Study tour participants visit HRSA offices in Washington, D.C., to hear more about HRSA’s mission and activities.
Ukraine has the second largest HIV epidemic in eastern and central Europe; an estimated 220,000 citizens were living with the disease as of January 2016. As part of national efforts to help curb the impact and spread of HIV, the Ukrainian government is expanding and scaling up HIV services – training is an integral part of this scale-up.
To this end, the International Training and Education Center for Health (I-TECH) is working with national partners in Ukraine to build local capacity to provide high-quality continuing medical education (CME) on HIV and related topics.
Most recently, I-TECH arranged for representatives from the Ukrainian Center for Socially Dangerous Disease Control (UCDC) of the Ministry of Health and the Ukrainian Family Medicine Training Center, based at Bogomolets National Medical University, to participate in a weeklong study tour in Washington, D.C.
“Participants found the study tour to be extremely informative and timely given reforms to health workforce development currently under way in Ukraine,” said Anna Shapoval, I-TECH Ukraine Country Representative. “The information obtained and contacts established through the study tour will help to inform development of an HIV-focused professional medical association in Ukraine.”
The aim of the association will be to advocate on behalf of medical providers, educate health professionals on new developments in clinical practice and relevant legislation and other issues affecting HIV medicine and patients, and potentially provide crucial CME opportunities.
Tour participants met with representatives from CME training networks, HIV-focused professional medical associations, and organizations involved with CME accreditation and physician licensure in the U.S. Highlights from the tour include:
Meeting with the U.S. Human Resources and Services Administration (HRSA) on HRSA’s mission and activities, including the AIDS Education Training Center Program and other initiatives to improve HIV services in the U.S.
Informative sessions with the Maryland State Board of Physicians and Federation of State Medical Boards on the role of state medical boards in physician licensure
An overview and discussion on CME accreditation requirements and standards for commercial support
Meetings with various HIV-focused professional medical associations to discuss their establishment, funding models, advocacy work, CME and certification offerings, and lessons learned
The study tour participants identified several aspects of the U.S. CME and licensure systems to explore further and potentially apply in Ukraine, including decentralized licensure, nongovernmental CME accreditation, and diverse CME providers such as universities and professional associations.
This project 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.
The Dogg performs to a crowd in Katima Mulilo, Namibia. The Dogg plans to set an example by getting circumcised next month.
Namibian newspaper New Erareported today that hip hop artist The Dogg (real name Martin Morocky) has agreed to be circumcised next month by Dr. Bernard Haufiku, Namibia’s Minister of Health and Social Services, as part of the country’s voluntary medical male circumcision (VMMC) program. The procedure is to take place on Minister Haufiku’s birthday, Sept. 19.
The International Training and Education Center for Health (I-TECH), with PEPFAR funding, has supported the VMMC efforts of the Ministry of Health and Social Services (MOHSS) in the Oshana and Zambezi regions on many fronts. Between 2010 and 2014, I-TECH supported health care worker training in the provision of VMMC nationwide and has supported the delivery of VMMC procedures since November 2014. Since the start of this year, I-TECH has also been engaged in critical efforts to create demand for the procedure.
Marocky, who lost both of his parents to HIV/AIDS, was previously involved in the MOHSS’s “Break the Chain” campaign to reduce concurrent sexual partnerships in Namibia. He’s been a VMMC ambassador since May 2016, serving as the face behind a nationwide concert and social media campaign urging 15- to 49-year-old men to “get the smart cut.”
The Dogg shares the message of HIV prevention with a school in Katima Mulilo.
So far, Marocky has held nine concerts in the Erongo, Oshana, and Zambezi regions, as well as delivered encouragement to young men through radio talk shows and TV advertisements. He has also spoken one-on-one to young men about the preventive benefits of VMMC — namely, that the procedure can reduce the risk of HIV infection by more than 60%.
“I’ve encouraged ‘the smart cut’ through my music and appearances,” said Marocky. “But I’m now looking forward to protecting myself and setting a personal example for young Namibian men.”
The musician will join the more than 11,200 men in Oshana who have undergone a VMMC since 2009. More than 80% of the 12,250-plus procedures performed with I-TECH support since January 2015 are in the high-priority 15- to 29-year-old age group.
