Category Archives: Health Systems

World Health Worker Week – Improving Capacity to Defeat Malaria

The Frontline Health Worker Alliance reminds us that, “Frontline health workers are the backbone of effective health systems – and are those directly providing services where they are most needed, especially in remote and rural areas.” These are the people who make delivery of essential malaria prevention and case management services possible. They further note that April 3-9, 2016 is World Health Worker Week and “is an opportunity to mobilize communities, partners, and policy makers in support of health workers in your community and around the world.”

Nigeria CDD performs RDT in Upenekang Community Ibeno LGA Akwa Ibom StateUnfortunately the very areas of the world that have the most malaria also have the greatest shortage of health workers as seen in Africa, South and Southeast Asia. In this situation skills and dedication of every single available frontline health worker are crucial for defeating malaria. This can only be achieved if they are up-to-date in the latest malaria programs.

For example, most malaria endemic countries in Africa have updated their malaria in pregnancy guidance to reflect the need to provide intermittent preventive treatment (IPTp) at every antenatal care visit after the 13th week of pregnancy with doses at a month interval. This means a pregnant woman may now receive 3 or more doses. What is still needed in many countries is full dissemination of this guidance to all frontline health staff so that they can implement this service correctly and fully.

DSCN3778As we move toward malaria elimination, more people will live in areas with unstable or epidemic transmission. The chances of developing severe malaria will increase. Updated skills on managing severe malaria that results in convulsions, chronic anemia and death are needed for these frontline staff.

Enhanced skills in surveillance are now needed as we move toward malaria elimination. Good diagnostic, record keeping and reporting skills are needed by frontline staff to help identify malaria transmission hotspots. Skills are also needed on treatment regimens that include transmission blocking medicines.

Vector control will remain an essential part of defeating malaria, but health workers will need to learn about new technologies as these become available. They will need skills for better targeting of complimentary interventions like larviciding. Continual efforts to manage routing distribution of long lasting insecticide-treated nets must ensure that health workers have the skills and resources to follow-up and promote actual use of the nets for their intended purpose.

Vaccines and other new technologies will become available for controlling malaria. Health worker capacity building will be needed to ensure each of these new additions to the malaria arsenal are implemented in the most effective manner.

From the foregoing we can see that there are many reasons why the malaria community should observe World Health Worker Week now and continue to build health worker capacity to defeat malaria throughout the year.

Update on Malaria and HIV/AIDS

63719_10152358606695936_7047535049294543967_nWorld AIDS Day is a time to reflect on the broader impact of HIV and its interactions with other infectious and chronic conditions that must be managed through an integrated health system. The past few months have yielded a variety of published studies on the HIV-Malaria link ranging from pharmacological, and physiological to health systems issues. A brief summary follows.

Having HIV does have consequences on malaria infection. Serghides et al. studied malaria-specific immune responses are altered in HIV/malaria co-infected individuals. Fortunately these researchers learned about “the importance of HIV treatment and immune re-constitution in the context of co-infection.”

Malaria, HIV and Pregnancy

Pregnant women are an important group in the population to protect from both HIV and malaria. The link between the diseases may not be one of influencing each other but in the fact that they both appear in the same population with similar negative consequences. Women are at increased risk of anemia in pregnancy due to malaria and/or HIV infection according to Ononge and co-workers. Normally a pregnant woman in a malaria endemic area passes on malaria antibodies to their newborns.

Moro et al. learned that, “Placental transfer of antimalarial antibodies is reduced in pregnant women with malaria and HIV infection.” Chihana and colleagues studied HIV status in Malawian pregnant women and follow-up their children. They reported that, “Maternal HIV status had little effect on neonatal mortality but was associated with much higher mortality in the post-neonatal period and among older children.”

Drug Interactions and Issues

Hoglund and colleagues studied interactions between common antimalarial and HIV medications. They found that, “There are substantial drug interactions between artemether-lumefantrine and efavirenz, nevirapine and ritonavir/lopinavir. Given the readily saturable absorption of lumefantrine, the dose adjustments predicted to be necessary will need to be evaluated prospectively in malaria-HIV coinfected patients.”

