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Tom Ellman, �MSF Southern Africa�

Lessons learned in responding to HIV and TB service disruptions among conflict and natural disaster affected populations

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Overview

  • Basics of HIV and humanitarian settings
  • Overview of MSF and HIV in conflict
  • MSF Experiences
  • Lessons learned

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Background

  • Conflict and forced displacement are rising
    • Estimated 2 billion live in unstable settings and 100 million displaced
  • Conflict increases vulnerability to HIV and TB
    • Risk and prevalence varies)
  • Access to quality health services is massively disrupted
    • Providers leave, facilities damaged, supply chains broken
    • Population movement
  • Data is usually of poor quality or absent

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MSF HIV activities in unstable settings

*84 projects reporting on political context

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Conflict in Cabo Delgado 2020-2023

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Conflict Disruption in Cabo Delgado�

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  • Activities are basic IPD and mobile and fixed OPD
  • Main health priorities are MCH and HIV/TB

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(Data from CQUIN 2020)

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HIV/TB response in Palma

  • Priorities
    • Find and restart treatment
      • Link with community and partners
    • Identify highest risk
      • Pregnant women
      • Infants missed by PMTCT
      • Malnourished children
      • Known AHD and TB
        • Catch-up CD4 and VL
    • Commodity supply
      • HIV/TB/Contraception
    • Monitoring system

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M&E SYSTEM – REPORTING FROM OPEN MRS

ART Cohort in Open MRS as of 18/11/2023 – NOT UP TO DATE DATA IN OPEN MRS

Ever Enrolled

n = 5533

5347

Active (in Open MRS)

n = 153

Dead + Stopped Tx

n = 521

Unknown

n = 4673

Transfer Out

n = 186

CS Palma

n = 25 (16%)

CS Olumbe

n = 46(30%)

CS Muti

n = 60(39%)

CS Pundanhari

n = 19(12%)

CS Quionga

n = 3(2%)

CS Maganja

n = 0 (0%)

Data Source: Open MRS

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Conflict in Agok, South Sudan, 2022

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  • MSF providing PHC alongside MoH
  • Population flee to Twic and Abyei
  • Twic Chronic care unit - March 2023

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Differentiated Service Delivery in CAR

  • Decentralisation
  • Task-sharing
  • Long ART refills
  • Fast drug pick-up
  • Group models

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Summary of Priorities�

  • Rebuild supply chain with long ART refills
  • Develop simple paper-based monitoring (including unique ID)
  • Basic rehabilitation (lab and facilities)
    • OPD and mobile clinics
  • Link with partners to list, trace, and re-engage ART/TB treatment
  • ‘Catch-up’ PMTCT (including contraception) and ‘missed’ infants
  • HIV/TB screening among malnourished children and IPD adults

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Conclusions: “Leave no-one behind”

    • All HIV and TB programmes are vulnerable to disruption

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    • Preparedness across government and partner strategies and policies
      • Differentiated service delivery principles (including 6 month refills)
      • Engaged and literate community networks
      • Simplified and self-management where possible
    • Specific preparation for disruption
      • Scenario planning
      • Awareness and training of emergency response providers
      • Buffer stocks, ‘push’, and parallel supply systems
      • Adapted (paper-based) monitoring systems and decentralised initiation

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Thankyou for your attention

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Opportunities: Putting the Last First

  • Targetted HIV testing for at-risk populations (KP, AGYW, STI, TOP) and delivery of HIV ST if feasible
    • PEP/PREP delivery for high-risk populations
  • Support for AHD management (specifically CD4, TB, crypto)
    • VL and CD4 catch up opportunity
  • 4 month TB regimen for kids
  • Identify kids and ‘catchup’
  • 3HP for TB TPT
  • Simplification/DSD
    • 3-6 month ART refills
    • SAT for TB and Xpert/LAM based initiation

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Advocacy priorities

  • Agreement for initiation and continuation of TB/HIV in adults and kids at mobile clinics and above
    • Assigning NIDs must be decentralised
  • ‘Push’ supply to increase cohorts rapidly
  • Community DOTS (sat!!!) for TB and long refills for ART
  • AHD tests and management at decentralised sites

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Main Priorities: Mobile services, Restart, Catch-up, QI opportunity

  • PMTCT including contraception and HIV testing of new ANC mothers and babies and ART
    • Proactive efforts to test and initiate PMTCT or ART on mothers missed at earlier ANC and/or previous births
  • Active screening for malnutrition and HIV
    • testing and treatment for mothers and children
  • AHD package at MSF supported hospitals and screening in PHC
    • Laboratory rehabilitation and supply
  • Proactive efforts to list, trace, and re-engage those previously on ART and TB treatment
    • Primarily through partners, APEs and activistas
  • Ensure TB screening,(ideally with TPT and contact tracing) and access to adult and child TB treatment
  • Linked to all the above support to MOH on lab and drug commodity supply chain, buffer stock maintenance, and data management
    • Negotiate exception supply including importation, long refills, ‘push’ system (incl paeds)
    • Data system with agreement on allocation of NIDs and TB treatment, access to national system, supply links

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HIV and TB data

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  • Palma Hospital had 5707 at time of conflict attack march 2021 and 429 returned by aug 2022
  • HIV Testing started in ANC in Q3 2022.
      • Of 115 1st ANC in Aug 2022, 113 tested, and 9% HIV positive
  • Of 201 children in feeding centre, 14 tested of whom 6 positive

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