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Volga River AIDS Alliance Project

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AIHA and AIDS Healthcare Foundation (AHF) developed the Volga River AIDS Alliance (VRA) to support the efforts of Togliatti City and Saratov Oblast to scale-up ART and related care and support to 1,500 PLWH, as well as to institutionalize training capacity in the Volga Region to support future scale-up efforts.


Active from December 2006 through December 2008, the Volga River AIDS Alliance was supported by USAID through its Global Development Alliance Initiative. The project built on the many accomplishments of AIHA’s USAID-funded Saratov/Bemidji and Togliatti/Providence partnerships, which were established in 2004 to create model HIV/AIDS care, treatment, and support programs that could be replicated throughout Russia.


AIHA, AHF, and the Minister of Health of Saratov Oblast entered into formal Memorandum of Understanding during the International AIDS Conference in Toronto in August 2006; the Mayor and the Head of Health Administration of Togliatti City entered into a similar MOU later in the month in Togliatti City, completing the VRA structure. AIHA, with its registered office in the Russian Federation, led the training
components of the project, served as the implementing partner of the development alliance project, and provided on-site operational oversight, monitoring, and reporting. AHF provided expertise in clinic operations and management and professional mentors.


As a direct result of the project’s success and AIHA’s direct discussions with the Ministry of Health and Social Development (MOHSD) and the Russian Health Care Foundation in the case of Togliatti City, both Saratov and Togliatti City were selected as Global Fund regions and received ARVs and other support to scale-up care and treatment to 1,000 and 500 patients respectively.

Through AIHA’s well established coordinative mechanisms with the GFATM-Russia and the MOHSD, the project was fully coordinated and consistent with Russia’s AIDS strategy and served as a model and training site for the entire Volga Region. The project’s Performance Monitoring and Evaluation Plan with outcome and output data and indicators were fully in compliance with the MOHSD, USAID and PEPFAR reporting requirements.


Project Background


Saratov Oblast and Togliatti City in Samara Oblast have high incidence rates of HIV/AIDS and represent primary targets for care and treatment for the Russian Federation and the Global Fund. In 2006 Saratov Oblast had an HIV prevalence rate of 230 reported cases per 100,000. As of February 2004, the Oblast had 6,140 officially registered HIV/AIDS cases, but the actual number of infected individuals was estimated to be as much as five times higher than that.


In recognition of the severity of the problem, Saratov was selected as one of the first 10 Global Fund Round-4 regions in 2005. With Global Fund support, Saratov received ARVs for 1,000 adult patients beginning in late Summer 2006. Togliatti city’s HIV prevalence rate is one of the highest in the country with 1,232 cases per 100,000. As of February 2004, 9,114 of the Oblast’s 21,005 officially registered HIV/AIDS cases were in Togliatti. Experts estimate, however, that the actual number of infected individuals is as much as five times higher than that. By 2006 more than 1,100 infants had been born to HIV-infected mothers and 73 children had been diagnosed with HIV. With the support of AIHA, Togliatti submitted an application to the Global Fund and was selected as one of a second group of a dozen high priority sites to receive funding beginning in 2006. Togliatti received ARVs for 500 adult patients in the spring of 2007.

The availability of Global Fund resources presented significant challenges for Russian medical personnel, who suddenly had a critical need to rapidly expand human resource capacity and replicate, scale up, and further strengthen recently initiated care and treatment programs developed under existing USAID awards to AIHA and URC. AIDS centers in both Saratov and Togliatti were unable to meet the projected service demands and had to initiate the development of decentralized, community-based treatment and care of PLWH through infectious disease specialists at primary level healthcare clinics, which were staffed by specialists who have no experience or training in HIV/AIDS care.


Saratov Oblast chose four replication sites in Engels, Balakovo, Balashov, and Volsk where ARVs were provided at the primary care level. Only in Engels had the AIDS clinic received training and technical
assistance through the existing AIHA-URC project. There was an immediate need to replicate the work done in Engels to the three other sites and to help all four sites develop the capacity to provide HIV management at the primary care level. Togliatti has constrained resources and staffing at the AIDS Center level, therefore there was an even greater need to build capacity at the level of narcology, TB, STI and primary care clinics in the city.


The MOHSD and the Global Fund principle recipient requested urgent support in the key areas of need identified in both Togliatti and Saratov:

  1. Training of care teams, particularly in the introduction and monitoring of ART, TB and HIV co-infection, and adherence for IDUs;
  2. Continuous support to clinical staff through preceptorships, mentoring, and/or ongoing clinical exchanges to assist them to meet the challenges of introducing ART to large numbers of patients over a very short time period;
  3. Developing and implementing organizational models that enable the integration of services, as well as better referral systems and data exchange essential to monitoring quality, adherence, and operational efficiency during scale-up;
  4. Building of indigenous training capacity by integrating and institutionalizing AIHA-developed training programs in the continuous medical education system on a regional basis;
  5. Providing access for care providers to protocols, guidelines, and international evidence-based practice information through the Internet and other resources;
  6. Meeting current gaps in medications and supplies not currently covered by the GF or the Russian MOHSD. While the GF provides ARVs and lab needs for adult PLWH, for example, they do not currently adequately cover pediatric ARVs and drugs for some HIV-associated conditions, such as hepatitis clinical management.


