Human Capacity Building Strategy to Support Antiretroviral Therapy Scale Up in Ukraine Meeting (Jan. 2007)

The Regional Knowledge Hub for the Care and Treatment of HIV/AIDS
Human Capacity Building Strategy to Support Antiretroviral Therapy Scale Up in Ukraine Meeting

NMAPE, conference room, 9 Dorogozhytska Street, Kiev, Ukraine
January 25, 2007, 09:30–16:00

MEETING SUMMARY
Participants:
  • Yuri Vdovychenko, National Medical Academy of Post-Graduate Education (NMAPE), First Vice-Rector
  • Nina Goida, National Medical Academy of Post-Graduate Education, Vice Rector
  • Volodymyr Zhovtiak, All-Ukrainian Network of PLWHA, Head of Coordination Counsel
  • Bogdan Zaika, All-Ukrainian Network of PLWHA
  • Natalya Ageyeva, All-Ukrainian Network of PLWHA
  • Alla Shcherbinska, Ukrainian National AIDS Center (NAC), Director
  • Lydmyla Storozhuk, Ukrainian National AIDS Center (NAC), Deputy Director, Medical Issues
  • Svitlana Antonyak, Department of HIV/AIDS Infection (Lavra AIDS Clinic), Kiev's Gromashevsky Institute of Epidemiology and Infectious Diseases, Head of Department
  • Volodymyr Kurpita, WHO/Ukraine, HIV/AIDS Coordinator
  • Sergiy Filippovych, International HIV/AIDS Alliance, Ukraine, Head of Team: Treatment, Procurement and Supply Management
  • Volodymyr Ivchuk, World Bank HIV/AIDS Control in Ukraine Project Group, Head of International Programs Department
  • Valeriy Khmarsky, World Bank HIV/AIDS Control in Ukraine Project Group, AIDS Component Manager
  • Trudy Larson, Department of Pediatrics, University of Nevada School of Medicine, USA
  • James Smith, AIHA, Executive Director
  • Zoya Shabarova, AIHA, Regional HIV/AIDS Coordinator
  • Alla Volokha, AIHA / Knowledge Hub, Medical Director
  • Grigory Naumovets, AIHA / Knowledge Hub, ICT Coordinator

Opening and welcome greetings.

The meeting was opened by a welcoming greeting to the participants from James Smith. He thanked everyone for the attendance and spoke about the Knowledge Hub, its founding partners, mission and results up to date. He pointed out that the Knowledge Hub’s activities are unique not only in Ukraine but also in region, where Ukrainian experience is regarded as a model because of systematic approach to HIV/AIDS care and treatment human capacity building in connection with national care model, consensus building with main national and international stakeholders on training methodology, multidisciplinary care team approach, adult learning methodology, quality assurance system.

James Smith asked the participants to introduce themselves. After the introductions he invited NMAPE First Vice Rector Dr Vdovychenko to welcome the meeting participants. Dr Vdovychenko welcomed the meeting participants on the behalf of the NMAPE. Speaking about the Knowledge Hub’s activities in Ukraine he noted that the successful realization of its training program is very important for Ukrainian postgraduate medical education. National certification by NMAPE of physicians who successfully completed series of Knowledge Hub trainings is very important result of cooperation between NMAPE and Knowledge Hub. He wished the meeting success in achieving its goals.

National plan of HIV/AIDS care and treatment: care model, results up to date and plans. Presentation by Dr Scherbinskaya

Dr Scherbinskaya presented the latest epidemiological data: 103,110 persons are officially registered as HIV infected as of November 1, 2006; among them – 17,443 with AIDS. Approximately 7,500 people need treatment and 4,752 (63%) are receiving antiretroviral therapy (ART), including 652 children.

Road map to provide universal access to prevention, treatment, care and support was developed and in 2006 Ukrainian Ministry of Health (MOH) issued Prikaz on further treatment scale up. National strategy to provide care and treatment to people with HIV/AIDS is based on (1) defining the care model; (2) development of national ART protocols for adults and children; (3) training caregivers on ART at Regional Knowledge Hub with further certification; (4) multidisciplinary team approach (physician, nurse, social worker).