DSCN4994 AngolaDrugs taken during pregnancy to prevent malaria are influenced by HIV status. It is known that Intermittent Preventive Treatment with sulfadoxine-pyrimethamine should not be administered to HIV-positive pregnant women taking cotrimoxazole prophylaxis. González et al. wanted to learn whether mefloquine (MQ) could be used by HIV+ pregnant women. Unfortunately they learned that, “MQ was not well tolerated, limiting its potential for IPTp … (and) … MQ was associated with an increased risk of mother to child transmission of HIV.”

Health Systems Issues

Haji and co-investigators reported that malaria care seeking was delayed in Ethiopia because “Children whose guardians believed that covert testing for HIV was routine clinical practice presented later for investigation of suspected malaria.”

The need to adjust clinical guidance and practice as prevalence of malaria changes was addressed by Mahende et al. in Tanzania. They observed that, “Although the burden of malaria in many parts of Tanzania has declined, the proportion of children with fever has not changed.” More accurate diagnosis is needed as demonstrated by the various causes of febrile illness they found including in addition to malaria, respiratory illnesses, blood infections, urine infections, gastrointestinal illness and even HIV.

Finally Mbeye and colleagues report that cotrimoxazole prophylactic treatment reduces incidence of malaria and mortality in children in sub-Saharan Africa and appears to be beneficial for HIV-infected and HIV-exposed as well as HIV-uninfected children. This lesson from HIV programming can have broader implications for malaria control strategies.

Integrated control of infectious diseases is essential for population health, especially at the primary care level. Hopefully research as shown above can assist in planning better services for people living in areas that are endemic to both malaria and HIV.

Health Systems Strengthening: Achieving Lasting Results for IPTp

call to action IPTAt the Call to Action for Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp) during the just concluded American Society of Tropical Medicine and Hygiene Annual Meeting, Elaine Roman of Jhpiego/MCSP advocated for strengthened health systems as a basic approach to enhancing IPTp coverage. Below is a summary of her remarks.

Why should we strengthen the Health System? Addressing the health system at all levels leads to improved outcomes and comprehensive coverage. Increasing IPTp uptake requires strengthening antenatal care (ANC) and other components of the health system.

ANC within a strong health system provides an opportunity to improve the health of pregnant women and their newborns. Malaria in pregnancy (MIP) is a maternal and newborn health issue. When health systems are weak, there is greater likelihood of negative consequences on mother and newborn.

Elaine Picture1Improving Health Systems for enhanced IPTp addresses the following health systems components:

  1. Integration: Reproductive Health Programs and National Malaria Control Programs
  2. Policies and Guidelines: Consistency across national documents
  3. Capacity Development: Bother In-Service Training and Pre-Service Education
  4. Quality Assurance: Linked directly with support supervision
  5. Community Engagement: Promotion of early ANC and Promotion of IPTp uptake
  6. Commodities: Ensuring availability at ANC of sulfadoxine-pyrimethamine (SP) and supplies, as well as long-lasting insecticide-treated bed nets
  7. Monitoring and Evaluation: Facility-level data collection and Data for decision- making
  8. Finance: Sustained and comprehensive services

Elaine Picture2Systems strengthening works. Strengthened Health Systems for IPTp in Kenya resulted from community engagement, training, supervision: leading to IPTp1 coverage of 91.6% and IPTp2 (or more doses) coverage at 61.1%.

In Ghana, Capacity development, commodities, community engagement improvements resulted in IPTp2 (or more doses) coverage of 44% to 65%

In Zambia development of clear policy, integrated training, supervision led to IPTp2 (or more doses) coverage increasing from 63% in 2007 to 72% in 2012.

Moving forward we must advocate for strengthening health systems that will lead to increased IPTp uptake and lasting gains. We must focus on ANC, complemented by efforts at community and policy levels. Finally we must address each health system component, based on country context.

