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CITY
AIDS AMERICAS Americas Leadership Initiative for AIDS Competence in Cities |
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First Annual Workshop and Conference A Program of CIFAL Atlanta Session 3: Best Practices Sharing: Peer assist reviews Topic: Measuring Changes Jamaica: Developed several instruments in the late 90’s:
San Pedro Sula –Honduras: Convida Project Focus on prevention among teens. Have problem measuring behaviors changes among adolescents
Honduras – Yoro:
Port of Spain
Oakland, USA: Care and treatment program “New Connections” (NGO) Each case manager has 70 active clients – countywide 756 clients.
Durban, South Africa
San Juan, Puerto Rico
Jamaica: wants to know how San Juan achieved # 5. Broke up ministry of health in separate parts – 4 decentralized regions, and reconfigured services. Decided where we were. Started on year 2000 and then set a target where we want to be, and talked to ministry and set the target with them. Then they signed a service level agreement with the local bodies to move the figures from the baselines to the target. We set ourselves. Honduras: what is the specific program? Jamaica: Mother and child transmission – related to something else and was applied to aids. When we started we 60% and now at 83%. We recognize that we need to measure where we are. Some of the measurement has been done, but are not where Puerto Rico is at. We’d like to learn in order to make further decisions. Puerto Rico: The Program started in 1986. Program is multi-serviced, we look at hospitalizations, so we got to look in terms of our outcome—bring it down to below 10%. We had started with development and implemented ambulatory unit/treatment – bring down stigma, where we could deal with patients from 7am to 7pm. Later on we build it till 10 pm. We looked for resources. Bring down hospitalizations; half of our patients are now hospitalized. So what happened is whenever a patient is with HIV, IV antibiotics, are placed, hospitalization is down to 1-1.5%. Haart therapy – had problem with getting the medications to patients. The pharmacy gets all services, homecare, treatment, medications, dental to deal with the problem. Money is too much for medication – we were dealing directly with the company for the order – got with time delay – sometimes municipalities had not paid them, and would not give us the drugs – patients started protesting, the municipality decided to contract a distribution company to supply for all of Puerto Rico. Our system started dealing with the problem of not having medication – we order every day – so we have a minimum stock, when we get to the minimum stock, the medication has to be ordered, we have all the haart therapy drugs. To deal with a having a better outcome – our quality of care of patients, adherence – we have less than 39% of adherence to medications. We started working on our staff – continue training our staff, from pharmaceutical company, we have an institutional person to continue training – our doctors didn’t know anything about it. We had continuing training. Adherence is another issue that we were dealing with. So we are right now. We have a protocol to identify factors to do with adherence. We started working with our patients to measure their adherence, with lab reports, to follow their adherence, when patients were having problems, somebody would tell them to go back to the physicians. Cd4 result (every 3 months) and PCR results. South Africa: have NGOs and organizations – how do you monitor them? Do you give funding to them? San Juan: we have a system an epidemiologic system to collect data on community cases of aids – 6800 cases in Puerto Rico are actually in San Juan whose population is ~500000 people. We are the only program in San Juan that has developed all this resources – municipal and federal funding. We have different CBOs. We have 35 agencies in 32 towns including San Juan some of them are CBOs that receive funding. What we have established is a coordination of support with these agencies, and in San Juan we have developed coalition with different agencies in order to not duplicate services. We have agencies that deal with food services, addiction management, etc. some agencies get money for medications, so there will be no duplication. A system to get all those agencies patients that get medications from different agencies, -- a tracking system for patients that are getting medications from one agency only. Honduras: how does your work with prevention – which mechanism/strategy have u used to measure prevention? Speaking of younger people as well? San Juan: we have a department that has 9 health centers – each center has a part for prevention, education, health. This program is unified with schools a project of values for adolescents with schools were they identify the sectors that are raising of certain sectors – we approach these areas first, it’s been 4-5 years since we’ve been doing this, find promoters of conferences in schools as well as the teacher gets involved, also in elementary school to get the teachers involved. Written tests have been applied by the health department. They show us which methods to use – focus groups. The thing that measures the best is when schools have a survey which see the prevention movement we have another project that approaches reduction. Trinidad: What are you measuring? Knowledge or sexual behavior? San Juan: both – actions as well as values. We have been able to measure for 5 years how adolescent pregnancies in schools have dropped. We got two schools that had a big problem, addiction, adolescent pregnancy – elementary schools had kids with drugs, so they started learning problems at elementary schools. We started measuring elem. Schools and middle schools. We see that middle schools have brought down pregnancy and addiction – they still have problems, but it’s lower now. We did well. We have been funded again for 5 years for risk reduction that is part of the prevention program basically education and prevention. How to predict that adolescents get to have the tests? We have theatrical performances // incentives for students// they do a painting after the year – every school has to develop a work of art, and then each school competes, and the best painting gets a prize. The school has an idea, and they give an incentive to the student, and also if there’s a student that has changed, they recognize him. Honduras: in our country the kids do the exam, without having the consciousness of what they mean. San Juan: there’s also another project funded // mental health // promoters don’t all go to the same school// they work with HIV sections in school//psychological help// program for women that are pregnant with HIV// people are not obliged to participate// they do group activities// music// arts, and they get awards such as t-shirts, pencils, pens, things that they like. We do mental health, and housing as well. We identify what is the problem with each school one form to measure/ lower the pregnancy rates, drop-outs, drug addicts. We