Ukrainian National AIDS Center (NAC) developed the computerized system of ART monitoring to ensure quality of treatment. Six interregional laboratories have capacities to conduct CD4 count, viral load and PCR tests. NAC together with WHO experts are conducting monitoring visits to the regions in addition to preceptorship program at Kiev Lavra AIDS Clinic for physicians from the sites.

Dr Scherbinskaya described the following challenges to provide care and treatment to people with HIV/AIDS:

  • Late identification and referral of patients;
  • Lack of experience to manage patients on ART in the regions;
  • Low level of adherence to ART among injecting drug users (IDU)s, substitution therapy (ST) is not widely available in the regions;
  • ART in not available in penitentiary system because of undeveloped infrastructure to provide medical care at State Department to Carry Punishments;
  • System to provide medical care to patients with HIV/Tuberculosis (TB) is not developed;
  • Regulations to provide palliative care to patients with AIDS are not developed.

The following issues remain to be problems: (1) access to treatment for all groups of population, including IDUs, (2) development of care and support system; (3) workforce development and provision of needed resources; (4) wide partnership to approach challenges. According to national estimates 225,690 people belong to the high-risk groups; 118,683 people are partners of high-risk population groups and 337,600 people are living with HIV in Ukraine.

With regard to universal access to ART, Dr Scherbinskaya provided the analysis, which showed that within the current system to provide ART 38% of patients in need receive ART in 2006 (11,960 people in need of ART and 4,550 people on ART), in 2010 this number will be 18%.

(39,950 people in need of ART and 7,110 people on ART). If the universal access will be implemented, then 50% of patients in need will receive ART in 2006 (11,960 people in need of ART and 5,960 people on ART) and 100% of people who need ART (51,500) will be able to get treatment in 2010.

 

Report on the Knowledge Hub training activities in Ukraine: June 2004-December 2006.

Presentation by Ms. Shabarova.

Ms. Shabarova provided background information on the Regional Knowledge Hub:

it’s purpose, funding partners, start-up operational support, participating institutions, implementing institution and strategic partners. She pointed out that the focus of the Knowledge Hub’s activities is not just to provide trainings to healthcare practitioners, but to support the development and implementation of a national HIV/AIDS care and treatment human capacity building plan which in turn supports a national HIV/AIDS strategy.

Describing the Knowledge Hub training approach Ms. Shabarova analysed the target audience for trainings, faculty, training materials, teaching methods, quality control system, and national certification.

The key results of the of the Knowledge Hub’s successful activities since 2004 were defined by Ms. Shabarova as development and adoption of 21 course curricula with related training materials; provision of 97 courses for 2,472 participants from 8 countries in the region. As of December 31, 2006, in Ukraine, under the programs funded by International HIV/AIDS Alliance (under GFATM grant to Ukraine) and UNICEF/Ukraine, the Knowledge Hub conducted 45 training courses for 1,107 Ukrainian participants (569 healthcare professionals) from 24 Ukrainian regions. 107 physicians received NMAPE certificates on adult and pediatric ART. Nearly 20 potential new national faculty were developed through Training of Trainers (TOT) courses (July 2006 and January 2007).

Ms Shabarova described Knowledge Hub experience in development of training programs, stressing the following main elements: (1) development of consensus among national stakeholders and donors on treatment model, related training approaches and workforce development needs; (2) curricula development; (3) development of trainers roster and faculty team composition; (4) proposal development, contracts negotiations to secure funds for training; (5) program and administrative planning; (6) monitoring and evaluation.

Main components of training planning and organization were presented. Ms Shabarova also described in detail what it takes to implement each training course and related follow up activities. She provided information on costs related to Knowledge Hub operations (core costs) (June 2004 – September 2006) and funds received for training implementation in Ukraine. Knowledge Hub spent $458,315 for core costs (Knowledge Hub staff labor and office costs, training materials development, translation of latest evidence based information on HIV medicine, development and maintenance of Knowledge Hub seb site, etc.). In addition, the Knowledge Hub spent (and received from various donors) $912,271 to conduct trainings (to cover participants and faculty related costs, costs directly associated with implementation of trainings, production of training materials, etc.) Because donors that contract for training are generally not willing to support core costs, the AIHA uncompensated subsidy for the Knowledge Hub since its inception has been and continues to be significant.