Expanding Health Ministry Capacity to Deliver Malaria and Other Health Commodities at the Community Level in Nigerian States

Bright Orji of Jhpiego‘s Nigeria office presents a poster at the American Society of Tropical Medicine and Hygiene 2014 Annual Meeting at noon on 5th November. The poster represents Jhpiego’s technical assistance provided to seven Nigerian States as part the World Bank Malaria Booster Program. The abstract follows:

CDI ModelThe highly participative process of community directed interventions (CDI) was first pioneered in 1996 by the African Program for Onchocerciasis Control for the delivery of ivermectin. CDI was further tested and found effective in delivering other health commodities.

In 2007 Jhpiego began a proof of concept project in Akwa Ibom State, Nigeria and learned that CDI could be a useful vehicle for increasing access to and coverage of malaria in pregnancy interventions. Building on this success, Jhpiego expanded this work to include integrated community case management of malaria, diarrhoea and pneumonia. through community led efforts.

Number trainedThe World Bank Malaria Booster Program, observing Jhpiego’s efforts in Akwa Ibom State, asked the Nigeria National Malaria Control Program to enlist Jhpiego’s help in building the capacity of seven State Ministries of Health (MOH) to organize CDI for what was termed the malaria plus package consisting of community case management and health promotion activities. The scale-up process started with workshops for state CDI implementation teams consisting of staff from malaria control and primary health care in the MOHs.

services providedThen these state teams developed their own intervention packages and organized workshops for local government teams, who in turn trained staff from their front line health facilities. These facility staff mobilized communities in their facility catchment areas (wards) to select volunteers for training on the CDI process and intervention package.

Although technical assistance was provided to each state, challenges arose including commodity supplies and coordination among different program units within the state MOHs. In conclusion, state teams can train local government teams, ultimately cascading CDI to the community in order to scale up maternal and child health interventions.

Jhpiego at ASTMH: Performance Quality Improvement for IPTp in Kenya

Monday afternoon (3 October 2014) at the American Society for Tropical Medicine and Hygiene Annual Meeting in New Orleans, Jhpiego and USAID/PMI are sponsoring a panel on “Integrating and Innovating: Strengthening Care for Mothers and Children with Infectious Diseases.” If you are at the meeting please attend to learn more about our Malaria activities in Kenya.

Endemic areasOne of the panel presentations is “Performance Quality Improvement Lending to Corrected Documented Outcomes for Intermittent Preventive Treatment in Kenya,” by Jhpiego staff Muthoni Kariuki, Augustine Ngindu Isaac Malonza, and Sanyu Kigondu, who are working with USAID’s Maternal & Child Health Integrated Project (MCHIP).

According to Malaria policy in Kenya all pregnant women in malaria endemic areas receive free intermittent preventive treatment with SP have access to free malaria diagnosis and treatment when presenting with fever have access to LLINs (National Malaria Strategy (NMS) 2009–2017).

By 2013 80% of people living in malaria risk areas should be using appropriate malaria preventive interventions. Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine Pyrimethamine (IPTp-SP) intervention is recommended for use in malaria endemic region.

PQI approachMCHIP broadly implemented Capacity Development and service delivery and improvement interventions that also had impact on the delivery of malaria in pregnancy services through collaboration with the Ministry of Health divisions/units at national level: (malaria, reproductive health, community health).

At county level scale up provision of IPTp at facility level took place in 14 malaria endemic counties. This included 8 counties in the lake endemic region including Bondo sub-county (the MCHIP model sub-county) and 6 in the coastal endemic region.

