Bishan Guracha Orientation 1
Bishan Guracha Orientation 1
Bishan Guracha Orientation 1
REFRESHIMENT ORIENTATION
FOCUS AREA
1. Different Reform (EHCRIG,Civil Cervantes adm )
2. Program Update (HIV/AIDS,NCD and NTD and MCH)
Part I:
HIV/AIDS Program New Initiatives Update
40 % 88 % 92%
9
According to 2022 EPHI spectrum estimate:
National HIV
Prevalence:0.91, Incidence: 0.01
Vertical Transmission=12.04% (2022), 9.35%(2023)
Oromia HIV
Prevalence: 0.64, Incidence: 0.01
Vertical Transmission=15.82% (2022), 10.18%(2023)
Goal and Objectives of National Road Map
The goal is to attain epidemic control by 2025
Both new infection and AIDS death <1/10,000 population
Reduce the number of new infections to < 7400
Objectives by 2025
Reach 95% of KPP with combination prevention – Behavioral, biomedical and structural interventions
90% of KPP use condoms at last high-risk sex
90% of Eligible people access PrEP
VMMC coverage reaches 90% in high-incidence regions (Gambella)
Reach 90% of PWID with needle syringe and 40% with OST
Reduce stigma and discrimination among PLHIV below 10%
Ensure there are policies and legal frameworks that support HIV programs targeting KPPs
HIV/AIDS Treatment Global Target By 2030
95 percent of
95 percent of
95 percent of people people on
people who know
living with HIV know treatment have
their HIV status are
their HIV status suppressed viral
accessing treatment
loads
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2. HIV Case Finding and type of RTK
•HIV Screening Tool
•HTS
•Pr-EP
•ICT
•HIVST
•Recency
Combination HIV Prevention
Is an approach that seeks to achieve maximum impact for preventing new HIV infections by:
Behavioral interventions: reduce behaviors that increase risk of HIV transmission. Eg:
condom promotion,SBCC..
Biomedical interventions: directly influence the biological system through w/h the virus
infects a new hosts.eg: condom use, PrEP, PEP, VMMC, STI screening & Mgt, HTS &
ART
Structural intervention: social, legal, political & environmental enablers
1. All pregnant at first ANC visit, laboring, and postpartum women with unknown HIV status
2. Partners of HIV positive pregnant/ postpartum women
3. Sexual partners of index cases and all under 19 children of PLHIV; biological siblings and biological
parents.
4. Female sex workers with unknown HIV status.
5. All TB patients and presumptive TB cases with unknown HIV status
6. All patients with Sexually transmitted infections (STIs) and their partners
7. Children orphaned by AIDS.
8. Patients with clinical signs or symptoms of HIV/AIDS visiting health facilities
NB:
The above-mentioned target population are directly eligible for HTS. Other patient/client should be
screened by national HIV risk screening tools). It‘s mandatory that all health care providers MUST
use HIV risk screening tool at every POC/SDPs.
Spectrum of HIV Diagnosis and Type of RTK
.
1. Collect test items and other 2. Remove device from package & 3. Collect specimen using a new
necessary supplies label with panel ID disposable pipette provided with
the kit
Note: The Invalid test results should be retested with new test
device.
The Ethiopian Public
23
Ministry of Health-Ethiopia
Health Institute
First Response
• Purple colored control line will appear irrespective of the reactive or non-reactive
specimen.
Ensure that the test device & other components are at room temperature (15°C
to 30°C) before starting the procedure.
Label the test device with the patient identification number. Place the test device
on a flat, clean and dry surface.
Hold the assay buffer bottle vertically and add one drop of assay buffer to
the specimen well.
Interpret test results at 15 minutes after adding assay buffer to the specimen
well.
25
• These proteins are also linked to colloidal gold and impregnated below the test region
of the device.
Two drops of serum, plasma or whole blood is applied to the sample port, followed
by two drops of Wash Solution and allowed to react.
The antibody protein colloidal gold complex moves chromatographically along the
membrane to the test and control regions of the test device.
Excess conjugate forms a second pink/red band in the control region of the device.
• Two pink/red lines of any intensity adjacent to letter “T” (test) and adjacent to “C”
(control). This indicates a Reactive result
• A pink/red line of any intensity adjacent to the letter “C” (control), but no pink/red
line adjacent to "T” (test). This indicates a Non-Reactive result.