Ms Shabarova analyzed the following main strengths of Regional Knowledge Hub:

  • Clear program direction to respond to the HIV/AIDS epidemic through highly relevant curricula that aligns with national care and treatment plans.
  • Multidisciplinary team approach. By bringing together teams of professionals and teaching them how to work cooperatively to maximize the strengths of each member, the Knowledge Hub is contributing to a system that is robust enough to meet the needs of these patients.
  • The high quality of its training plan. The Knowledge Hub’s careful mix of didactic and clinical exercises with case experience and professional mentoring, high level of faculty competency and commitment contribute to the care teams’ success in mastering the material.

According to Ms. Shabarova, the Knowledge Hub’s main challenges reflect the traditionally stratified nature of the healthcare system in the region, the urgency of the demand for a highly qualified workforce to meet scale-up requirements, and the low priority that is often placed on human resource capacity building within national and donor budgets.

  • Much remains to be done to overcome the vertical structure of the national AIDS systems and develop collaborative approaches among specialists, including those working in tuberculosis and narcology.
  • Other challenges that the Knowledge Hub faces stem from the enormous unmet need of HIV/AIDS patients in the region, much of which has not even been adequately documented. While the Knowledge Hub is already training caregivers in a core curriculum, it is also working quickly to expand its offerings to help care teams continue to improve their competency and to address the needs of diverse patient populations.
  • Retaining trained caregivers, monitoring of their performance and documentation of further training needs remains to be a challenge due to shortage of funding for implementation of these activities and low priority of workforce development for national stakeholders.
  • The Knowledge Hub is also challenged in its efforts to rapidly build national training capacity when care providers are still in the early stages of acquiring the necessary experience and knowledge to serve as effective trainers. In addition, the adult learning techniques and practical learning approaches essential to effective clinical training have not been traditionally used in the region, increasing the difficulty developing national faculty at a rapid pace.
  • Finally, while capacity building needs in the region remain very high and demands on the Knowledge Hub continuous, there continues to be a marked gap in resources from national and donor budgets to meet these demands. Notwithstanding its success in mobilizing co-funding from GFATM and other sources, the Knowledge Hub continues to require ongoing subsidies (as described earlier) to cover even the most basic management and administrative costs.

The Knowledge Hub has learned important lessons that guide its work going forward and that may also be of use to others in the international aid community hoping to create change.

  • Commitment to guiding principles: The Knowledge Hub’s early success confirms its commitment to basic principles.
  • Teams need ongoing training opportunities: Refresher training courses should be provided on a more regular basis to trained care teams. An expanded array of training opportunities should include preceptorships and "twinning” opportunities.
  • Teams must nurture distinct professional roles: While teams need a common approach, they can only benefit from the multidisciplinary approach if the unique role of each professional is understood and if individuals have the confidence in their skills to perform these roles.
  • HIV/AIDS Care Requires a Broad Skill Set: While the Knowledge Hub has always aimed for multidisciplinary approach, the first years of training has shown that teams need more opportunities to explore topics such as tuberculosis and HIV/AIDS co-infection, narcology, palliative care, and mental health issues.
  • Initial approach for ART care team composition which includes infectious disease physician, nurse and social worker/ART aid can be expanded to include TB and Narco specialists to target care and treatment needs of people with HIV/AIDS who are “triple affected” by HIV, active IDU and TB.

Notwithstanding the challenges that it faces and the unmet needs that still exist, the Knowledge Hub has proven to be an effective model for coordinating and strengthening national responses to HIV/AIDS, in particular building human capacity to provide universal access to antiretroviral treatment in the region.

