A multidisceplinary team for management of patients with HIV in kingdom of Bahrain
Ministry of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Globally, an estimated 35.3 (32.2–38.8) million people were living with HIV in 2012. An increase from previous years as more people are receiving the life-saving Antiretroviral therapy. There were 2.3 (1.9–2.7) million new HIV infections globally, showing a 33% decline in the number of new infections from 3.4 (3.1–3.7) million in 2001. At the same time the number of AIDS deaths is also declining with 1.6 (1.4–1.9) million AIDS deaths in 2012, down from 2.3 (2.1–2.6) million in 2005. The kingdom of Bahrain is a country in the Arabian Gulf; it has a population of 1,234,571. Since the beginning of the HIV epidemic, there has been strict screening program for HIV. In Bahrain there are currently 238 HIV patients living .The services that where given to the HIV patients were fragmented between primary care, secondary care, laboratory and the public health laboratory. There was no structured program to care of these patients. Proper follow up was difficult with missing appointments and hard to get labs to monitor their progress as the lab results where run between different labs. Most of these patients were followed in the primary care health centers and were followed by a family physician. There is a good registry of all the patients who were positive and the data was closely monitored by the public health department. There have been several initiatives to improve the service without good results. As per the reconditions internationally of the UNAIDS is to have 90% diagnosed, 90% on treatment and 90% controlled. So we are aiming in this committee to achieve this goal; within the next two years. We started in 2012 with only 39 patients on treatment currently we have 120 patients on treatment and we are calling through the public health for the rest of the patients. So the main problems were : 1. fragmentation of services 2. very low rate of HIV patietns on treatment 3. very mow rate of controlled HIV patients on medications 4. high rate of stigma 5. not reaching the patients needed to be on treatment : homeless, female, poor 6. high rate of inpatietns admission and mortality

B. Strategic Approach

 2. What was the solution?
The initiative is 1. Meeting the new vision of the United nation, 90/90/90 foe hiv 2. Reaching all hiv patients and provide the best treatment possible 3. Decreasing stigma about hiv HIV care committee started on Jan-2012, under care of Dr. Jameela Al-Salman (chairperson of the medical Department). The committee consists of eight members:  (Chief of HIV Care Committee),  (Consultant of the pathology / Microbiology SMC medical lab),  (Public health consultant-Head of communicable diseases group),  (ID Doctor),  (ID Doctor),  (Head medical Technologist),  (Pharmacist Technician),  (Staff Nurse/HIV Coordinator). This committee worked to provide helps to the HIV patients, reduce the mortality, and follow up with the patients their treatment and investigations. The importance of the committee is to solve patients’ problems, ease their treatment, and reduce the cost of their treatment. Purpose of the committee:  Encourage other members from another department to cooperate and work together for easy and faster treatment.  Reduce stigma for HIV patient. The change: IN 2012, a multidisciplinary team was established for HIV management involving major stakeholders: public health, infectious diseases, pharmacists, nursing and virologists. The team established a system which capture each step of patients care to improve its quality. It was established by under a higher authority in the secondary care. This team meets regularly, where we started with putting an action plans to form an integrated system to provide the best care for these patients. The main objectives of this team were the followings: 1. To structure a program which optimize the patient journey. 2. To capture all the positive Bahraini patients and to improve their compliance 3. To introduce up to date new HIV medications 4. To implement the international guidelines for HIV management 5. To create and follow quality indicators that can measure the progress of the team work. We started collecting the basic data which involved the followings: 1. First form: The demographic information about the patients, their risk factors, their progress and response to treatment and their follow up, their prevention protocol. 2. The second form include the serial of their blood tests specifically, HIV viral load, CD4 count and the genotyping. 3. Third form: Lists form the pharmacy where we assigned one pharmacist to look after these patients, where we get an updated list of the patients with their medications and if they missed taking them to call them urgently to ensure compliance. We assigned a Nurse coordinator for the HIV service and who overlooks the whole process of data collection, entering and providing patient support services These data were entered in a soft copy excel sheets to analysis the data. The data were followed up closely and discussed in regular meetings. Over the same period we introduced new and updated HIV medications to increase the response rate to HIV medications. At the same time they were a lot of educational services provided to the staff. We are in the process of publishing patient educational materials. A software database was established to include all patients: to record their visits, labs results, clinical progress, medications regimen and their appointments to flag missed ones. Objective of the committee: a) Improve the quality of patients care. b) Provide social base and social support. c) Provide the best care to the HIV patients. d) Provide the medication as patient needs. e) Provide the needed lab test. f) Provide routine visit to the patients in the clinic. g) Access to health care system h) Decrease stigma about hiv among health care workers and community