Quality Improvement through Performance Quality Improvement (PQI) process was instituted to enhance service delivery. The MCHIP era in Bondo Strengthened ANC Services using the following:

  • Development of MIP Standards-Based Management and Recognition (SBM-R) standards
  • Orientation of facility in-charges, supervisors and service providers on the standards
  • Monitoring of IPTp uptake using DHIS2 data
  • Feedback to facility in-charges and supervisors on DHIS2 findings
  • Collection of ANC data from ANC registers (2011-2013)
  • Feedback to facility in-charges and supervisors on ANC data

Quality improvement in the malaria in pregnancy component was undertaken with the objective to improve quality of MIP services including IPTp data management at facility level using PQI approach. An Example of a MIP SBM-R standard is seen below.

Sample StandardIn-service training focused on orientation of facility in-charges on PQI who then continued orientation at Facility Level. Overall we oriented 1200 facility in-charges and 100 supervisors on the standards. Facility in-charges cascaded orientation to 2,441 service providers.

ANC DataWe then analysed ANC data from DHIS (2011-2013) indicated proportion of pregnant women receiving IPTp2 was higher than IPTp1 (IPTp2+ doses reported as IPTp2 dose). We helped improve reporting by  service providers not oriented on use of the ANC register in order to reduce data errors.

In conclusion, PQI is a best practice in provision of MIP services. Standardization of knowledge among service providers is essential in provision of quality MIP services. Development of facility in-charges as mentors in the facility to ensure continued orientation of new service providers.

Use of appropriate monitoring tools is necessary to assist in assessment of quality of services provided including data management. Feedback to service providers is one of the performance rewards and encourages participation in knowledge acquisition

 

 

Improved Malaria Services in Malawi: Jhpiego and USAID at ASTMH

ASTMH 2014Monday afternoon (3 October 2014) at the American Society for Tropical Medicine and Hygiene Annual Meeting in New Orleans, Jhpiego and USAID/PMI are sponsoring a panel on “Integrating and Innovating: Strengthening Care for Mothers and Children with Infectious Diseases.” If you are at the meeting please attend to learn more about our Malaria activities in Malawi.

One of the panel presentations is “Improving Malaria Outcomes in Malawi: Focusing on Integration of Services at all Levels” presented by John Munthali, Senior Technical Advisor, Jhpiego/Malawi. John works with Support for Service Delivering Integration-Services (SSDI-S), a USAID bilateral program (2011-2016) with Partnerships in 15 Districts involving the Ministry of Health, Jhpiego, Save the Children International, Care Malawi and Plan International.

Malawi IPTpSSDI-Services focuses on Malawi’s Essential Health Package (EHP) Focal Areas with particular emphasis on Maternal Health, Newborn and Child Health, Family Planning and Reproductive Health, HIV/AIDS and TB, Nutrition and Malaria. Aspects of the Malaria Component include Intermittent Preventive Treatment and Insecticide Treated Bed Nets

SSDI-S is based on Promotion of the continuum of care from household to hospital. Health Facility Approaches address Improved Technical Capacity of Health Workers, Functional Health Facility, and Data-informed Decision Making. Community Approaches involve Improved Technical Capacity of CHWs, Functional Village Clinics, and Community Mobilization. Integration is a major concern such that there are no missed opportunities of EHP services at all levels.

Positive Trends since have been seen since Inception. Malaria in Pregnancy interventions supported the National Malaria Control program to review the Malaria in Pregnancy guidelines and training manuals to adopt the new WHO policy recommendations. 74 Trainers were trained in all 15 districts. MNCH services were established in selected districts. 344 HSAs were trained. 70 community-based Core Groups oriented on MNCH. SSDI supported ongoing MNCH activities through review meetings and distribution of reporting forms.

Malawi IPT2 improvementsAs a result of these integrated high impact interventions there has been a remarkable increase in the uptake of IPTp 2 (16% in June 2012 to 64% in Sept. 2013) by pregnant women in the SSDI-services focus districts. Central to this increase is the integration of services at the facility level where malaria has been highly integrated into maternal, newborn and child health. The project has also seen IPTp 1 uptake maintained at above 91% in all the 15 districts

Malaria Care capacity building has resulted in improved iCCM services delivered by Health Surveillance Assistants (HSAs) at village clinics. iCCM is serving as the foundation for community-based treatment of malaria by HSAs while at facility level IMCI provides an integrated approach to manage childhood illnesses including malaria.