 

Report on recent assessment of challenges faced by HIV/AIDS care providers presented by Dr. Trudy Larson, KH Faculty Member and WHO-Ukraine consultant for GFATM 6th round proposal

Dr Larsen outlined the following problems, faced by trained care teams. They were identified during monitoring visits and TOT trainings in which Dr Larsen took part as a faculty:

  • Collaboration with other specialists (TB, Narco, Oncology) and their understanding of the needs of patients with HIV/AIDS;
  • Discrimination from other specialists;
  • Need to increase primary health service provider’s knowledge on HIV/AIDS, particularly in remote areas;
  • Need to have more resources (e.g., disposable supplies, tests, condoms) in order to apply knowledge;
  • Discrepancies between situation on the ground and reports – therefore decision makers do not often know needs and problems in real settings;
  • To define “workload” for multidisciplinary care team (e.g., is 100-150 patients optimal number?)
  • To define how many care teams needed to provide treatment and care to 50,000 PLWH in 2010;
  • To define standards of care and needs on ART, OIs treatment, etc.;
  • To balance the training of specialists on HIV/AIDS, including TB and Narcology specialists;
  • To include HIV/AIDS in the undergraduate curricula for medical institutions;
  • To conduct trainings for decision makers and managers on HIV/AIDS to better understand the problem;
  • Potential national faculty need to have regulations, which allows combining clinical and pedagogical work;
  • Potential national faculty need more training on clinical and adult learning issues before they can carry out their training roles.

 

First Round table discussion:

The participants discussed the main challenges on national workforce development outlined by Ms. Shabarova and Dr. Larson. Participants agreed with outlined challenges and problems and discussed possible ways to address them.

Human capacity building needs for Ukrainian health care workers for 2007-2008 (as reflected in the National program for Years 4-5 Overcoming HIV/AIDS epidemic in Ukraine, supported by GFATM).

Presentation by Dr. Filippovych

Dr Filippovych presented the following summary of treatment component implementation: total 4,767 people received ART in 20 Ukrainian regions as of January 2007. Opportunistic infections (OIs) treatment received 7,912 patients (including 5,094 people who received PCP prophylaxis). 4,487 HIV infected pregnant women and 4,464 children received prevention of vertical transmission of HIV; and infant formula was provided to 3,610 children exposed to HIV. 679 people receive post exposure prophylaxis. 4,458 tests were conducted as part of TB diagnostic procedure at AIDS centers. All AIDS Centers received technical financial assistance. International HIV/AIDS Alliance funded development of national recommendations on treatment and diagnostics, purchased equipment and tests for ELISA, CD4, viral load and PCR tests. The ST was initiated in 8 regions and 11 sites, 458 IDUs received ST, including 294 with HIV/AIDS. Knowledge Hub conducted ART for IDUs on ST training for 11 multidisciplinary care teams. Dr Filippovych also described the results of the training component, implemented by the Knowledge Hub (please see related information in Knowledge Hub presentation summary above). In addition to Knowledge Hub training, NGO “Time. Life. Plus” conducted preceptorship program: 19 caregivers from the regions received on-site training at Lavra AIDS Clinic and Lavra AIDS Clinic experts conducted visits to 12 regions to provide mentoring.

The following activities are planned for 2007-2008:

  • Scale up of ART to 7 new regions and implementation of ST in 15 new regions (37 new sites);
  • 6,000 patients on ART;
  • 6,000 patients on ST (including 1,250 on ART and ST);
  • 9,200 HIV infected pregnant women receive prevention for vertical transmission of HIV;
  • 30,000 patients of TB institutions received VCT;
  • 17,000 patients from STIs and TB clinics received VCT;
  • 270 caregivers received training on care and treatment for HIV/AIDS;
  • 57 multidisciplinary teams received training on ST;
  • A HIV/AIDS curriculum is introduced into national system of postgraduate education.

Dr Filippovich outlined the following training needs to build national human capacity to provide care and treatment on HIV/AIDS: (1) ART and OIs; (2) ART for IDUs on ST; (3) pediatric ART; (4) access to ART and VCT at prison system; (5) development of palliative care system; (6) VCT at STIs and TB clinics; (7) ART and ST in primary health care.

Human capacity building needs for Ukrainian health care workers on HIV/AIDS care and treatment for 2007-2008 (World Bank HIV/AIDS project).

Information from Dr Khmarsky.

Dr Khmarsky informed meeting participants about the history and current situation with the World Bank Loan on HIV/AIDS and TB to Ukraine. The loan was suspended last year due to low level of funds utilization and was renewed early this year after Ukrainian Government submitted revised strategic plan after series of negotiations with World Bank officials. As for now, MOH Project Implementation Unit is planning to issue a tender to provide 11 trainings on adult and pediatric HIV/AIDS care and treatment. Currently, the terms of reference for this tender is under review at the World Bank office in Washington DC. The implementation of the project will begin in March 2007 and results are expected in June 2007.