• No pink/red line appears in the device window adjacent to the letter “C” (control)
irrespective of whether or not a pink/red line appears in the device window adjacent
to “T” (test). This is an Invalid result. An invalid result must be repeated.
Perform A1
Proper interpretation of each test results
A1+
A1-
Report as HIV
according to the validated testing algorithm
Negative
is important to accurately diagnose and
Perform A2
Perform A3
Whool blood
1drop/30µl 1drop 15-20minutes
One Step Serum/Plasma
2drop (line 2) =
Whool blood 20µl
1drop 15-25minutes
1st 1drop (line 1)=10µl
Response Serum/Plasma
er
Sex rtn
pa
par x
tne Se
r( s)
Providers trained on HTS including index testing procedures, IPV screening, adverse event
monitoring, 5Cs, and ethics.
Adherence to 5C‘s (consent, confidentiality, counseling, correct test results, and connection
to prevention/treatment)
IPV risk assessment and provision of first line response, including safety check and referrals
to clinical and non-clinical services (if not provided on site)
Secure environment to store patient information.
Site level adverse event monitoring reporting system
• ICT Registers
Key Population and Social Network Strategy
• SNS is strategy that uses social network connections to locate individuals engaging sexual
partner/s and it can also be applied for FSWs, drug injecting partners and social contacts of
key population members with HIV and of those who are HIV- negative and at ongoing risk.
• The assumption of SNS is that people in the same social network share similar risk behaviors
that predispose them for HIV
There are four major phases to a social networks program.
Recruiter Enlistment
Engagement (Orientation, Interview, and Coaching)
Recruitment of Network Associates
HTS
Key Population Service
What makes them key populations?
Disproportionately affected by HIV
Engage in behaviors that:
• Put them at high risk for HIV (Substance use, Unprotected, condom less vaginal and
anal sex, Multiple sex partners)
• Are socially unacceptable
• Often criminalized
• Experience stigma and discrimination for engaging in these behaviors
A comprehensive package of services has been defined to respond to HIV among key
populations
HIV Self Testing
• Is a process in which a person collects his or her own specimen (oral fluid or blood) and then performs an HIV
test and interprets the result, often in a private setting, either alone or with someone he or she trusts. It should be
offered as an additional approach to HTS and should always be voluntary, not coercive
• Directly assisted: trained/ oriented providers, or peers giving individuals an in person demonstration before or
during HIVST on how to perform the test and interpret the test result. The assistant will provide pretest
information, demonstration, and interpretation of the result.
• Unassisted: refers to when individuals self-test for HIV and only use an HIVST kit with manufacturer-provided
instructions for use.
• For individuals with non-reactive self-test results, the assistant should advise the self- tester to retest in 3-6
months if the client has an ongoing risk to HIV infection.
Secondary distribution of HIV self-testing (HIVST) kits, through index cases to their sexual partner/s and by
index clients attending general health care to their sexual contacts, can increase the number of HIV case detection
on key and priority population. Hence, providers working in all service delivery points should consider secondary
HIVST-kit distribution as an alternative approach to enhance case finding among key and priority populations
Recency Testing
Recent HIV infection is HIV infection acquired in the past 12 months.
Recency testing distinguishes between recent (HIV infection acquired in the past 12 months)
and long-term HIV infection.
Recent HIV infections are presented as high viral load, immature and weak immune
response, continued high risk behavior, High probability of ongoing transmission (40%-60%
of transmissions).
Recency testing provides opportunity for interruption of transmission by contact tracing and
it increase yield of HIV testing.
Probable recent infection: confirmed newly diagnosed HIV positive individual who tested
positive for recent infection.
Confirmed recent infection: confirmed newly diagnosed HIV positive individual who tested
positive for recent infection and has high viral load.
Purpose of Recency Testing
Site Level Response
Document all probable recent infections and risk factor information about the newly identified
HIV positive cases to provide enhanced response and timely monitoring.
Site level response includes:
All newly diagnosed HIV positive individuals should be linked and start ART within the
same day.