In conclusion, it is feasible to integrate MNCH programs at all levels using SBCC and Systems Strengthening. Having an integrated project looking at the whole spectrum of health services (system strengthening, service delivery and behavior change) can help improve programming & service delivery.

Jhpiego Malaria Team at the American Society of Tropical Medicine & Hygiene Conference

ASTMH 2014Jhpiego’s Malaria Team is co-hosting a symposium on Malaria in Pregnancy and presenting several posters at the upcoming ASTMH 2014 annual meeting in New Orleans, 2-6 November. Below is an outline of these events for those who may be in attendance. Jhpiego also will have a booth in the Exhibition area – please visit it.

Symposium: Integrating and Innovating: Strengthening Care for Mothers and Children with Infectious Diseases, 1:45 – 3:30 p.m., Marriott – Mardi Gras Ballroom D (Third Floor): Co-Faciliators: Elaine Roman, Jhpiego | Erin Eckert, USAID/ PMI

  • Improving Malaria Outcomes in Malawi: Focusing on Integration of Services at all Levels, John Munthali, Jhpiego, Malawi
  • Performance Quality Improvement Lending to Corrected Documented Outcomes for Intermittent Preventive Treatment in Kenya, Muthoni Kariuki, Jhpiego, Kenya
  • The provision of HIV and IPTp Services in Antenatal Care in Malawi: Views of Health Care Providers from a Qualitative Study, P. Stanley Yoder
  • Mothers and Mycobacteria: Implications of the Intersection of TB, Pregnancy, and Maternal and Newborn Health, Charlotte Colvin
  • Wrap-up: The Growing Role of Infectious Disease in Maternal Mortality Reduction: How to Attain the Post-MDG targets, Allisyn Moran

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Poster Sessions:

Poster Session A: Monday 12:00 – 1:45 p.m., Marriott Grand Ballroom (Third Floor)

  • Quality Inspired Project – A Key to Achieving Results with Malaria Interventions, Grace Qorro, Jhpiego Tanzania
  • Prevention of Malaria in Pregnancy: Community Health Volunteers (CHVs) Promote Community-based Activities to Increase Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp) in Kenya, Augustine Ngindu, Jhpiego Kenya

Poster Session B: Tuesday 12:00 – 1:45 p.m., Marriott Grand Ballroom (Third Floor)

  • Improving Maternal and Neonatal Health: Complementary Role of the Private Sector Increasing Uptake of Intermittent Preventive Treatment for Malaria in Pregnancy in Kenya, Augustine Ngindu, Jhpiego, Kenya

Poster Session C: Wednesday 12:00 – 1:45 p.m., Marriott Grand Ballroom (Third Floor)

  • Expanding Health Ministry Capacity to Deliver Malaria and Other Health Commodities at the Community Level in Nigeria, Bright Orji, Jhpiego, Nigeria

AHI: Achieving People Centered Health Systems in Five African Countries

The African Health Initiative (AHI) will be presenting a second panel During the upcoming Third Global Symposium on Health Systems Research in Cape Town (30 September-3 October), entitled “Achieving People Centered Health Systems in Five African Countries: Lessons from the African Health Initiative.”

AHI was established in 2008 by the Doris Duke Charitable Foundation and seeks to catalyze significant advances in strengthening health systems by supporting partnerships that will design, implement and evaluate large-scale models of care that link implementation research and workforce training directly to the delivery of integrated primary healthcare in sub-Saharan Africa.

globalsymposium_logosThe five AHI country projects (Ghana, Mozambique, Rwanda, Tanzania and Zambia) will be sharing their experiences during the panel presentation. We will be tweeting at each panel presentation, and you can follow at: #HSG2014 and “Health  Systems Global” and “Bill Brieger Malaria“.