have to intervene continuously. Identifying different regions that need work, and they start changing strategies accordingly. We do surveys and reports to identify the areas that are lowering/or increasing, that need more/less work. In each specific sector, how many are evident with HIV. We have specific instruments for this project, and that have to be followed up consistently. We have been for working for years to achieve a 5 on this project. We have been able to develop our program, evaluate, develop through many years, and many resources. We get money, so we have better chances. We have mental health services, case management, dental, an infectology, we have a daycare system. Before 94, we had an aids institute, when it was initiated. Many findings, many evaluations, we have licenses to evaluate us, to give us our permit to continue. We got laboratory, pharmacy. We identify our problems and then work on them. Jamaica: just listening to you, Jamaica would also be at 5. We have health system; now every ministry of health and 4 regional health services do the work. We meet every 3 months, and set a target to reach x percent, and each region would tell where they are. What we don’t have is this aggregated data. We don’t have access to the data from the ministry of health. Even worse, within the city of Kingston, there are 40 divisions each counselor is elected. And I can’t tell you what the prevalence of HIV in my region is alone. But I can tell you what Jamaica’s prevalence is. San Juan: you could measure the outcomes as a whole. You could measure bringing down of HIV cases, hospitalizations. Jamaica: what happens is the clinics/hospitals they see people from all over, so it’s not an accurate prevision. We have primary and secondary systems. People come from different areas, in order to avoid stigmas. San Juan: this is an issue that has to be developed locally—our system is computerized, with data entry and everything. We cannot compare with anybody, because we have the best resources. We have a city hospital. We do have different centers, but our aids patients we run it at one facility, so they don’t go anywhere else. You cannot compare Kingston with San Juan. We also do research in our program. We have a program to treat co-infected patients. We have medications for opportunistic infections. We have mixed funding from municipal and federal funding. We have a mayor that is committed. One of the things that you asked is how things work. Our patients are very empowered; they have been getting empowered. They started a strike, called the news when they were not getting medications. We developed volunteers so they would tell us when things were not working. The patients come to us now before they go to the press. There were many protests, and the mayor said “you’ve got to fix this”. We have outreach, health fairs, the department goes to a community for testing. People do respond. Our infections in terms of %ages was over 15%, now every year, our testing runs from 1 to 1.5%, not higher than that. We have a lot of mobilization, so we’re able to move around, and we have a lot of promotion. Not only San Juan which has the highest cases in Puerto Rico. They have identified the data, we report to the department of health. They have identified a big significant dropdown of cases of HIV in Puerto rico. I work for the department of health. When I work in maternal / child health, the problem was there, now the program of department of health the activities were being initiated, for the last 5 years, the program to go out on a big basis on a weekly basis. Immunization for children, everyone has to be there. We have a structure, mobile units, and the health departments. We have been building up a big structure, we’re teaching clinic to the medical campus, nursing program, because we need to have HIV doctors/ nurses who want to work with HIV patients. South Africa: our city is 4 million people, and ANC ranges from 30 – 37% of pregnant mothers. We have a range of programs from business that are looking at awareness, prevention and care, antiretroviral, the largest problem is our social/political. Our economy is good. The critical issue is around vulnerability for risk groups. We have a large port, and there is a migrant labor. Women work away from home, and are going back and forth. It’s a complex issue. We’re not a very homogenous society, there are strong cultural factors. The Zulu king is married to 10 wives. Multiple partners is a cultural issue, and hard to break, and you can’t do it in five years. So because of that, in we’ll be spending a lot of time in the issue of prevention. How do you assess that they’re making a change, even just for the young? It’s these guys who are influencing the young kids. It’s kind of a mixture of things. What you do at school is compromised by what the parents do at home. San Juan: you have to bring the school to the home. We work with parents as well. We have brought the parents to school, and try to work with them. We have to negotiate. The problem with the parents is that when the kid is on the program, they don’t want him to be in. So you have to go to the parents, and force them. Parents have to get involved. Sex workers are the ones that are best protected, because they go to our programs. Some parents don’t come to the school, so we have to go to them. All parents want the best for their kids, so we have to negotiate with them. We set up criteria and set up in a table. We have identified like this which problems need to be worked on. The secret is to involve your local government. Honduras: I represent two sectors, one rural community, and rural communities that haven’t been integrated. Because this things are for big cities – habilitations. The rural communities have meetings and we put ourselves in number 1 in measuring changes, but for one of our projects we put ourselves as number 4. we have to evaluate and measure the hypothesis, we also have people specialized in doing evaluations on the sides, post – evaluations. San Juan: in Salvador, The peer groups, the remote areas had women that died from child birth, they didn’t have health promoters. They developed a system in which they had a stipend, with money that was not American; they had eighth graders who had the highest levels of incidents. For example, so each community has a health promoter, but each family lives far from each other. They had to do research to measure all criteria. The families that were in higher risk, would get more immediate care. They would do something to get more taxes, in order to raise money. Now the health promoters have this information with HIV. And the info is shared even with midwives, which had a problem of high mortality. They intervened with hospitals and midwives in order to bring down the death rate. So the midwives would identify the highest risk families, and tell the people to go to the center, and thus they began to develop a little clinic for the areas. Midwives also give pre-natal care, and take health prevention to people. |
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