Currently, only about a quarter of Namibian men are circumcised. Overcoming cultural hurdles and mobilizing men to get the procedure has become a high priority for the MOHSS.
“Training clinicians in the procedure is only half the battle,” said I-TECH Namibia Country Director Norbert Forster. “Getting the word out to young men about the benefits of VMMC is crucial to ensuring the success of this intervention. The Dogg’s campaign has gone a long way toward changing minds and attitudes.”
The MOHSS and I-TECH are jointly engaging in a number of additional demand generation activities, which mainly focus on school-aged boys and young working men. One such activity, a bicycle lottery, is highlighted below.
Community Members Win Bicycle Lottery After Volunteering for VMMC
The MOHSS, with the support of I-TECH, has awarded the first two winners of new bicycles in a lottery held at Katima Mulilo State Hospital in the Zambezi Region.
The lottery was implemented to encourage more men to come in for VMMC; Zambezi remains the region most affected by HIV/AIDS in Namibia.
The first winner is an NDF soldier. His winning ticket was drawn out of the first group of men who were circumcised between March 1 and April 30, 2016, in the Zambezi region. The second winner, drawn from the May to July cohort, was a 16-year-old attending Mavuluma Senior Secondary School, a remote school in eastern Zambezi region.
During June of this year, the MOHSS Zambezi region team managed to mobilize and circumcise a total of 773 men as part of its I-TECH-supported VMMC program. The vast majority of recipients were between 15 and 29 years of age.
This project was 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.
President Pedro Pablo Kuczynski and Patricia García. Photo courtesy of the Ministry of Health of Peru Twitter feed.
On July 28, Peruvian President Pedro Pablo Kuczynski swore in the country’s new Minister of Health: Dr. Patricia García, alumna of the University of Washington School of Public Health (MPH 1998, Epidemiology). Dr. García is an Affiliate Professor at UW’s Department of Global Health and was Vice Dean of research at the School of Public Health at Cayetano Heredia University, where she received her doctorate and PhD in medicine.
Among her list of credits, she also served as a member of the External Advisory Board of the UW’s Department of Global Health and was the first woman to chair the Peruvian National Institute of Health.
Dr. Chris Behrens (center) and participants at a pilot training event in Uzhgorod.
In June 2016, the academic and professional communities involved in training family physicians and general practitioners in Ukraine received another valuable guide to a highly sensitive topic.
The International Training and Education Center for Health (I-TECH) in Ukraine, the Ukrainian Family Medicine Training Center (UFMTC) at the Bogomolets National Medical University (NMU), and the International Renaissance Foundation, all under the auspices of the Ministry of Health (MoH) of Ukraine, published “Use of Narcotic, Psychotropic Substances and their Precursors in the Practice of Family Medicine.” This facilitator’s guide (published in Ukrainian) was developed by Ukrainian and international experts in the fields of palliative care, controlled drug use, and pain management.
“The uniqueness of this publication is its extremely topical and, until recently, understated issue in Ukraine: provision of medical care with the use of controlled drugs, including opioid analgetics,” said Kateryna Amosova, Rector of the Bogomolets NMU.
The guide incorporates recent, groundbreaking updates in Ukrainian legislation. Resolution #333 of the Cabinet of Ministers of Ukraine and Order #494 of the MoH legitimize primary health care providers to prescribe and manage opioids for pain management in palliative care and opioid substitution therapy (OST).
“I-TECH Ukraine was honored to be able contribute to the development of the in-service training course that promotes most progressive principles of palliative care and OST provision for patients, including those with HIV, tuberculosis, and other HIV-associated diseases,” said Anna Shapoval, Country Representative for I-TECH Ukraine. “As always, we express our profound gratitude to the Ministry of Health of Ukraine, HRSA of the U.S. Department of Health and Human Services, CDC in Ukraine, and the International Renaissance Foundation for supporting this project.”
The goal of this training curriculum is to provide participants with the skills and knowledge required to form competencies in applying narcotic, psychotropic substances, and their precursors in the practice of family medicine, specifically in combination with treatment of drug addiction, tuberculosis, and hepatitis.
Participants work at the pilot training in Uzhgorod.