Ukraine proposal for GFATM Round 6: care model and related human capacity building needs.

Presentation by Mr. Zhovtyak.

Mr. Zhovtyak described the goal, main objectives, target groups of the Round 6 proposal. The overall goal of the proposal is to reduce HIV transmission and HIV- and AIDS-related morbidity and mortality in Ukraine through interventions focused at most at-risk populations. The main objectives are:

  • Objective 1: To ensure sufficient access to integrated prevention, treatment, care and support for vulnerable populations;
  • Objective 2: To scale up comprehensive HIV care and treatment and ensure equitable access for IDUs and other vulnerable populations;
  • Objective 3: To expand access to comprehensive adherence counseling, psycho-social support and care for people living with HIV (PLWH);
  • Objective 4: To create a supportive environment for a sustainable and efficient response to HIV and AIDS in Ukraine;
  • Objective 5: To monitor and evaluate grant implementation and strengthen the national monitoring and evaluation (M&E) system.

Proposal listed the following priorities for 2007-2011: (1) ART and monitoring for most vulnerable groups; (2) HIV/AIDS prevention and treatment; (3) prevention and treatment of OIs; (4) HIV-associated TB; (5) ST. Also, there are needs to focus on advocacy for ARV drugs price reduction, determine ART needs and it’s access on local level; provide regular update of clinical protocols; provision of ART and related monitoring to 5,000 people with HIV/IDUs/TB; procurement and supplies chain management; providing technical assistance to NAC and capacity building to State Department of Prison System; scale up trainings for multidisciplinary teams on ART, OIs, TB and ST; development of Ukrainian HIV/AIDS Professional Association and piloting of projects focused on ART decentralization.

Then Ms. Zhovtyak described training courses, which are planned within each Proposal Objective. With regard to Objective 2 and Service Delivery Area “ART and monitoring for most vulnerable groups” the following trainings are planned:

  • Workshop for NAC, oblast coordination councils, local community networks and MOH representatives to develop an approach on ART scale up;
  • Training on data case management for local community networks (including confidentiality);
  • Trainings on TB coinfection and ST for 14 multidisciplinary teams, which were trained on ART within the Round 1;
  • Trainings on ART for IDUs on ST and TB for 27 multidisciplinary teams, which were trained on ART within the Round 1;
  • Trainings on collaboration with local community networks for 16 care teams, trained during the Round 1;
  • Series of trainings for every of 72 new and extended teams on ART/TB/ST;
  • Establishment and further development of National Training Center.

The following trainings are planned within Service Delivery Area “Prevention and Treatment of OIs”:

  • Workshop focused on national recommendations review;
  • Series of trainings for extended care teams on TB/HIV coinfection;
  • Trainings for new staff;
  • Trainings for selected TB clinics staff.

According to Mr. Zhovtyak, program can start at the end of summer -- beginning of autumn 2007 (after the LFA review of PRs will be completed).

Second Roundtable Discussion:

Based on information provided in the presentations and the first round table discussion, the participants discussed the following key issues:

  • The development of undergraduate and post-graduate curricula on HIV/AIDS to reach the broadest possible audience of health professionals;
  • Development of a National Training Center as a sustainable institution capable of carrying out ongoing capacity building for specialized care and treatment of HIV/AIDS in Ukraine.

