Differentiated Service Delivery and COVID-19

Updates on policy and practice adaptations from Mozambique and the Democratic Republic of Congo

June 2 |Le 2 Juin | 2 de junho

• Please type your name, organization and email address in the chat box

• If you would like to join the CQUIN-COVID WhatsApp group, please also add your telephone number ☺

• Please ask questions to panelists in the Q&A box

• Veuillez saisir votre nom, votre

organisation et votre adresse

électronique dans la boîte de

discussion

• Si vous souhaitez rejoindre le groupe

CQUIN-COVID sur WhatsApp,

veuillez également ajouter votre

numéro de téléphone ☺

• Veuillez poser vos questions aux

panélistes dans la boîte à questions

et réponses

• Por favor, digite o seu nome,

organização e endereço de e-mail no

chat

• Se quiser juntar-se ao grupo CQUIN-

COVID WhatsApp, adicione também o

seu número de telefone. ☺

• Por favor, faça perguntas aos

painelistas na caixa de Q&A

• Be sure you have selected the language of your choice using the “Interpretation” menu on the bottom of your screen.

• Assurez-vous d’avoir sélectionné la langue de votre choix à l’aide du menu <<Interprétation>> en bas de votre écran Zoom.

• Certifique-se de ter selecionado o idioma à sua escolha usando o menu de interpretação na parte inferior do seu ecrã

Welcome/Bienvenue/Bem-vindos

2CQUIN-COVID Webinar | June 2, 2020 |Le 2 Juin | 2 de junho

• Dra. Aleny Couto, Head of HIV Program, Ministry of Health,

Mozambique

• Dr. Mahoudo Bonou, Senior QI Technical Advisor, EGPAF,

Mozambique

• Mr. Lourenço Sumbane, Community Activist, PLASOC, Mozambique

• Dr. Ingwe Chuy Richard, Heald of Care & Support/DSD Focal, Ministry

of Health, DRC

• Mme. Clarissa Mudiambu, La Superviseur National des PODI,

UCOP+, RDC

Panelists & Agenda/Panélistes et ordre du jour/Painelistas e Agenda

3CQUIN-COVID Webinar | June 2, 2020 |Le 2 Juin | 2 de junho

DSD and the COVID-19 Response

Mozambique

DSD and the COVID-19 response, updates on policy & Practice adaptations

The CQUIN Project

COVID-19 in Mozambique

Until June 1st:Government Measures – emergency state Level 3 since April 1st

1. Agglomeration restriction (≤ 10 people)2. Severe agglomeration restriction in the

commercial sector3. Obligatory severe reduction of employees in

presential regime (rotativity)4. Prohibition of all events. Sports activities and cults

10,970 10,716

254 96 155 2 -

2,000

4,000

6,000

8,000

10,000

12,000

The CQUIN Project

Changes in Guidelines and Practices Changes (1)

Infection control and RoC education

1. Community HTC suspended.

2. Home visits by peer educators andother HIV activists suspended

3. All support group meetingssuspended, except for CAGs.

4. RoC in CAGs educated to keep socialdistancing, and group meetings are onlyto deliver drugs

5. Lay personnel dedicated to HIV C&Tactivities now working to organizepatient flows, provide COVID-19prevention education and screening.

Reduce the frequency of RoC visitsto the HF

1. 3MDD and fast track scaled up to all1593 ART HFs

2. 3MDD for all patients older than 2y/o

3.3MDD for TPT, CTX and other NCDs

4.CAGs eligibility criteria extended

5.VL sample collection and resultdelivery aligned with the clinicalconsultation or drug pickup.

6

The CQUIN Project

Changes in Guidelines and Practices Changes (2)

Reduce waiting times in the HF

1. Patients at the HF go directly to adesignated consultation room.

2. Psychosocial support is done in theclinical consultation room

3. HFs provide drugs in the consultationrooms (one stop shop) or have moredrug pickup points besides thepharmacy.

4. Patients on Fast Track and 3MDD haveclinical consultation every 6 months. Atmonth 3 and 9 go directly to thepharmacy to pick their drugs.