The guide is based on the results of three pilot training events that took place in October through December 2015 in Uzhgorod and Kyiv. Dr. Chris Behrens, Clinical Associate Professor in the University of Washington’s Department of Global Health, co-facilitated the first event in Uzhgorod. Dr. Behrens also co-authored the guide, along with leading experts from the Bogomolets NMU, the Ministry of Internal Affairs of Ukraine, the National Police of Ukraine, the State Service of Ukraine for the Drug Use Control, the Ivano-Frankivsk Oblast Clinical Center for Palliative Care, the Kyiv and Kryvyi Rih City AIDS Centers, and the International Renaissance Foundation.
The course covers such essential themes as:
The role of family physicians and primary health care facilities in using narcotic and psychotropic drugs and their precursors;
Legal and organizational principles of applying narcotic and psychotropic drugs and their precursors in primary health care practice in Ukraine;
Mental health; pre-conditions and types of opioid addiction; HIV/AIDS and other infectious diseases in IDUs; palliative and hospice care;
Principles and use of opioid maintenance therapy in primary health care, including the patients living with HIV/AIDS; and
Principles and use of narcotic and psychotropic drugs and their precursors in provision of palliative and hospice care, including patients living with HIV/AIDS.
The MoH of Ukraine recommends this guide as a tutorial for clinical interns and doctors enrolled in in-service or continuous medical education training programs, as well as for faculty of the Ukrainian medical universities and colleges that train doctors and nurses as general practitioners and family doctors. The guide has been already disseminated to about 60 medical universities and the largest medical colleges in Ukraine.
This project 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.
A PMTCT Client Retention training includes tablet-based self-study modules.
In Zimbabwe, health care workers often need to build confidence and skills in caring for HIV-positive infants and children. The International Training and Education Center for Health (I-TECH) has employed an innovative approach to support these front-line staff – a case-based, self-study PMTCT Client Retention training.
During the introductory session, participants are oriented to the course, given self-study tips, loaned tablets and instructed on their use, and given a pre-course assessment. Participants also attend a half-day classroom session at the beginning and end of the five-week course.
A WhatsApp discussion group is also set up to send messages of motivation and reminders and for participants to share issues during the course. WhatsApp is widely used in Zimbabwe as an inexpensive mobile phone platform to message individuals and groups.
WhatsApp for collaborative problem solving
Elizabeth is a primary care nurse who was among a cohort of 30 participants in one of these trainings, conducted in Mashonaland Central Province. About one week into the course, Elizabeth faced a situation at work where she was confused about how to apply national guidelines to one of her pediatric patient cases. Elizabeth chose to bring the issue to her training cohort. Below is a sample of the discussion that ensued among several members of the group, showing that a number of the cohort were similarly perplexed:
Elizabeth: A woman came to our clinic. She was ill. She wanted to get tested because she was ill for a long time on and off. The woman tested positive. Because she is breastfeeding an 11-month-old baby l commenced her on Option B+. l tested the baby with antibody RDT [rapid diagnostic test] and tested negative. l commenced the baby on cotrimoxazole prophylaxis. The question is: Was it necessary for the baby to be given NVP [nevirapine] prophylaxis since the baby tested negative and is now 11 months OR should l give the baby NVP prophylaxis for 6wks from now????
Elizabeth received a range of responses from her cohort:
NVP is only given from birth up to six weeks. Commence mother on Option B+, baby on cotr prophylaxis collect confirmatory DBS [dried blood spots] for the child.
I agree with ~nr
Cotr prophylaxis and confirmatory DBS only for the baby. Thanks guys.
Baby should still get NVP for six wks since still breastfeeding — meaning baby is still exposed.
As per NVP shld be given — the first dose at birth, the second dose 48hrs after first dose, then third dose 96hrs after second dose. Prophylaxis shld be given as soon after delivery as possible. When prophylaxis is delayed the less likely that the infection will be prevented.
By age of 14 days, infection already would be established in most infants. So l think it’s not necessary to give NVP as prophylaxis.
