Health Online Course Reaches Thousands Worldwide

Treats served at an end-of-course celebration in Kenya, 2016

Training on leadership and management is a critical component of the University of Washington (UW) International Training and Education Center for Health’s (I-TECH’s) health systems strengthening efforts. To that end, I-TECH has worked closely with the UW Department of Global Health E-Learning Program (eDGH) since 2012 to offer a heavily subscribed online course on leadership and management to health care workers in low- and middle-income countries.

Designed and taught by I-TECH Executive Director and UW Professor of Global Health Ann Downer, Leadership and Management in Health (LMIH) is a 12-week course focusing on the practical leadership and management skills required for working in complex global health environments. Weekly modules include content on team building, accountability, supervision and delegation, conflict management, financial management, use of data for decision-making, and effective communication.

“I want to express my gratitude for giving me the opportunity to do the UW course on Leadership Management in Health. …I find myself going back to these documents again and again to understand and imbibe what is given. I feel that the simple narrative of the course material has made all the difference.”

–2016 course participant from India

Participants from Tunisia, 2015

The course consists of recorded lectures, required readings, a weekly online discussion forum, quizzes, self-reflection assignments, and a final verbal presentation. It is targeted to practicing health care professionals and public health specialists who already have some experience managing people. In most cases, LMIH participants gather in weekly site-specific, in-person discussion groups led by a volunteer facilitator to discuss the material and apply it to their particular linguistic, cultural, social, and political environment.

“We just finished our site discussion this afternoon and the level of contribution and application to our various office settings was wonderful. …I have told my Chief Executive … about the course and he is thinking of asking all Management Staff to do it compulsorily in the next episode.”

–2017 course site facilitator

Due to high enrollment, the course is now offered twice a year, with a completion averaging 84%. Approximately 4,500 individuals are enrolled in the latest offering of the course, representing a nine-fold increase in five years. More than 10,000 health workers in 65 countries have graduated from LMIH since 2012.

Participants from Myanmar, 2017

According to a survey conducted by eDGH, more than half of graduates from the spring 2016 cohort now mentor colleagues on leadership and management-related job tasks. In addition, 67% said they were given new responsibilities or projects as a result of course completion, and 74% reported that they had maintained contact with other students from their sites.

“We consistently hear that how empowering the course is,” said Anya Nartker, E-Learning Project Manager with eDGH. “The course uses a blended model, where participants are required to meet with their local site each week to apply what they are learning in the course, and share problems that they support each other in solving.”

 

I like the idea of all students teaming together and working together despite their backgrounds and level of education. There were many who were highly educated and some who were moderately [educated], and we all understood and accommodated each other.

–2016 course participant from Kenya

Course graduates have requested a deeper exploration of certain topics introduced in LMIH. As a result, a certificate series of three online courses is being developed that will include LMIH; a new course titled Global Project Management; and a third online course, Fundamentals of Implementation Science.

The Global Project Management online course will be offered as a stand-alone course from July-September 2018, co-taught by Dr. Downer; I-TECH Deputy Director, Chichi Butler; and I-TECH Senior Program Manager, Harnik Gulati. The certificate will be offered in 2018.

Record Numbers for India Online Seminar

I-TECH India set a new attendance record for its twice-monthly online learning series on HIV/AIDS.

The “Nutritional Aspects in HIV infected Children” lecture—part of the National Distance Learning Seminar Series (NDLS)—was attended by 342 participants from across the country, including all 10 Centres of Excellence (CoEs ) and 71 ART Centres.

The lecture was presented by Dr. Pushphalatha, Professor of Pediatrics, Bowring CoE Bangalore. The last record was 285 participants for Dr. Rewari’s sessioNDLS 1n on National ART Guidelines in 2012.

The series is aimed at health care workers and physicians working with HIV/AIDS patients. National experts present on variety of advanced care, comprehensive management, and treatment topics via live webcast sessions across several states and districts around the country. The goal is to create a dialogue amongst clinicians in regard to management of moderately complex cases. These 60-minute sessions are conducted in English and use a case-based format during the live session and allows participants to engage in follow-up communication across the sites.

I-TECH launched the Global Health Clinical Seminar Series (CSS) in July 2007. With the goal of improving the quality of HIV care delivered by health care workers in resource-limited settings, the series brought together expert clinicians and health care workers in a web-based, interactive format from around the world. India was the first country in the I-TECH network to use this model to design and implement their own series in 2010.

To support country programs in the global network, I-TECH  developed The Global Health Webinar Series Program Package as a resource for organizations interested in creating a successful global health webinar series. Drawing from the experience of I-TECH’s Global Health Clinical Seminar Series (CSS), this program package offers critical tools for the planning, implementation, and evaluation of a webinar series in a variety of settings. The package also offers lessons learned and best practices by I-TECH’s CSS in the four years it was running.