Innovations and Best Practices

1. Psychosocial support done by phone call.

2. VL>1000 result delivered by phone call,including enhanced adherence counselling.

3. HFs where instructed on how to fill thepatient file in order to be possible todistinguish between patients who whereincluded in DSD because of COVID-19 andthose who had the “formal” criteria.

4. Monthly ZOOM calls with the provincialHIV teams, to identify problems, share bestpractices and gather information to updateguidelines.

5. Monthly data analysis to identify gaps andrealign strategies.

7

8

The CQUIN Project

Clinical Consultations, Tx New, Tx Curr and VL Trends

9

Monthly consultations Tx New Tx Curr VL (sample collected, result)

The CQUIN Project

Defaulters and 3MMD Trends

10

8% 8% 8%

10%

0%

2%

4%

6%

8%

10%

12%

Jan Feb Mar April

Monthly Defaulters

32% 33% 34%

45%

9% 9% 9% 9%

0%

20%

40%

60%

80%

100%

Jan Feb Mar April

3MDD and CAG Coverage

3MDD CAG

The CQUIN Project

Priority Questions

• Develop/ adapt more DSDs to ensure better coverage.

• Clinical follow-up of RoC enrolled in DSD after the end of the pandemic if not virally suppressed.

• Relaxation of eligibility DSD criteria – is it the right direction?

• Current discussions on the return of:

• Home visits

• Community HIV counseling and testing

11

Impact and mitigation of COVID 19 on HIV services in Gaza and

Inhambane province

Mahoudo Bonou, MD, Senior QI Technical advisor, EGPAF Mozambique , mbonou@pedaids.org

Impact of Covid-19 on continuity of services

• Staff:• National and provincial level staff work from home (teleworking)

• HF based stuff continue to give support and services as normal – provided with PPE

• Trainings:• Most trainings cancelled, few took place via Zoom video conferencing

• HIV program activities:• Community activities suspended – no LTFU tracing, no HIV index testing and no preventive visits

• HF patient flow redesigned to allow all patients to be screened for COVID-19

• Patient/Community sensitization to come to HF only when needed

• 3MMDs for all ART patients with exception of pediatrics <20kg

• Antenatal visits – modified to quarterly visits

• Child at risk consultations and post partum consultations – monthly in 1st 3 months, quarterly thereafter

• In person technical support and activity supervision suspended

• Expansion of IDART (pharmacy system) suspended

EGPAF Response To COVID 19

• Scale up of 3MMD

• IPT inclusion in 3MMD

• Modification of patient

flow in HF to allow for

COVID-19 screening

• Zoom TWGs meetings

• Zoom Covid-19 taskforces

meetings

• Zoom clinical sessions &

trainings

• Zoom data discussion

sessions

• Phone teleconferences

where the network is bad

• Tele counselling (adherence

counselling, preventive calls, TB

and Covid-19 screening

questionnaire)

• Tele tracing (LTFU, missed

appointments etc.)

• Use of WhatsApp groups

for quick circulation of

information and for

technical support (C&T, TB,

PSS & Community etc)

Quick reproduction and

distribution of:

• Covid-19 flowcharts &

treatment guidelines

• HIV and TB program

guidelines in context

of Covid-19

Distribution to provinces

supported and staff of:

• N95 masks

• Cloth masks

• Goggles

• Gowns

• Detergents (bleach)

• Buckets with tap

• Soap

• Alcohol sanitizers

• Community based HTC

suspended

• Focus on Facility based

HTC and linkage

Data slides

32040

16560

58366

22954

69386

32144

0

10000

20000

30000

40000

50000

60000

70000

80000

Gaza Inhambane

3MDD enrolment

March April May

57%

42%

82%

62%

50%

68%69%

74%74% 74%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Gaza Inhambane

Preventive calls for eligible patients

week 1 week 2 week 3 week 4 week 5

4%

3%

5%

4%

5%

6%

0%

1%

2%

3%

4%

5%

6%

7%

0

20000

40000

60000

80000

100000

120000

140000

Feb March April Feb March April

Gaza Inhambane

Patients with missed drug pick up

missed pick up drug pick up % miised drug pikc up

M&E for COVID era HIV service delivery

• CDC guidance:

• Quarter 2 reporting deadline extension by 1 month

• Open MRS upgrades to continue – remotely

• Suspend manual data collection –

• Guidance on moving EPTS in case HF repurposed as COVID-19 treatment center

• Adaptations made:

• Data operators working in shifts to respect physical distancing – due to space challenges

• PPEs (masks and gloves) as well alcohol sanitizers distributed to all data operators

• Remote upgrades and remote supervision

• Weekly electronic listings for preventive calls + update of database records

• Weekly electronic listings for missed appointments and LTFU + update of database records

• Indicators to be monitored monthly to follow impact of Covid-19:

• 1st ANC visit ( trend and compared with same period last year)

• EID 4-8 weeks, 2-9 months (trend and compared with same period last year)

• HTC (all tested patients) (trend and compared with same period last year)

• TB (new TB cases) (trend and compared with same period last year)

• Early retention (trend)

• Currently on ART (TX-CURR) (trend)

• HIV VL (collection and suppression) (trend)

• 3MMD (trend)

Resposta dos utentes aos cuidadosResponse from the recipient of care community /Réponse du bénéficiaire de soins communautaire

Lourenço Sumbane, Community

Activist, PLASOC, Mozambique

18

Differentiated service delivery (DSD): “Fundamental intervention in the context of

COVID-19”

Richard INGWE CHUY : MOH DSD Focal Point in DRC

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

COVID-19 Situation

❑ As of May 2020:

✓ The COVID-19 response committee

reported 2,966 cases located in 7 out of the

26 provinces

✓ More than 90% are located in Kinshasa

✓ The average daily case detection and case

notification is around 120

✓ 69 deaths recorded since the first COVID-

19 case notification on March 10th,2020

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

❑Eligibility criteria:✓At least 12 months on ART

✓One suppressed VL (< 1000 copies/ml)

✓Adherence and observance to treatment

✓Absence of OIs during the last 3 months

✓No pregnancy

✓Aged 15 years and above

✓No treatment side effects

✓Good nutritional status (BMI > 16)

Differentiated service delivery

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

Group models (DSD) and COVID-19

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

Fast-Track and COVID-19✓ Pursuit or intensification for stable patients

already enrolled in a 6-month ART

dispensation scheme

✓ For all newly identified HIV+ patients: 3-

month ART dispensing

✓ For patient on ART for at least 3 months: 3-

month ART dispensing

✓ Close follow-up by phone calls, SMS, SMS

reminders

✓ 3-month dispensation for TPT and

cotrimoxazole

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

Major changesReduce the frequency of patient visits in health facilities in order to prevent the spread of coronavirus among patients and providers

Yes

No

✓ Scheduled appointments (phone calls to set appointment date and time)

✓ Follow-up by phone based on an agreed schedule (WhatsApp, SMS reminders and phone calls)

✓ Home-based visits by peer educators for ART refills based on a plan developed by HCWs and peer educators

✓ Provision of personal protective equipment to peer educators

✓ Briefing of peer educators on COVID-19 preventive measures

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

Major changes❑Provide all patients with at least a 3-month ART supply

✓Patients on ART less than 12 months

✓Patients on ART for 12 months or more enrolled or not in DSD

✓Children whatever their age

✓Pregnant and lactating women

✓TB patients new and old cases

❑Inform patients on warning medical symptoms or signs requiring their presence at the facility for a medical consultation

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

Major changes❑For newly enrolled HIV+ patients (less than 6 months on ART)▪ At least once a month, organize phone calls to:

✓Screen for side effects

✓Assess and support adherence to treatment

✓Screen for TB and COVID-19

❑For TB patients▪ Write ART starting date on ARV boxes

▪ Inform TB patients about the importance of starting ART 15 days after the start of their TB treatment

▪ Organize a phone call or send an SMS reminder the day before ART start date to remind TB patients about their ART start date

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

Priority questions

• Scale-up of the major changes on ART, TPT and cotrimoxazole dispensing in all health zones affected by COVID-19