One member of the cohort was a district nursing officer (DNO). He shared that he had deliberately delayed responding until others had weighed in. He not only gave advice but also encouraged the group to refresh themselves on the resources available on their tablets:
Sorry for a late response. Remember key things in your scenario: mother is positive, baby is breastfeeding and is 11 months. … Infant is still at risk, therefore cotri prophy, infant feeding counselling and a continuation of routine FCH [family and child health] care will help. Then 6wks after stopping breastfeeding conduct rapid HIV test again. If negative stop cotri prophy and continue routine care. If positive CT cotri prophy, initiate ART.
He then referred Elizabeth to an algorithm in the national ART guidelines, which were included for easy reference in an application on the participants’ tablets.
This exchange showed the potential use of WhatsApp for support in clinical decision making, in the absence of a warmline for consultation. Upon returning to the classroom, participants engaged in discussion around the WhatsApp conversations, with particular attention paid to the case that Elizabeth had brought to the group. Other members of the cohort reported that they had watched the exchange with interest though they did not contribute.
The cohort members reported that the case was educational for them, and many of them indicated that they would like to continue their group for ongoing support.
As for Elizabeth’s young client, a rapid test was collected and returned negative. Results of the DNA test are still being awaited by the group with much interest. As one member wrote: “We cannot afford to lose that child, wherever she is. … She is still our child.”
The International Training and Education Center for Health (I-TECH) is presenting three posters at the 7th Annual Consortium of Universities for Global Health (CUGH) conference in San Francisco on April 9-11. The theme of this year’s conference is “Bridging to a Sustainable Future in Global Health.”
A critical component in sustainability is the ability to collect accurate and meaningful data through electronic medical records (EMRs) – the subject of two abstracts from the I-TECH Kenya team.
In addition, online learning and electronic learning (e-learning) provides opportunities for health care workers in resource-limited settings to gain critical knowledge and skills while minimizing their need to leave the workplace.
In close partnership with the University of Washington Department of Global Health’s eLearning Initiative (eDGH), I-TECH piloted e-learning modules for KenyaEMR and transitioned the HIV management diploma program at the University of the West Indies into a blended learning program that incorporates online courses.
The transcript tab allows learners to read along with the narration.
Since 2012, the Kenyan Ministry of Health, PEPFAR, and partners have supported implementation of electronic medical record systems (EMRs) at more than 600 public-sector health facilities. The International Training and Education Center for Health (I-TECH) has supported scale-up at more than 300 of these sites.
However, implementation is just part of the story. Successful, sustained use of EMR data depends upon the knowledge and skills of front-line health care workers. To address this need, I-TECH and eDGH developed and piloted two interactive e-learning modules on EMR data quality and EMR data for decision-making.
I-TECH and eDGH found that facility staff were motivated to use EMR e-learning modules and apply what they had learned. Participants found the content relevant to their jobs and cited an interest in additional scenarios and modules. Self-paced e-learning modules were determined to be a viable solution for standardizing sustainable training on EMR systems.
To support progressive EMR data quality improvement, I-TECH developed a Routine Data Quality Assessment (RDQA) standard operating procedure and analysis tool. The RDQA procedure was defined in collaboration with the Kenyan Ministry of Health and integrated within existing policies and procedures.
From 2014 to 2015, 180 baseline and repeat assessments were conducted. I-TECH supported facility personnel to share results during county-level EMR review meetings; these presentations motivated other sites to plan for RDQAs and fostered a culture of ongoing data quality improvement. The RDQA procedure for EMR data has now been institutionalized as a method for progressively improving EMR data quality in Kenya.
In partnership with the University of the West Indies (UWI), eDGH and I-TECH transitioned a one-year diploma program in the Management of HIV Infection to a blended learning platform that combines online courses with either a clinical practicum or a research project.
The shift in pedagogy, methodologies, and technologies was achieved through a three-phased approach designed to not only train UWI faculty and staff, but also transfer online facilitation skills to them and sustain those skills.
In its second year as a blended learning online program, the diploma program has scaled up to include health care workers from Cayman Islands, Jamaica, and Suriname.
These projects are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under U91HA0680, International AIDS Education and Training Center. The content and conclusions of this post are those of the authors 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.
Anna Shapoval, Country Representative, and Iryna Yuryeva, Senior Training Developer, with the National ClASS Guidelines.