ICT services should be provided for sexual partners and eligible biological children
Above-Site level response
o Primarily based on the identification and analysis of clusters based on the CBS data.
o The type and level of public health response is guided by the magnitude and the spread of
transmission. Some clusters may require routine public health actions such as ICT Services
and linkage to care and treatment services, while other clusters may require enhanced
response activities (e.g. targeted demand creation and testing as well as strengthening
partnership of relevant stakeholders)
3. Linkage and ART initiation flow chart
The Effect of leak PipeCOA Cohort Dynamics
Factors That Increase TX_CURR
Contributors for cohort Growth
1. Case detection
ICT/PNS
2. Treatment initiation
RBT
VCT
Tx- 3. Retention
4. VL testing coverage & suppression
new
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ta
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t
Los
Dro
TO
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Dea
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HIVST
SNS
KP
f
Sel
Factors That Decrease TX_CURR 51
Key elements of chronic HIV care are
1. Retesting for verification 9 Screening for and managing mental health
problems and substance use
2. Complete clinical assessment (history
taking, complete physical examination and 10. Adherence and psychosocial counseling
relevant lab tests) and support
3. WHO clinical staging 11. Nutritional assessment and counseling
4. Prevention, screening and management of 12. Screening for other STIs
opportunistic infections and co-morbidities 13. Prevention screening and treatment of
5. Rapid ART initiation cervical cancer.
6. Patient monitoring and follow up 14. Management of pain and symptoms.
7. Support for disclosure and assisted 15. Pregnancy status, family planning and
partner notification contraception.
8. Risk reduction counseling and 16. Document all relevant client
combination HIV prevention approaches information.
Attention
Approach to CD4 Testing
• Viral load testing remains the primary method used to monitor the effect of therapy. CD4 testing is used to
identify individuals with advanced HIV disease.
• Individuals who have documented viremia (most recent VL >1,000) should have a CD4 performed to diagnose
presence of advanced HIV disease and determine eligibility for the advanced disease package
IV .Prevention and Palliative care:
ART Choric care,TPT(3HP),CxCa, HIV and Mental Health illnesses
1. End TB…..
Interventions to reduce TB associated morbidity and mortality among PLHIV
• PLHIV and HIV negative HH contacts <15 years are the priority targets to take TPT for TB prevention.
TB preventive treatment recommended for
1.Adults and children living with HIV who are unlikely to have active TB
on appropriate clinical evaluation
•Children 12 months or older who are living with HIV and are
unlikely to have active TB on appropriate clinical evaluation and
• Infants aged <12 months living with HIV who are in contact with
a case of PTB and unlikely to have active TB on appropriate clinical
evaluation should receive TPT
2. HIV-negative adult and child contacts
3. Other HIV negative at-risk groups (pts on dialysis, organ transplant and
patients with silicosis )
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TB preventive Treatment options
1. Daily INH for 6 months (6H)
2. Daily INH for 9 months (9H)
3. Rifapentine + isoniazid weekly for 3 months (3HP)*
4. Rifapentine + isoniazide daily for 1 month (1HP)**
5. Rifampicin plus isoniazid daily for 3 months for children and adolescents
<15y (3HR)*
6. Rifampicin daily for 4 months (4R)**
Selection of TPT regimen for PLHIV
Selection of TPT regimen
Age group and ART regimen
Preferred regimen Alternative regimen
4j= ABC +3TC + DTG 2i = ABC + 3TC + LPV/r 5i=TDF + 3TC+ LPV/r
4k= AZT + 3TC + DTG 2j = TDF + 3TC + DTG 5m = ABC + 3TC + DTG
4L= ABC + 3TC + EFV 2k = AZT + 3TC + DTG 5n= AZT + 3TC + DTG
4h=other first line
5o= TDF + 3TC + DTG
1i = Other specify 4L= ABC + 3TC + EFV
2l=other secondline 5j=other second line
ARV Drug Regimen vs TPT
3rd Line Adult 3rd line Pediatric
3a=DRV/r+DTG+AZT/3TC 6c=DRV/r+DTG+AZT+3TC
3b=DRV/r+DTG+TDF/3TC 6d=DRV/r+DTG+TDF+3TC
Infant and children <2yrs of age Daily rifampicin Plus isoniazid Daily isoniazid preventive
for 3 months (3RH) treatment (IPT) for 6 months
Eligible adolescents aged >2-14 Weekly isoniazid Plus rifapentine Daily isoniazid preventive
years for 3 months (3HP) treatment (IPT) for 6 months
-3RH will be used as alternative
Algorithm for adults and adolescents ≥15 years living with HIV
No Contraindications
contraindication to 3HP Other TB diagnosed
diagnosis
Follow up and
If eligible: If not eligible: consider TPT
H= isoniazid Defer preventive once illness
R=Rifampicin Initiate alternative treatment until
HP= isoniazid/Rifapentine
regimen resolved
contra-indication
(6H) resolved
Children aged < 15 yrs living with HIV, with and without household TB exposure
Age Age
Refer for further diagnostic work- 0-12 months > 12 months
up (Xpert; CXR) f
Close contact of START TPT c,d,eI
Yes
PTB index case?