 3. How did the initiative solve the problem and improve people’s lives?
In general we were able to : 1. identify all patients who are currently living with HIV in the country and improve the data base and all the statistics 2. we created a data base for all patients with all the blood work including viral load, CD4 count and their treatment and the response to treatment and the risk factors 3. increase the rate of HIV patients accessing health care system and maintained on treatment 4. worked on decreasing HIV stigma through extensive workshops and educational session for all health care workers 5. providing the best treatment 6. we smoothed the service we are providing for all HIV patients as it was very fragmented between primary care, public health , secondary care , laboratory , and pharmacy 7. increased the compliance by calling the HIV patients 8. decreased the rate of in patients and mortality of HIV patients 9. in addition to the workshops , a yearly symposium is being done for the update in the care of HIV to include all health care workers The program structure was reviewed regularly to optimize our services. We have a great success over the last three years where we started with uncontrolled 40 patients on medications. Now, most of patients 90/94 on treatments have good results. The reminder is being tracked to start their treatment. Up to this date: we are following, 115 patients 98 of them are on regular medications. In regard to the viral load, up to this date, 30.out of 125 patients were undetectable (30%), and now after two years 49 patients out of 115 (42.6%). Achievements of the HIV care committee:  Stigma training trainer Workshop.  Trained around 300 staffs.  Provide the medicine, and replace some medication which is not effective.  To follow the blood tests and provide the best medical management for the patients and adjust the medication.  Involve the public health  Collect all the information about the patients’ medicine, CD4%, CD4 count and genotype it is make easy to follow patients’ care.  Provide a team work system for the best care of the patients  Side effect of the medicine is less.  No repetition to the expensive blood test, as was happening in the past as it is monitored and regulated by the coordinator.  Improvement in the patients lab result. As at least half of the patients are controlled with undetectable viral load with the new system.  Reduce the rate of mortality.  Decrease the number of inpatient  Increase the average of HIV patients’ age.  A complete and regular Meeting and minutes.  Brochures with information about the medications (under print). Increase the quality of the HIV care in Bahrain to be a unique model for the countries Statistics: This is a statistic of HIV patients according their age and gender: GENDER NO TOTAL FEMALE 21 90 MALE 69 AVERAGE NO TOTAL 11_20 2 90 21-30 5 31-40 23 41-50 21 51-60 28 61-70 10 71-80 1 Figure (4) shows statistics according the lab test: CD4 COUNT <200 23 TARGET NOT DETECTED 23 CD4 COUNT 200-300 19 V.LOAD <75 9 CD4 COUNT >350 50 HIGH LEVEL 44 NOT DONE 2 NOT DONE 18 TOTAL NO. OF PATIENTS 94 TOTAL NO. OF PATIENTS 94

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The initiatives is creative and innovative in the following ways : 1. the multidisplianry approach and getting the concerned parties from different sections and departments to work together and avoid the fragmentation which negatively affect patients care 2. creating a tailored database to accommodate our needs and the types of services we provide 3. to work in decreasing stigma through continuous educational programs 4. the follow up closely of all patients and ensure that they attend their appointments and take their medications and call them to ensure that 5. the ability to follow the international guidelines in the management of HIV patients with the limited manpower in experts in physicians trained in HIv care