Highlights of the second panel follow:

Community health workers in Tanzania

Community health workers in Tanzania

It is a common claim that randomized controlled trials (RCT) are the ‘gold standard’ for scientific inference, with rigor derived from the imposition of stable interventions and statistically robust controls, and power derived from operational units as study observations. In health systems research, however, the ‘gold standard’ is more appropriately based on the relevance of research to decision-making. As a consequence, impact research is appropriately combined with implementation research, and units of observation are based on the way that systems function and decisions are made.

Mixed method complexity trials are indicated, with units of observation that integrate research with management processes. Presentations by scientists who are engaged in complexity trials in Ghana, Mozambique, Rwanda, Tanzania, and Zambia will highlight statistical designs that violate conventional standards of RCT, but derive rigor from mixed method research, hierarchical observation and modeling, and plausibility trials.

“Proof of utility” is derived from the operational adaptation of project implementation to local realities, monitoring process and outputs, testing impact, and revising strategies over time as needed. A learning process approach produces evidence-generating localities where operations serve as realistic models for large scale change in national systems.

DSCN6602aVarious terms used in the scientific literature to characterize this theme, such as ‘open systems theory’, the strategic approach, or participatory planning, each embracing the perspective that people centered service systems are essential to health systems strengthening. Practical examples of how to achieve people centered programming, however, are rare.

This panel presents five case studies that have confronted the challenge of developing, testing, and sustaining people-centered health systems in resource constrained settings of sub-Saharan Africa. These are outlined below.

– The Ghana Essential Health Interventions Programme tests the child survival impact system strengthening interventions. When monitoring identified perinatal health problems, priority was shifted to improving newborn and emergency referral services. Combined with political advocacy, changes increased access, improved quality, and expanded the range of services.

DSCN6373– The Mozambique project improves service quality by giving facility, district and provincial managers skills for identifying and fixing systems problems. Initial skills-building through training in leadership and management had only transitory effects. An evidence-driven redesign improved facility and district level operations and improved accountability.

– In Rwanda health-center-focused quality improvement data identified strategies for compensating health centers for reaching specific operational goals. Initial results show that the scheme has enhanced performance and fostered cross-center learning.

– The Tanzania Connect Project tests the survival impact of deploying community health workers. Connect monitoring showed that unmet need for family planning was inadequately addressed. Connect was redesigned to include comprehensive doorstep family planning services.

Zambia’s Better Health Care Outcomes through Mentorship and Assessment project was developed from people centered lessons emerging from scaling up an HIV program. A 42 cluster stepped wedge tests the impact of improving outpatient care with training, structured forms, electronic data capture, and community engagement. In response to implementation challenges, volunteer density was increased and mortality and clinical data capture operations were reformed.

While the studies employ contrasting designs, the projects share an adaptive approach to implementation. A concluding session summarizes lessons learned and implications for health systems strengthening in Africa.

Attending Antenatal Care Does Not Guarantee Antimalaria Services

A new article by Clementine Rossier and colleagues compares access to maternal health services in Ouagadougou, Burkina Faso and Nairobi Kenya.  In both settings a very large proportion of pregnant women registered for antenatal care (ANC).  Twice the proportion of Nairobi women (47%) attended up to four times compared to those in Ouadougou (22%).  In both settings, the likelihood of attending four ANC visits increased with educational level of the women.

ANC Does Not Mean IPTp AccessAlthough the article does not discuss services received at ANC, we can consider the implications for malaria in pregnancy (MIP) control since ANC is a major platform for MIP service delivery. Here the demographic and health survey (DHS) and its malaria indicator survey (MIS) component are of help.  Both countries had a national survey in 2010 (their most recent).

Interestingly in 2010 Burkina Faso overall had better ANC registration (05%) than Kenya (86%). In neither country was intermittent preventive treatment in pregnancy (IPTp) coverage good. 25.7% of pregnant women in Kenya received one dose of sulfadoxine-pyrimethamine for IPTp, while 20.8% did so in Burkina Faso. IPTp2 coverage in Kenya was similar at 25.4%, but in Burkina Faso it dropped to 10.6%

DSCN7718The important lesson here is that even with good ANC registration, women have no guarantee of receiving life saving malaria prevention services.  If registration was lower we might suspect issues of local beliefs and other community barriers, but the situation in both countries points to health systems failures like inadequate drug supplies and health worker lapses.

