Developing and Scaling Delivery of Advanced HIV Disease Services (DDAH) Project

Overview

The DDAH project aims to a) sustain and transition the quality improvement (QI) AHD model in Malawi; b) replicate, optimize, and adapt the AHD model in Côte d’Ivoire; c) generate evidence in Lesotho; d) and enhance and measure impact across the project countries. These objectives are anchored in EGPAF’s strategic approach to AHD programs implementation described below: 

1. Operationalize a comprehensive AHD package of care in alignment with national policies and global best practices. 

EGPAF’s package of care follows the priority actions to reduce AHD-related morbidity and mortality, outlined in the WHO’s AHD guidelines (AHD guidelines July 2017, STOP-AIDS Technical Brief 2020, Consolidated ART guidelines 2021) as well as subsequent, evidence-based best practices. These include several rapid, point-of care diagnostics that allow patients to be diagnosed with AHD more efficiently and allow patients to faster access needed counseling, ART regimen changes, and treatment for opportunistic infections. For example, WHO recently recommended the less toxic, better tolerated single, high-dose regimen of liposomal amphotericin B as part of combination treatment regimen to treat cryptococcal meningitis.3 There is also the recently introduced rapid, instrument-free test that provides actionable results at the point of care, enabling health care workers to rapidly identify people living with AHD. TB is the leading cause of death for people living with HIV. WHO currently recommends shorter, more patient friendly tuberculosis preventive treatments (TPT). For children, in particular, the DDAH project will strengthen pediatric AHD implementation envisioned in the WHO STOP-AIDS technical brief through development of a pediatric AHD toolkit. Pricing; country registrations or inclusion in national guidelines and essential drug lists; and weaknesses in supply chain systems, among other factors, delay availability of these novel innovations and improvements in AHD diagnosis and treatment at clinics. EGPAF supports countries to rapidly adapt these advances in AHD diagnostics, treatment, and implementation approaches. 

2. Strengthen the capacity of sites to adequately screen, treat, and retain clients with AHD through differentiated models of care. 

Care models are needed that fit the precise needs of those presenting with AHD, ensuring that health care workers have the capacity to diagnose, care for, and treat people living with AHD. 

EGPAF supports decentralization of care, including screening, treatment, and prevention, to lower-level health care facilities. EGPAF developed a training package and adopted a package of tools to assist health care workers in identifying AHD, and EGPAF is adapting and delivering differentiated models of care that meet the needs of patients who are presenting or reengaging in care with AHD. These tools ensure that health care workers can effectively use new drugs and diagnostics without overburdening their already busy workload. 

Recognizing that not all aspects of AHD care can be fully decentralized to the primary health care level, EGPAF is supporting a hub-and-spoke model of care. The DDAH project is implemented based on this model, where a differentiated package of services is provided to clients depending on health care facilities’ level and staffing capacity. The project leverages strengthened, bi-directional (upward-downward) referral systems. The project is grounded on continuous QI (CQI) principles, and the health care facilities participate in CQI collaborates spearheaded by health care facilities’ own work improvement teams (WITs). The training and tool packages acknowledge that people living with AHD are at higher risk of loss to follow-up, so intensified, community-based care is needed. Given that comprehensive care for people living with AHD may require laboratory samples and, potentially, clients to move across health care facilities and community levels, EGPAF’s package suggests strengthened communications and linkages between these hub-and-spoke referral networks. 

3. Generate evidence, develop innovative approaches, and facilitate local learning and sharing of best practices for AHD. 

In addition to providing AHD care at its own sites, EGPAF plays an active role in research projects designed to estimate the burden of AHD, project demand for AHD products, and optimize a set of tools and models of care for addressing AHD. EGPAF believes it can leverage successful implementation of innovative diagnostics, drugs, and care management approaches. EGPAF organizes forums to share best practices for AHD within programs and continues to engage in local learning as part of its role as a leader in the global fight against HIV and AIDS.