Under-graduate and post-graduate curricula on HIV/AIDS:

Ukrainian National AIDS center raised the question about development and introduction of postgraduate HIV/AIDS course. James Smith confirmed that AIHA/Knowledge sees this as a high priority now that the training of specialized HIV/AIDS care teams on introduction of ART is well underway. He went on to describe the AIHA/Knowledge Hub experience with St-Petersburg Medical Academy of Postgraduate Education (MAPO) on the development, introduction and certification of such courses in the Russian Federation and stated that the Knowledge Hub can further discuss with Ukrainian partners potential collaboration based on this recent Russian experience. Also James Smith pointed attention to the funding aspect of course implementation: in order to institutionalize such trainings, the MOH or interested institutions and donors need to commit funds to pay NMAPO to participate in and carry out such course. James Smith also shared AIHA/Knowledge Hub experience in Russia to develop the undergraduate curricula together with Moscow medical institutes. Course will be offered as “elective” for students during 4th year of study. Also, James mentioned that currently Knowledge Hub and Clinton Foundation are developing the course “Introduction to HIV/AIDS Care and Treatment” for infectious disease physicians and nurses, which can be adapted as postgraduate HIV/AIDS course. Therefore, the Knowledge Hub has experience in development of curricula, which can be adapted for postgraduate education in Ukraine.

Establishment of the NationalTrainingCenter:

The following main objectives for NTC were identified: (1) coordination of under- and post-graduate HIV/AIDS curricula development and course implementation; (2) providing continuous education to health professionals on HIV/AIDS care and treatment; (3) further introduction of adult learning methods; (4) coordination and utilization of experience of current training projects implemented by different agencies (Knowledge Hub, Clinton Foundation, Canadian Pediatric AIDS Project, PATH, others); (5) review and development of the curricula. Funding for National Training Center has the separate budget line in the Ukraine Round 6 Proposal to GFATM.

During discussion, it was mentioned that NMAPO, NAC, Lavra Clinic can be considered as potential national sites for National Training Center

James Smith stated that the Knowledge Hub/AIHA is fully committed to the establishment of a fully functional National AIDS Training Center and is prepared to work with selected national partner(s) in the coming 18 months to develop the National Training Center by mid 2008.

Meeting participants discussed the main elements of successful workforce development activities, which were outlined in Ms. Shabarova’s presentation, as they relate to the establishment of the NTC. Professional administration and transparency of spending and financial reporting are very important elements of successful fundraising and maintaining effective relationships with donor agencies. Curricula development, which takes into account not only national, but regional experience and needs, can be effective programmatic and cost-effective approach.

During the discussions, the issue of development of national faculty was raised again with focus that this process requires long-term commitment from potential faculty, donors and the National Training Center as well as related regulatory changes (allowing clinicians to combine practice and teaching, increase number of staff at AIDS centers to have the possibility for potential faculty to conduct trainings without compromising patients clinical needs, etc.).

Participants agreed that it is very important to initiate discussion on the main elements of National Training Center development. The importance of identifying the national institution, which can be interested and motivated to work on establishment of National Training Center, was stressed. Again, the shortage of managers and qualified cadres on HIV/AIDS care and treatment were discussed.

Ms Ageyeva concluded that it is important to have additional staff at AIDS centers, who can assume educational functions and conduct trainings in a systematic way. However, as was earlier clarified by Dr Scherbinskaya, according to the Ministry of Finance regulation, the number of staff for oblast AIDS centers is based on population numbers and not on HIV prevalence rate, patients on ART. This presents a tremendous challenge to the regions, which need to have more specialists to provide access to HIV/AIDS care and treatment, particularly in the regions with high HIV prevalence.

Dr Filippovich summarized the discussion, stating that, while it would be logical and even desirable that an organization (like NMAPO) take on longterm responsibility for the NTC, it is impossible to force or mandate that leadership. Sustainability of training programs should be based on national system of workforce development. Within GFATM Round 1 program in Ukraine, it is possible to start to develop postgraduate program selecting qualified and motivated NMAPO faculty.

Meeting Conclusion

James Smith summarized that the meeting archived it’s main objectives: to review and discuss the lessons learned during Knowledge Hub training activities to date, to discuss the current and future learning needs of Ukrainian health workers with respect to HIV/AIDS care and treatment, and to discuss and coordinate among main donors Ukraine’s human capacity building priorities for the next 2 years, including the critical next steps of (1) engaging the undergraduate and graduate schools of the health professions in HIV/AIDS related education, and (2) development of National Training Center as a sustainable capacity building agency for Ukraine. Meeting presentations and summary report will be posted on the Regional Knowledge Hub web site (www.aidsknowledgehub.org).

James Smith thanked everyone for their active involvement into the discussion and for the participation in the meeting, and adjourned the meeting.