The service delivery situation in both countries has changed dramatically since 2010. Kenya has refined its malaria map and is focusing IPTp on areas of stable and high transmission. Burkina Faso has received greater influx of financial support from the Global Fund and the US Agency for International Development. Hopefully the 2014 DHS/MIS studies currently in progress in both countries will paint a better picture. Of course, unless health systems issues are being addressed, funding alone will not solve the malaria service gaps.

Malaria at AIDS2014

Malaria and HIV/AIDS interact on several fronts from the biological, clinical, pharmacological to the service delivery levels.  The ongoing 20th International AIDS Conference in Melbourne, Australia (July 20-25, 2014) provides an opportunity to discuss some of these issues. Abstracts that are available as of 20th July are mentioned below and deal largely with integrated health service delivery issues. Details can be found at http://www.aids2014.org/. Also keep up to date on twitter at https://twitter.com/AIDS_conference, and on Facebook at https://www.facebook.com/InternationalAIDSConference.

8577_760104147337737_5024191_n1. Increasing HIV testing and counseling (HTC) uptake through integration of services at community and facility level (TUPE358 – Poster Exhibition). E. Aloyo Nyamugisa, B. Otucu, J.P. Otuba, L. Were, J. Komagum, F. Ocom, C. Musumali (USAID/NU-HITES Project, Plan International – Uganda, Gulu, Uganda).

HTC integration at community outreaches and facility service points increases service uptake by individuals, families and couples that come to access the different services that are offered concurrently such as immunization, family planning, cervical cancer screening, circumcision, Tuberculosis, malaria, nutrition screening services and other medical care.

2. Asymptomatic Malaria and HIV/AIDS co-morbidity in sickle cell disease (SCD) among children at Mulago Hospital, Kampala, Uganda (TUPE074 – Poster Exhibition). B.K. Kasule, G. Tumwine, (Hope for the Disabled Uganda, Kampala, Uganda, Watoto Child Care Ministries, Medical Department, Kampala, Uganda, Makerere University, College of Veterinary Medicine, Animal Resources & Bio-security, Kampala, Uganda).

The prevalence of HIV/AIDS and asymptomatic malaria in children attending SCD clinic were quite high with the former exceeding the national prevalence supporting the view than Ugandan children with SCD die before five years. Children were significantly stunted and underdeveloped which could have made them prone to increased clinic visits. National health programmes should focus on the health needs of children with SCD by integrating HIV/AIDS care, nutritional therapy, and malaria control programmes.

3. Technical support (TS) needs of countries for preparation of funding requests under the Global Fund’s new funding model (NFM) (THPE427 – Poster Exhibition). A. Nitzsche-Bell, B. Hersh (UNAIDS, Geneva, Switzerland).

The results of this survey suggest that there is very high demand GF funding in 2014 and a concomitant high demand for TS to assist in the preparation of funding requests. TS priority needs span across different technical, programmatic and management areas. Increased availability of funding for TS and enhanced partner coordination through the Country Dialogue process are needed to ensure that countries have access to timely, demand-driven, and high-quality TS to maximize mobilization of GF resources under the NFM.

4. Optimizing the efficiency of integrated service delivery systems within the existing scaled-up community health strategy in Kenya: pathfinder/USAID/APHIAplus Nairobi-Coast program experience (THPE351 – Poster Exhibition). V. Achieng Ouma, D.M. Mwakangalu, P. Eerens, J. Mwitari, E. Mokaya, J. Aungo Bwo’nderi, S. Naketo Konah (Pathfinder International, Nairobi, Kenya, Pathfinder International, Service Delivery, Mombasa, Kenya, Ministry of Health, Division of Community Health Strategy, Nairobi, Kenya, Pathfinder International, Research and Metrics/Strategic Information Hub, Nairobi, Kenya, University of Portsmouth, Geography, Portsmouth, United Kingdom).