• One of short-course TPT regimen recommended by WHO for treatment of latent TB infection
• Full course of treatment: 12 doses administered once weekly for three months duration
Specific counselling points for 3HP:
What do you need to know about administering 3HP ?
Isoniazid 300 mg 3 3 3 3 3
Rifapentine 150 mg 6 6 6 6 6
Rifapentine 150 mg 2 3 4 5 5
Isoniazid +
150 mg /150 mg 2 3 4 5 5 FDC being developed
Rifapentine FDC
Notes to the algorithm
1. Follow appropriate national guidelines for 3. Contraindications to 3HP/6H use:
investigation of TB disease 1. Active Hepatitis (acute or chronic)
2. WHO recommends symptom screen 2. Regular & heavy alcohol use
1. Cough, fever, weight loss, night sweats to rule out TB 3. Severe peripheral neuropathy
2. No chest X-ray 4. Pregnant and breastfeeding mothers* (for rifapentine only)
3. No proof of infection (TST/IGRA) 5. Unwilling/unable to use non-hormonal forms (barrier
methods) of contraception (rifapentine only)
These are therefore not necessary for TPT initiation 6. On Protease Inhibitor or NVP – based ART (rifapentine
including 3HP only)
Indication C/I
• >2 years • pregnant/BF
• >15 years on Non-PI Based • <2yrs
• 2-14years not on DTG but EFV • <15yrs on DGT-based
• Not HIV-Exposed on NVP • Any age receiving PI-Based
Management Ctd…
Actions to be taken if patients missed doses of 3HP:
• Encourage a weekly routine of taking medications i.e. Sunday. If a patient misses Sunday, they can take
3HP within 3 days and go back to their normal Sunday routine
• If they miss a dose for more than 3 days there are two options:
1) They can skip this dose and go back to their original chosen day i.e. Sunday and continue until all
12 doses have been taken
OR
2. Start the new schedule on the day they remembered to take the dose i.e. Schedule was a Sunday and
only remembered Thursday, they now start a once weekly Thursday routine and forget about
Sundays
• The 12 week course should be completed within 16 weeks which provides some leeway for missed doses
(11 doses can be counted as complete although not ideal)
• For TPT completion is 6/9:Complete full course of therapy with nine months and interruption <3months is
resumed the same and adde mised dose at end but>3months is re-initiated new course of Tx
3HP- drug safety and adverse events
• Overall, 3HP is a safe, tolerable and effective treatment for latent TB
infection.
Minor adverse events are likely to occur in small proportion of individuals/patients.
Rarely serious adverse events may occur, and hence both the health care provider and
patient should be vigilant and manage such events rapidly.
Drug reactions are usually mild and self-limiting, but occasionally they can be severe.
• Most adverse events associated with 3HP are due to drug reactions (rash, hepatitis, flu-like
syndrome) or drug-drug interactions (lowering of drugs used to treat other conditions)
3HP – what sorts of adverse events
TIME
• LPV/r is the preferred 168 boosted PI option, but ATV/r may be considered if more appropriate formulations
• After failure of a first-line LPV/r-based regimen, children can be switched to DTG based regimen as per table below.
• After failure of a first-line regimen of ABC or TDF + 3TC, the preferred NRTI backbone option for second-line ART is
AZT + 3TC and failure of a first-line regimen is containing AZT + 3TC, the preferred NRTI backbone option for
AZT+3TC+DTG ABC+3TC+LPV/r
1. Patients who fulfill the criteria of treatment failure and with no signs of clinical failure
2. Patients who are initiated on second line ART at hospital and became stable with no signs of OI
or drug toxicity and transferred out to health centers having second line ART.
VI. Elimination of Mother to Child
Transmission (eMTCT)
What is new on ANC schedule?
WHO FANC MODEL 2016 WHO NEW MODEL
All pregnant women should be tested for hepatitis B surface antigen (HBsAg) at least once
and as early as possible particularly in settings with a ≥2% HBsAg seroprevalence in the
general population.