On January 26, the Ministry of Health (MOH) of Ukraine formally adopted the national guidelines on Clinical Assessment for Systems Strengthening (ClASS) and approved ClASS as a formally recommended national qualitative methodology/tool. The ClASS Guidelines were developed by a team of 10 experts from the International Training & Education Center for Health (I-TECH) and the Ukrainian Center for Socially Dangerous Diseases of the MOH of Ukraine (UCDC).
The ClASS methodology in Ukraine offers four key modules/tools: Clinical, VCT, Administrative, and Financial. Two additional modules that will help assessing HIV/TB integrated services and HIV labs are in the process of development with input from the national and international experts. They are expected to be formally approved later this year.
“This is a significant accomplishment and the product of a very small team who put tremendous efforts, time, and energy to develop national guidelines in the course of just few months,” says Anna Shapoval, Country Representative for I-TECH Ukraine. “We are extremely proud and humbled by the fact that our joint efforts of promoting ClASS in Ukraine in the past two years are sustained in the form of this publication.”
On February 2-3, I-TECH and UCDC conducted the national dissemination workshop in Kyiv. ClASS Guidelines were presented to the group of the national ClASS reviewers, representatives of the eight Oblast AIDS Centers (OACs) from the regions that participated in the assessment to date, as well as OACs from the three new regions interested in applying ClASS. Along with local partners, I-TECH and UCDC discussed potential benefits that participation in ClASS could offer, just some of which include:
A positive platform for mentorship and sharing experience with the national ClASS reviewers, most of whom represent various health facilities and work in various regions of Ukraine;
Sound, evidence-based assessment findings, which may be successfully used for development of the strategic and working action plans and for attracting additional financing from budget and off-budget sources, donors including additional technical assistance; and
Preparation for accreditation and compulsory certification.
The future plans in regard to ClASS promotion in Ukraine include assessments of additional regions, development of at least two additional modules, training of the second group of the national ClASS reviewers, and applying ClASS toward at least two OAC as part of their preparation for the accreditation or mandatory certification.
Following the workshop, over 100 copies of the publication were immediately sent out to the U.S. Centers for Disease Control and Prevention (CDC) office in Ukraine, other international agencies, the MOH, all Health Departments of all Oblast State Administrations, all Oblast AIDS centers, scientific medical libraries, libraries of the Ukrainian medical universities, and continuous medical education academies.
“These guidelines open new opportunities for applying ClASS methodology and tools in Ukraine in different contexts and, most importantly, upon request from specific health care facilities or regions,” says Ms. Shapoval. “This differentiates ClASS from other top-down evaluations or approaches.
“The level of enthusiasm about ClASS among our national and local partners is inspiring, and with the additional modules on labs and HIV/TB co-infection being finalized and plans to train and certify the new group of national reviewers, we hope I-TECH will continue expanding its work around ClASS in Ukraine in the coming years.”
This project 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.
Dr. Regine Juste (left) works on iSanté with Dr. Marinho Elisma, I-TECH Haiti’s Lead Clinical Mentor.
For a decade, the iSanté electronic medical record system and OpenELIS lab software, developed by the International Training and Education Center for Health (I-TECH), have allowed health care providers to document HIV patient care and patient care histories.
The evaluation also identifies strengths and challenges in POC use of the iSanté and OpenELIS systems in clinics and hospitals in Haiti, in order to guide improvements in the quality of I-TECH’s technical assistance.
The move to point of care
Until 2012, most sites used iSanté primarily to capture data that providers had recorded on paper forms. In 2012-13, with impetus from the Haitian Ministry of Health and funders, I-TECH supported some iSanté sites to move toward POC implementation.
This involves providers using iSanté during patient visits to enroll patients, review health history, capture clinical assessments and treatment plans, and record drug and laboratory orders.
Evaluation shows positive impact
Through in-depth interviews and focus group discussions with hospital personnel, I-TECH was able to grasp the positive impact of iSanté POC system use has on care and treatment.
Facility personnel at all levels were satisfied with the transition to POC system use. All five sites evaluated reported increases in provider confidence and improved human resource management, citing reduced provider workload and more effective use of provider time.