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The program is implemented by the HIV team and the infectious disease unit in Salmaniya medical complex The people benefited from the program are 1. directly : all hiv patients living in Bahrain (238) 2. indirectly : And it extends to all at risk group such as IV drug users , pregnant ladies ( we have zero maternal-fetal transmission ) homeless and teenagers , though increasing the awareness among the public to decrease the rate of new hiv patietns 3. The health care workers also benefited by increasing their knowledge through all the educational activities conducted : as we have educated a large number of staff as part of the program
 6. How was the strategy implemented and what resources were mobilized?
The action plan for the program was as follow 1. creating the team of the concerned parties 2. several initial meetings to set the timelines and the objective of the team to concentrate on the steps further 3. the main parameters that we concentrated are : - creating the data base to know starting with how many patients we have to manage - creating the database for the high risk group to direct the educational sessions - involving all the concerned parties to smooth the services among the different sections - the medications and their availability - the access of care for all hiv patients through getting their contacts and give them reminders and to call them as needed - the availability of the laboratory services for all patients and to get the results on a timely manner - the guideliens for treatment to update them - training the health care workers in the treatment of HIV - the stigma of HIV among health care workers and the public - the educational sessions , what types and how often and what are the target groups 4. based on the above parameters , we had regular meetings to address each point and work on it: - created several formats for the database based on our types of services that has been changed several times - regular meeting with the concerned and to provide links between all the services and how to put it all in one stop for the patietns and one center to receive all the care they needed and that needed a lot of change if the previous existing services - a lot of working has been done in changing the previous list of medications and provide new lists with a higher rate of compliance and less side effects despite budget limitation, we have close monitoring of all the patients on medications - the access of care for all HIV patietns especially the homeless , prisoners , females , teenagers and the poor ; with continous efforts from the team to follow up these patients and call them as needed - the laboratory services has been smoothed as we had earlier a lot of problems in getting blood work , getting results and their availability at the time of follow up , but now with assigned nurse coordinator we are getting the labs as she following all results and documents them - a lot of work has been done to decrease the stigma through a large number of educational sessions , workshops , symposium and educational materials - training health care workers form different background in the care of HIV patients 5. all the above steps have been part of the actions plan for 2012-2017 in regard to the sources needed : it was basically manpower form all different parties no financial resources needed , actually there was saving as a lost of loss because of repeated lab unnecessary , failure of treatment with consequences of complications , morbidity and mortality and inpatients admissions

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The main stakeholders are from :physicians, nurses, pharmacists , public health , virologist  (Chief of HIV Care Committee),  (Consultant of the pathology / Microbiology SMC medical lab),  (Public health consultant-Head of communicable diseases group),  (ID Doctor),  (ID Doctor),  (Head medical Technologist),  (Pharmacist Technician),  (Staff Nurse/HIV Coordinator). All the educational sessions were with the help of NGOs