103
2017_HMIS 2021_HMIS
Total Indicator:131 Total indicators:177
Continued: Dropped:
103 Modified: 3 New:71
25
105
9 Tuberculosis/TB/ & 22 22
20 Regulatory system 1 2
Leprosy
Total 131 177
10 Malaria 5 8
Reportable data elements from PMTCT register..21
S.N Reportable data element
1 No. of HIV positive pregnant women who received ART during ANC for the first time
2 No. of HIV positive Pregnant women who received ART during L&D for the first time
3 No. of HIV positive Pregnant women who received ART during PNC for the first time
4 No. of HIV-positive women who get pregnant while on ART and linked to ANC
5 No. of HIV exposed infants who received Virological HIV test 0- 2 months of birth
6 No. of HIV exposed infants who received an Virological HIV test 2-12 months of birth
106
PMTCT register cont….
S.No, Reportable data element
7 No. of infants born to HIV positive women started on co-trimoxazole prophylaxis within two
months of birth
9 No. of HIV exposed infants receiving HIV confirmatory (antibody test) by 18 months
10 No. of partners of pregnant, laboring and lactating women tested and know their results
13 Number of adults and children with HIV infection newly started on ART
14 Number of adults and children who are still on treatment at 12 months after initiating ART
107
PMTCT register cont….
S.N Reportable data element
15 Number of persons on ART in the original cohort including those transferred in, minus those
transferred out (net current cohort).
16 Total number of adult and pediatric ART patients with an undetectable viral load
<1000copies/ml in the reporting period
17 Number of adult and pediatric ART patients with a viral load test in the reporting period.
20 Number of clients who were on ART and screened for TB during the reporting period
108
PMTCT Reports of Y Facility of June Report
MTCT PMTCT
MTCT_TST Pregnant and lactating women who were tested for HIV and know their results 201
MTCT_TST.1. Number of Pregnant women tested and know their HIV result during pregnancy 193
MTCT_TST.2. Number of pregnant women tested and know their HIV result during labor & delivery 2
MTCT_TST.3. Number of women tested and know their HIV result during the postpartum period 0
MTCT_Test.4. Number of women with known HIV positive status attending ANC, delivery and postpartum for new pregnancy 6
MTCT_NW pos. Number of new HIV positive women during ANC, L&D and Postpartum 2
Percentage of HIV-positive pregnant women who received ART to reduce the risk of mother-to child-
MTCT_ART transmission (MTCT) during pregnancy, L&D and PNC
Number of HIV positive women who received ART to reduce the risk of mother to child transmission during ANC
MTCT_ART.1. for the first time 0
Number of HIV positive Pregnant women who received ART to reduce the risk of mother to child transmission
MTCT_ART.2. during L&D for the first time 0
Number of HIV positive lactating women who received ART to reduce the risk of mother to child transmission
MTCT_ART.3. during PNC for the first time 1
MTCT_ART.4. Number of HIV-positive women who get pregnant while on ART and linked to ANC 4
HEI-DBS/Ab test
MTCT_HEI_EID.1 Total Number of infants within 12 month received virological test result 1
MTCT_HEI_EID.1.1 Number of HIV exposed infants who received an HIV test 0- 2 months of birth
MTCT_HEI_EID.1.1. 1 Positive
MTCT_HEI_EID.1.1. 2 Negative
MTCT_HEI_EID.1.2 Number of HIV exposed infants who received an HIV test 2-12 months of birth 1
MTCT_HEI_EID.1.2. 1 Positive
MTCT_HEI_EID.1.2. 2 Negative 1
Percentage of HIV exposed infants receiving HIV confirmatory (antibody test) test
Antibody test by 18 months
Number of HIV exposed infants receiving HIV confirmatory (antibody test) by 18
MTCT_HEI_ABTST.1 months 2
MTCT_HEI_ABTST.1. 1 Positive
MTCT_HEI_ABTST.1. 2 Negative
111
HIV and Hepatitis Indicators
Sr # List of Indicators Remarks
1 Percentage of people living with HIV who know their status Existing
2 Number of people living with HIV currently receiving ART Existing
3 Number of adults and children with HIV infection newly started on ART Existing
9 Proportion of clinically undernourished People Living with HIV (PLHIV) who Existing
received therapeutic or supplementary food
What is expected
• The services should be provided as per SOP,Guidline,Algorism
• All necessary inquires like algorism, SOP and other reference should be
available in all SDP,
Example: ANC Re-test,RTK Algorism,VLT monitoring,
• ART Service should be integrated
• Providing staff has to be well updated (training)
• All service delivery units use HIVRST
Together we can break the
chain of HIV transmission !!!
CT
I
Thank You!!