Personnel also perceived a number of positive effects of system use on productivity and quality of care including benefits to patient experience (reduced wait times) and service quality.
Participants, experts, developers, and trainers of the pilot training event that took place in October 2014 at the UFMTC at NMU.
The International Training and Education Center for Health (I-TECH) Ukraine, in close partnership with the Ukrainian Family Medicine Training Center (UFMTC) at Bogomolets National Medical University (NMU), and under the auspices of the Ministry of Health (MoH) of Ukraine, has published a new facilitator guide, Modern Technologies for the Organization of Prevention of HIV/AIDS Transmission and Drug Use: The Role of Family Medicine Based Primary Health Care.
“This publication is a product of creative collaboration by a united team of experts in the areas of family medicine and HIV,” said Olga Vysotska, Director of the UFMTC at NMU. “It is a unique gift to the faculty of all departments at medical schools and colleges all over Ukraine that train medical doctors and nurses.”
The MoH of Ukraine recommends the guide as a tutorial for clinical interns and doctors enrolled in in-service or continuous medical education training programs, as well as for faculty of the Ukrainian medical universities and colleges that train medical doctors and nurses as general practitioners and family doctors.
The goal of the course is to provide participants with skills and knowledge in the early diagnosis, care, social adaptation, treatment, and early prophylaxis of HIV, specifically in combination with drug addiction, tuberculosis, and hepatitis, as well as to form the proper attitudes necessary for family physicians in Ukraine to provide effective services to HIV patients, and patients of at-risk groups.
The guide is based on the results of a pilot training event that took place in October 2014 at the UFMTC at NMU. Dr. Chris Behrens from I-TECH facilitated the event, along with nine leading national experts from NMU, the Ukrainian Center of Diseases Control (UCDC), the Ivano-Frankivsk Oblast Clinical Center for Palliative Care, and the Kiev City AIDS Center.
“It is the first of its kind in Ukraine; no such publications existed prior to this one,” said Dr. Vysotska. “In addition to their work on the most up-to-date clinical content, we really valued the methodological support provided by I-TECH during the training process and development of the guide, as well as the application of contemporary tools and approaches to adult education.”
The key areas covered by the course are:
HIV/AIDS epidemiology, both globally and in Ukraine, including the roles of primary health care and family medicine in responding to the HIV/AIDS epidemic
Pathophysiology, pathogenesis, and stages of HIV infection, including key diagnostic methods
Palliative care for HIV/AIDS patients by family doctors.
Antiretroviral therapy (ART)
Diagnosis and management of co-infection (HIV/TB/virus, hepatitis B and C) in family practice
HIV in pregnant women, including prevention of mother-to-child transmission
Management of patients with HIV and drug addiction, including opiate substitution therapy (OST)
Post-contact prophylaxis, including universal precautions (international and Ukrainian standards)
“The process of development of this product by a multicultural, multiprofessional team of experts was vibrant, mutually enriching, and very satisfying,” said Anna Shapoval, Country Representative for I-TECH Ukraine. “We are most grateful to the Ministry of Health of Ukraine, HRSA of the US Department of HHS and CDC in Ukraine for their support and guidance through this project and look forward to new initiatives of this kind together with our national partners.”
This project 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-supported HIV care and counseling in northern Ethiopia, in 2009. Photo courtesy of Julia Sherburne.
Although HIV patients in Ethiopia have greater access to antiretroviral therapy (ART) than they did a decade ago, ensuring that patients adhere to a full course of ART is still a major challenge. In response, in 2008, the International Training and Education Center for Health (I-TECH) launched a landmark HIV/AIDS Case Management program in several of the country’s regions where HIV prevalence was high.
This project was supported by the U.S. President’s Plan for AIDS Relief (PEPFAR), through the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA).
The goals of the project are to help control the HIV epidemic in Ethiopia, minimize transmission of HIV, and help HIV patients lead healthy lives. The project actively targets and engages patients considered to be likely non-adherents by assessing clinical, nutritional, domestic, and economic indicators. Those at risk of non-adherence are transferred to I-TECH-trained case managers located within ART clinics.
