"What started in 2005 as a pilot programme for tuberculosis and HIV care has grown into an Integrated HIV Care (IHC) programme that is reaching thousands of patients and impacting not only their lives, but also the lives of their families and their communities", says Dr Philippe Clevenbergh, Director of The Union Office in Myanmar, one of the 14 offices worldwide of the International Union Against Tuberculosis and Lung Disease (The Union).
The original collaborators were The Union and the Myanmar Ministry of Health, who received funding for the project from the Yadana Consortium operated by Total/MGTC.
"The overarching goal is to scale up access to ART, and Total/Yadana has been a partner from the beginning. With their support we created a successful model", says Clevenbergh, " but since The Global Fund and the Three Diseases Fund (3DF) have also become involved, we have been able to quickly scale up our provision of ART to HIV-infected patients." To illustrate this change, he points out that it took five years for the programme to reach 2,000 patients actively taking ART, while an additional 8,000 patients started on ART between January 2010 and June 2012.
The new funding also gave the IHC programme the opportunity to broaden its mandate and extend its reach. Services are now offered in 14 townships and are available not only to co-infected patients but also to any HIV patient. In addition, patients are no longer required to prove they are residents of the catchment area to receive services. These changes have greatly increased the scope of the project, but the model remains the same.
Our motto: in, by and with the public sector
The IHC model is based on what Clevenbergh calls the "4 P" approach -- a partnership that brings together the patients, the public sector and the private sector. The private sector is represented by The Union and the donors, who facilitate the integration of HIV care into existing public health services on behalf of the patients.
"Our motto is 'in, by and with the public sector'," says Clevenbergh. The IHC programme relies on the existing health facilities, infrastructures and human resources not only of Myanmar's National AIDS (NAP) and National TB (NTP) Programmes, but also of an array of other partners, including hospitals, township health centres, laboratories, social service departments, pharmacies and patient self-help groups.
While the public programmes deliver the services to the patients, The Union provides technical, human resources and financial support to enhance their performance and increase their reach. The Union also assists with monitoring and recording progress and identifying opportunities to use operational research to improve the overall functioning of the system.
"Over time we have all gained experience and confidence in our system and how we work together", says Clevenbergh. Today the IHC programme enrolls 400 new patients each month, providing diagnosis; treatment for opportunistic infections, including TB; ART; and biological follow-up. The IHC programme is part of the national effort to fight against HIV/AiDS and contributed to the NAP's A1 rating by the Global Fund performance scale.
"This enormous effort obviously requires a lot of participation and energy from many health care workers in the public sector, without whom it would be impossible to carry out such a task", says Clevenbergh. Their good performance, he adds, is what has made the programme attractive to donors, who are willing to support a model able to achieve their requirements.
Some key results of the IHC programme:
• > 10,000 patients are actively on ART as of July 2012.
• 83% of those started on ART are still taking it.
• 85% of patients are alive on treatment 12 months after starting ART.
• HIV testing for TB patients is now handled autonomously by township health centres.
• Dedicated out-patient departments have been opened at several facilities, including one at the Central Women's Hospital in Mandalay, which provides ART to pregnant women to prevent mother-to-child-transmission (PMTCT) and care for exposed babies until their HIV status is known.
• The programme has grown from 7 townships in Mandalay in 2005 to include sites in Pakokku, Lashio, Taunggyi, Monywa, Myeikhtila, Myinchan and Thar Ke Ta Hospital in Yangon, as well as the prisons in Mandalay and Taunggyi.
• 71 employees now work for the IHC programme through The Union Office in Myanmar.
• In 2012, The Union received its registration as an international non-governmental organisation in Myanmar and the memorandum of understanding with the Ministry of Health was renewed.
The future: continuing improvement on all fronts
The future for the IHC programme looks bright, and negotiations with donors for continued or expanded funding are underway. New developments designed to further enhance the programme include:
In Mandalay, the NAP has opened a "pre-ART" clinic offering baseline investigation and drug adherence counseling to enroll patients more quickly and prepare them to receive ART.
Plans are underway to upgrade the capacity of the Public Health Laboratory in Mandalay so that it can perform all laboratory investigations necessary to follow HIV-infected patients receiving ART. In collaboration with Fondation Mérieux, a molecular biology laboratory able to measure HIV viral loads has been established there.
A formal merger between the NAP and The Union has largely simplified the procedures for procurement and will potentially streamline systems across all the participating facilities.
New ART guidelines from the NAP, developed with input from The Union, permit adults to start ART at a higher level of CD4 count, which greatly increases the number of patients eligible for ART and increases their chance of a favorable outcome. A new first-line drug regimen has also been introduced and recommendations for PMTCT have been updated.
Comprehensive care for patients stabilised on ART for at least one year has been decentralised to township health centres, which now provide their clinical follow-up, dispense their medicines and handle blood sampling and results.
"We are all very pleased with our growth and what we have achieved", says Clevenbergh. "We met our 5-year funding target in 2 years, and this will make it possible to add another 6,000 patients by 2015. Our hope is that all these trends will continue. 10,000 lives have been saved, but there are still thousands more who require this care".
About The Union
The mission of the International Union Against Tuberculosis and Lung Disease (The Union) is to bring innovation, expertise, solutions and support to address health challenges in low- and middle-income populations. With nearly 10,000 members and subscribers from 150 countries, The Union has its headquarters in Paris and offices serving the Africa, Asia Pacific, Europe, Latin America, Middle East, North America and South-East Asia regions. Its scientific departments focus on tuberculosis and HIV, lung health and non-communicable diseases, tobacco control and research. Learn more at www.theunion.org