Positive Synergies between Global Health Initiatives and Health Systems
HIV and Haiti
Louise Ivers, MD, MPH, DTM&H Director of HIV Equity Initiative Partners In Health, Haiti Assistant Professor of Medicine Division of Social Medicine and Health Inequalities Brigham and Women’s Hospital Harvard Medical School, USA 8.7 million population 730 doctors 1013 nurses 3‐5% HIV prevalence Health Statistics
Highest maternal mortality à 670/ 100,000 live births
Lowest vaccination coverage à 54% children receiving measles vaccine by 12 months à Compared to 90% in rest of region
Highest infant mortality à Under 5 mortality: 80/1000 live births Global Health Initiative: HIV à Partners In Health
à Ministry of Health
à Global Fund for AIDS, TB and Malaria
à PEPFAR
à Private donors Positive synergy: by design
“Four Pillars” of the HIV Equity Initiative Positive synergy: by design
i ) Delivery of services
ii) Governance / organization of services
iii) National systems i) Delivery of Services HIV services delivery 2002‐2008
> 10,000 HIV‐positive people in care
> 3,500 people on ART
< 5% loss to follow up at 2 years
Accompagnateurs provide social support and observe doses of therapy Integration of HIV testing into primary care
1 yr after integration 2 yrs after integration
Ivers et al, IAS, 2006 HIV Prevention and Treatment Integration into Primary Health Care Ambulatory Visits per Day
Site Before July 02 End of 2003
Lascahobas 20 400
Belledere 0 150
Thomonde 10 250
Boucan Carre 10 250 Improved case detection: TB Thomonde à 6 cases TB 2000‐2001 à 155 cases of TB Aug ‘02 –Feb ’03
Lascahobas à 9 cases TB 2001 à 215 cases of TB Aug ‘02 –Feb ’03 Improved vaccination, antenatal care
Patient Visits: 7/2002–11/2003
Antenatal Care Visits: 7/2002–12/2003 Vaccine Administration: 1/2003–12/2003
Walton, et al, AJPH Vaccine uptake 2002‐2005
Number of children immunized Number of children immunized
3,000 BCG 3,000 BCG Measles Measles DTP3 DTP3 Polio Polio 2,500 2,500 TT2 TT2
2,000 2,000
1,500 1,500 # of children immunized # of children immunized children # of 1,000 1,000
500 500
0 0
2002 2003 2004 2005 2002 2003 2004 2005
Belladères Boucan Carré Lambert et al (unpublished) 2007 Contraceptive uptake 2002‐ 2005Number of users Number of users DMPA 1200 DMPA Norplant 1400. Norplant Pills Pills 1000 1200
1000 800
800
600 # of users # of users 600
400 400 .
200 200
0 0 2002 2003 2004 2005 . 2002 2003 2004 2005
Belladères Boucan Carré
Lambert et al (unpublished 2007) Maternal Health
Jan 2006 –Sept 2007 65,000 antenatal visits
4,200 institutional attended births
301 caesarian sections ii ) Governance / organization of services Human resources development à Clinical à Research à Management à Financial / accounting
Effective referral structures: health network Central Department: pop 550,000 Clinic
MD (45) RN, Pharm, Lab Auxillary nurses Expected HIV 20,000 ExpectedAjanAjan Sante/AjanSante/Ajan active TBFanmFanm 1500 AccompagnateursAccompagnateurs (2500)(2500)
Community iii) National systems Strong partnership with MOH
Support of public health infrastructure
Model for expansion in other departments