usaid/ethiopia pepfar mid-term evaluation of the ... - GH Tech

monitoring of ART side effects (such as checking liver function tests for those on nevirapine).Patient monitoring and documentation was also found to be weak in a number of HCs.The consequences of these limited skills can be serious for the patient, the health system, andpublic health. HIV-infected patients (especially those on ART) need to be appropriatelymonitored and managed to avoid morbidity and possibly mortality due to treatment failure, ARTside effects, and development of HIV-related diseases. With suboptimal care, HCs risk losingcredibility in the eyes of the community, HIV-infected patients, and the hospitals from whichpatients should be referred. Development of ART drug resistance in individual patients andtransmission of resistant virus to others threaten the future utilization of the most inexpensiveand accessible first-line therapies. The time to intervene to prevent all of these potentialconsequences is before instead of after these negative consequences begin to develop.5. Defaulters and adherence are significant issues. ART treatment defaulters and sub-optimal adherence areimportant concerns for all facilities providing ART, including HCs. Virtually all HCs visited by theevaluation team had adherence counselors, as well as some measures for tracing those who werelost to follow-up. However, the success of these measures varied between sites and dependedgreatly on the availability of and support for community outreach staff. There were manydifferent reasons cited for default, with different situations for HCs in rural and in urbanlocations. Despite multiple barriers, the ability of HCs to have close ties with the communityallowed many of them to have better follow-up rates than those of larger higher-level facilities.B. HIV Care and Treatment Service Delivery at the Health Center Level1. As a policy, provider-initiated HIV counseling and testing is in general integrated throughout the HCs. HCpolicies are for PIHCT to be widely available throughout HCs and offered in conjunction withmultiple different clinical services, including those for all patients diagnosed with TB, STIs, andother indicator diseases. However, it appears in practice that not all patients diagnosed with theseconditions are being routinely screened for HIV.2. Voluntary counseling and testing services are not well integrated with PIHCT. In contrast to relatively goodintegration of PIHCT and clinical services, VCT and PIHCT do not seem as well integrated. VCTand PIHCT record keeping systems and staff, for example, could be better integrated at the HClevel.3. As a policy, STI and HIV screening services are integrated. As noted above, HC policies are for HIVC&T to be provided for all patients diagnosed with STIs. Similarly, the routine initial evaluationof all HIV patients includes a clinical assessment for signs and symptoms of STIs, although thisassessment does not appear to be routinely conducted in patients being seen for follow-up visits.As noted below, availability and stock-outs of STI drugs are a concern. Laboratory screening forasymptomatic STIs is not performed at HCs, and most do not screen for syphilis.4. PMTCT services are well integrated in antenatal clinics, but implementation in the labor and delivery andpostnatal settings is variable. PMTCT includes HIV testing of all pregnant women, as well asprovision of ART drugs to infected women and their newborns to help prevent HIVtransmission. Clinic policies are for HIV C&T to be provided to all women seen in antenatalclinics. For those women who test positive, short-course combination therapy is offered,consistent with current national guidelines. It appears, however, that the actual implementation ofPMTCT throughout the HC system is variable. Two areas of particular concern are L &D andMid-term Evaluation of Ethiopia IMAI Program 32