“ART taken for life is a challenge, but missing a few pills can cause a rapid decline in the health of a patient suffering from HIV. A discontinued course of ART will create a resistant strain of HIV that is much more difficult to treat,” says Misti McDowell, former Country Director for I-TECH Ethiopia.
Poor adherence can also mean high risk of transmission in the patient’s community. The Case Management program helps mitigate that risk.
A new screening tool
I-TECH quickly realized that many patients attending adherence counseling sessions were suffering from mental health issues, including depression, anxiety, and substance abuse. It was also understood that many health workers did not have the competencies or skills to adequately engage in conversation with patients about their mental and emotional welfare.
I-TECH formulated a mental-health screening tool for all ART patients to better assist patients with ART adherence and mental health issues.
“Many HIV patients in Ethiopia become overwhelmed by depression, and commit suicide. The mental health component to our work has helped to prevent these outcomes, and manage mental health issues related to HIV diagnosis,” says Dr. Manuel Kassaye, I-TECH’s Care and Treatment Programs Director.
Shared experiences can save lives
In Ethiopia, there are currently only 42 working psychiatrists catering to the needs of an estimated population of 93 million. “The country is in need of a strategy to deliver mental health services to people,” says Dr. Manuel. I-TECH-trained adherence case managers, working in partnership with hospital clinicians, have directly helped to address mental health issues related to HIV in Ethiopia.
The majority of case managers selected and trained by I-TECH have themselves been diagnosed with HIV, ensuring empathic relationships with their patients.
“To be a good adherence support worker, I believe it is necessary to have HIV,” says Mulugojam Yilikal, who was trained as a support worker by I-TECH in 2008. “The case worker will have enough experience to empathize with the patient, to help guide them through their mental and emotional issues.”
She adds that patients feel secure and comfortable talking to people who also have HIV. “By opening up and talking freely with us, it benefits their mental health, and their adherence to taking their medication.”
Mulugojam’s brother tragically committed suicide in 2007, after struggling to come to terms with his HIV diagnosis. “I know that if this support and counseling service [had been] available to my brother, he would have been saved from killing himself,” she says. “If a patient confides to a support worker that they want to take their own life, they can be prevented [from doing so] through counseling.”
Genet Behre, 30, is married and has a 5-year-old son. She discovered her HIV status during a pregnancy check-up in 2009. She immediately started taking ART and reluctantly disclosed the news to her husband—who subsequently left her. Once disclosure is made, there usually follows a period of emotional and mental distress that often leads to household dysfunction. “It was a terrible time when I first found out,” says Genet. “I was very distressed, and came into conflict with family and friends.”
After being screened for mental health, Genet was offered counseling and medical treatment for her depression and anxiety. “After six months, I had stopped fighting with my family,” she says. “My life is now stable again, my home life is peaceful, and I have an income selling injera. The counseling and medical support I receive has helped me to live like ordinary people, and not fear for the future.”
After counseling, new hope
A peer support group has been set up by I-TECH, in which patients have a platform to confide in others and speak openly without fear of being judged. Here, people are encouraged to share personal experiences and coping strategies. The group focuses on helping patients cope with the stigma associated with HIV, and overcome any barriers to ART adherence, including social and economic problems.
Zenabe Teklu, 35, silently sits with her I-TECH trained case manager at Gondar Hospital. Although she barely speaks, she is evidently happy to be in the reassuring company of her mentor. Zenabe had two children who both tragically died within six months of being born. After the departure of her husband in 2007, her mental health started to deteriorate. Then, after developing physical sores in 2007, she was tested for HIV, and promptly joined I-TECH’s case support program. However, between 2007 and 2013, she continued to suffer strong symptoms of mental disturbance and suicidal tendencies.
In 2013, I-TECH introduced the mental health screening service at Gondar Hospital. Up to this point, Zenabe was mistakenly told that her depression and suicidal thoughts were symptoms of ART medication. Zenabe started receiving the correct medication and counseling shortly after hospital staff members had completed I-TECH training in mental health screening.
Zenabe, who currently works as a cotton weaver, is happy to have turned a huge corner in her life with the support of I-TECH: “My life is stable compared to how I was before. I no longer feel full of anger and depression. I have experienced a lot of trauma, but the support I get from my case managers helps me to live a normal life”.