 8. What were the most successful outputs and why was the initiative effective?
Results: The program structure was reviewed regularly to optimize our services. We have a great success over the last three years where we started with uncontrolled 40 patients on medications 65 patients are males and the rest are females. Age range from 11 to 74 years old. 23 patients have CD4 count < 200, 19 patients between 200 - 350 and 50 patients above 350. 35 % have undetectable viral load. (The time of abstract submission). In regard to the viral load, up to this date, 30.out of 125 patients were undetectable (30%), and now after two years 49 patients out of 115 (42.6%). Achievements of the HIV care committee:  Stigma training trainer Workshop.  Provide the medicine, and replace some medication which is not effective.  To follow the blood tests and provide the best medical management for the patients and adjust the medication.  Involve the public health to follow patients’ lab test and prepare the result as soon as possible.  Train a number of doctors to follow the patient medication and lab test and best practical guidelines.  Collect all the information about the patients’ medicine, CD4%, CD4 count and genotype it is make easy to follow patients’ care.  Provide a team work system for the best care of the patients  All the team from each department working together, to make easy treating the patient.  Side effect of the medicine is less.  No repetition to the expensive blood test, as was happening in the past as it is monitored and regulated by the coordinator.  Improvement in the patients lab result. As at least half of the patients are controlled with undetectable viral load with the new system. This in oppose to the past were they were rarely controlled.  Reduce the rate of mortality among the HIV patients.  Decrease the number of inpatient admission to the HIV patients over the last three years.  Increase the average of HIV patients’ age.  A complete and regular Meeting and minutes.  Brochures with information about the medications (under print).  Increase the quality of the HIV care in Bahrain to be a unique model for the countries. GENDER TOTAL FEMALE 90 MALE AVERAGE TOTAL 11_20 90 21-30 31-40 41-50 51-60 61-70 71-80 CD4 COUNT <200 23 TARGET NOT DETECTED 23 CD4 COUNT 200-300 19 V.LOAD <75 9 CD4 COUNT >350 50 HIGH LEVEL 44 NOT DONE 2 NOT DONE 18 TOTAL NO. OF PATIENTS 94 TOTAL NO. OF PATIENTS 94

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles that we faced were : 1. not enough manpower and infectious disease specialists to cover the needed tasks 2. the HIV stigma not only in the public but also among the health care workers which was very hard to overcome 3. getting all the stakeholders on the same team despite personal preference or departments or sections interests or plans 4. being able to conduct all these educational sessions within the limited time for the plan

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Answer: The key benefits were the followings: 1. decrease the rate of hospital admissions for HIV patients , we measured by calculating the rate 2. decrease the rate of HIV patients mortality , we measured by comparing the rates over the last few years since we started the program 3. decrease the stigma against Hiv patients 4. increase the rate of HIV patients accessing the care from around 10 % to 85% 5. increasing the rate of patients on treatment from around 10% to 55%. 6. Increasing the access of HIV patients who are homeless , IV drug users , patients with social problems and females 7. Decrease the rate of newborn that encounter HIV from the mother ( zero for the last couple of years )

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
As we stated in the main problem why this project was initiated is : 1. the HIV patients were not followed as they were suppose to and they were lost between different sections and departments in different places and different location 2. they were managed by family physicians not specialized infectious disease consultant which compromised the quality of care 3. they has to do different lab tests in different locations and facing different health care workers which breaks their confidentiality specially in a small community like Bahrain 4. their lab results were lost in different systems were a lot of time we needed to repeat the same tests several times . a lot of waste 5. the medications available were not up to standards , were we worked hardly to get the best quality of medications 6. in the pharmacy there is only one pharmacist who provide the medications for the patients to decrease the breaking the confidentiality and ensure the compliance and their trust in the health system 7. the HIV patietns they have to only attend one center for the care they needed instead of being scattered , which was reflected in better compliance and trust this great impact was measured by the increase in the rate of attending the clinic and the compliance with medications and better results of their response to treatment

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
in regard to females and young girls ,and most vulnerable we were ensuring the foloings : 1. antenatal HIV and other STds during pregnancy which is available in all local health centers 2. premarital testing and counclling regarding HIV and other stds 3. high rate of confidentiality after the testing and the results are only reported to the ID physicians taking care of HIV patients ( which is only one physician) and were the clinic is labeled as general ID clinic 4. we have a female nurse coordinator who communicate with them easily as one to one rate 5. calling them as needed to ensure compliance with medications and no side effects 6. offering and doing the HIV testing in centers treating ID drug users and for prisoners and offer treatment as needed 7. provide the social services and support for all the above group as needed

Contact Information

Institution Name:   Ministry of Health
Institution Type:   Ministry  
Contact Person:   Jameela Al salman
Title:   Head of HIV management team  
Telephone/ Fax:  
Institution's / Project's Website:  
E-mail:   l.talal@pmc.gov.bh  
Address:   P.o box 12 manama
Postal Code:  
City:   Manama
State/Province:  
Country:  

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