APHIAplus (a USAID sponsored health program in Kenya) supports the implementation of integrated government strategies that center around HIV, AIDS, and tuberculosis prevention, treatment, and care; integrated reproductive health and family planning services; and integrated malaria prevention and maternal and newborn health services. Lessons learned include the finding that integrated outreach holds potential to meet clients’ needs in an efficient, effective manner. For example, during a single contact with a service provider, a mother obtains immunization services and growth monitoring for her infant, counseling and testing for HIV, counseling on family planning, cervical cancer screening, and treatment of minor ailments. Results indicate better integration of HIV prevention, care, and treatment within complementary efforts that address key drivers of mortality and morbidity. Success in integration was fostered by a stronger focus on outcomes throughout the APHIAplus implementation cycle.

5. Long term outcomes of HIV-infected Malawian infants started on antiretroviral therapy while hospitalized (THPE070 – Poster Exhibition). A. Bhalakia, M. Bvumbwe, G.A. Preidis, P.N. Kazembe, N. Esteban-Cruciani, M.C. Hosseinipour, E.D. Mccollum (Albert Einstein College of Medicine and Children’s Hospital at Montefiore, Pediatrics, Bronx, United States, Baylor College of Medicine Abbott-Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi, Baylor College of Medicine, Pediatrics, Houston, United States, University of North Carolina Project, Lilongwe, Malawi, Johns Hopkins School of Medicine, Pediatrics, Division of Pulmonology, Baltimore, United States).

AIDS2014 bannerOne-year retention rates of HIV-infected infants diagnosed and started on ART in the hospital setting are comparable to outpatient ART initiations in other Sub-Saharan countries. Further studies are needed to determine if inpatient diagnosis and ART initiation can provide additional benefit to this population, a subset of patients with otherwise extremely high mortality rates.  Of the 16 children who died, median time from ART initiation to death was 2.7 months. Causes of death include pneumonia, diarrhea, fever, anemia, malnutrition, malaria and tuberculosis.

6. Killing three birds with one stone: integrated community based approach for increasing access to AIDS, TB and Malaria services in Oyo and Osun States of Nigeria (MOPE435 – Poster Exhibition). O. Oladapo, E. Olashore, K. Onawola, M. Ijidale. (PLAN Health Advocacy and Development Foundation, Programs, Ibadan, Nigeria, Civil Society for the Eradication of Tuberculosis in Nigeria, Programs, Ibadan, Nigeria, Community and Child Health Initiative (CCHI), Programs, Ibadan, Nigeria, Community Health Focus (CHeF), Programs, Ibadan, Nigeria).

Community Systems Strengthening (CSS) is a tested and successful strategy for providing integrated AIDS, TB and Malaria (ATM) services in resource-limited settings. 20 selected community based organizations (CBOs) working on at least one of AIDS, TB or Malaria were trained by PLAN Foundation on basics of ATM-related project management including monitoring and evaluation; demand generation through active referrals; and community outreaches. Empowering CBOs is an effective and low-cost strategy for increasing demand for ATM services in resource-limited settings. Integrating referral for ATM services increases effectiveness of and public confidence in primary healthcare services at the grassroots.

7. (Upcoming on 21st July) The health impact of a program to integrate household water treatment, hand washing promotion, insecticide-treated bed nets, and pediatric play activities into pediatric HIV care in Mombasa, Kenya (MOAE0104 – Oral Abstract Session). N. Sugar, K. Schilling, S. Sivapalasingam, A. Ahmed, D. Ngui, R. Quick. (Project Sunshine, New York, United States, U.S. Centers for Disease Control and Prevention, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infections, CDC, Atlanta, United States, New York University, New York, United States, Bomu Hospital, Mombasa, Kenya).