• Restricted ART supply in remote health zones (lockdown)

• Limited availability of ARVs (incomplete TLD transition)

• Limited availability of pediatric ARVs

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

REPUBLIQUE DEMOCRATIQUE DU CONGO

MINISTERE DE LA SANTE

IMPLEMENTATION OF COMMUNITY ART DISTRIBUTION (PODI) DURING COVID-19

By Mrs Clarisse MAWIKA Mundiambu

National PODI Supervisor

TEL: +243999901431

+243853525523

mail: mudiambuclarisse@gmail.com

▪ ART distribution point / PODI for stable patients with viral load<1000 copies/ml

▪ Operations:

▪ Service availability: 5 days/week but reduced to 3 days per week due to covid-19

▪ Recipients of Care are given appointments every 3 to 6 months

▪ Appointments are within urban areas, within the community

▪ Involvement of expert clients (peer educators)

▪ Implementing partners provide technical, material and financialsupport

COMMUNITY ART DISTRIBUTION MODEL (PODI)

ART Distribution to Recipients of Care

▪ Supply chain steps:

▪ Inventory of the PODI pharmacy

▪ Validation of patient listings by the PODI, the health center and the health district

▪ Making the order.

▪ Patients without appointment or patients enrolled in other facilities, receive ART basedon a referral form, using the security ART stock

PODI

Health

Center

Health

District

Partners

Validation of patient

listings

Re

po

rts

Protective Measures Related to COVID-19

▪ Adaptations to the PODI model related to COVID-19:▪ Reduction of frequency of services 3

days per week instead of 5 due to confinement measures

▪ Reduction of the number of appointments per day: 15 to 45 per day

▪ Health Care Workers are devided into 2 groups, working in a rotation

▪ Utilisation of face masks for health care workers and patients

▪ Physical distancing by ensuringadditional space between chairs in waiting

▪ Dispensing of 3 to 6 months of ART▪ No screening / testing for Covid.19.

Impact of COVID-19 on the PODI Model

In response to the confinement measures implemented by thegovernment of DRCongo the following solutions have been put in placeto track patients who missed appointments:▪ Telephone calls;▪ Distribution of ART at patients’ home;▪ Pick up of ART by a person designated by the patient

Related to HIV testing: Reduction of HIV testing services targeting specificcases. No sensitization sessions have been conducted

Other Challenges: ▪ No tools available for sensitization on Covid-19▪ No new patients are referred to the PODI▪ Interruption of HIV testing services

Merci Beaucoup

Thank you

• Slides and recordings from all past CQUIN webinars are posted to the website: https://cquin.icap.columbia.edu/cquin-covid-webinars/

• Relevant guidelines, protocols, articles, and training materials have been archived on the CQUIN website and additional resources can be found at http://www.differentiatedservicedelivery.org/

• Next week’s webinar – June 9 @ 8am EST: DSD, supply chain and COVID-19: What to expect and how to be prepared?

Useful links and next steps/Liens utiles et prochaines étapes/Links úteis e próximos passos

35

• Les diapositives et les enregistrements de tous les webinaires précédents de CQUIN sont affichés sur le site Web : https://cquin.icap.columbia.edu/cquin-covid-webinars/

• Les lignes directrices, protocoles, articles et matériels de formation pertinents ont été archivés sur le site Web de CQUIN et des ressources supplémentaires peuvent être trouvées à l’adresse suivante http://www.differentiatedservicedelivery.org/

• Le webinaire de la semaine prochaine —9 Juin à 8 heures HNE : DSD, chaîne d’approvisionnement et COVID-19 : à quoi s’attendre et comment se préparer?

• Slides e gravações de todos os webinars CQUIN passados são publicados no site: https://cquin.icap.columbia.edu/cquin-covid-webinars/

• As diretrizes, protocolos, artigos e materiais de formação relevantes foram arquivados no site do CQUIN e os recursos adicionais podem ser encontrados em http://www.differentiatedservicedelivery.org/

• Webinar da próxima semana – 9 de junho @ 8am EST: DSD, cadeia de abastecimento e COVID-19: O que esperar e como estar preparado