AIHA’s USAID-funded HIV/AIDS partnership program focused on improving staff capacity at AIDS Centers in each VRA city to provide quality HIV care. This was accomplished through skills-based training in various clinical areas, including adult and pediatric ARV, palliative care, TB and HIV co-infection, case management, and social support. The partnerships also provided one-on-one professional training through exchanges to HIV clinics in the United States and onsite mentoring by US partners during exchanges in Russia. As a result, the AIDS Centers now have trained personnel, better tools and skills, and new technologies that enable them to deal with increasing numbers of ART patients.


In addition, the partnerships focused on building HIV awareness and decreasing stigma at the primary care and social service levels by providing introductory HIV and infection control trainings to a wide range of health and allied professional. Hundreds of healthcare workers and other service providers received this training, which helped create a supportive environment at the primary care level for delivery of treatment and support to PLWH. Local AIDS Center capacity for working with evidence-based clinical information has been
strengthened through the establishment of AIDS Information and Learning Resource Centers, as well as the development of local operations management capacity and quality assessment and monitoring tools, including chart audits and a PMTCT database.

As a result of the partnership program, organizational changes for integrating TB, HIV, and narcology services have started occurring in both pilot sites, and administrative decisions have been made to provide coordinated HIV/AIDS services in selected primary care or polyclinic settings. Increased access to social services that are essential to case management and the promotion of high adherence strategies has taken place and a case management system and hiring process for case managers have been established. The VRA leveraged the gains made through the partnership activities described above while also bringing significant new resources and expertise to the scale-up effort in both regions.


Program Goals and Objectives



Key Outcomes and Achievements


At the AIDS Center in Togliatti (1 center) and Saratov Oblast (3 centers) the project helped to:


Within the oblast and city, the project also helped to:



Key Achievements in Saratov


• In December 2006, a Registered Nurse from AHF traveled to Saratov to conduct a preceptorship. Care teams from Engels AIDS Center, Balakovo Rayon Hospital, and Saratov AIDS Center received mentoring and recommendations on HIV treatment and care. The preceptor conducted two days of patient visits together with local physicians.
• Initiation of ART for adolescents and adults training for infectious disease specialists from Saratov region was conducted in December, 2006. US and Russian care providers jointly reviewed patient charts and discussed ARV treatment options and approaches, as well as TB and HIV co-infection management and contraception strategies.
• In April 2007, a US physician/nurse team provided a week-long training for 24 Russian infectious disease specialists from Saratov Oblast, including Balakovo, Engels, and Volsk. An intensive, three-day didactic training on initiation of ART for adolescents and adults was further strengthened by a two-day mentoring on ARV treatment and management, which included clinical case study reviews. American and Russian care providers jointly reviewed patient histories and discussed ARV treatment options and approaches, as well as TB and HIV co-infection management and contraception strategies. The course was held at the Saratov State Medical University.
• A preceptorship was conducted in Saratov Oblast in May 2007. Several care teams from the Balakovo, Engels, Volsk and Saratov infectious disease departments of their respective hospitals took part in the bedside mentoring in palliative care and management of opportunistic infections provided by an international expert from AHF.
• During the preceptor trips, a number of meetings with medical doctors, nurses, and heads of municipal polyclinics were held to define and discuss the roles of the policlinics and the AIDS Center in treatment, care, and support of PLWH.
• In October 2007, a team of a US nurse and a physician provided mentoring sessions for infectious disease specialists at Volsk, Balakovo, and Saratov AIDS Center. In Balakovo, 12 clinical cases were studied at two local polyclinics, a rayon hospital, and a TB dispensary. Local specialists had an opportunity to ask specific questions about cases and share their expertise. In Volsk, the experts visited the Central Rayon Hospital and met with local specialists who are providing counseling for eight patients that are on ARV treatment. Overall, there are 50 PLWH on ARV treatment in Volsk. Specialists from both cities were previously trained through the VRA.
• In April 2008, AIHA conducted an Introductory Pediatric ART for HIV course for care teams from St. Peterburg, Orenburg, Togliatti, and Saratov at the Republican Infectious Disease Hospital (Ust’ Uzhora
Clinical Center for Children and Women with HIV). Russian faculty conducted the training utilizing an international standard curricula adapted for Russia. The lectures and clinical sessions within this course
were based on WHO recommendations for ART for the NIS and focused on a team approach in HIV/AIDS care and treatment in children.
• Onsite Mentoring and HIV and TB Co-infection Clinical Training in Saratov and Togliatti was conducted in May 2008. A team of a US nurse and a physician provided didactic and clinical training to physicians on HIV/AIDS and the associated co-morbidities in Togliatti and Saratov. The first two days were didactic lectures on HIV and TB co-infection and pulmonary medicine in HIV and TB integrated rounds. The remainder of the week was spent visiting polyclinics and performing clinical preceptorships on both inpatients and outpatients. The second week was in Saratov, Russia for clinical preceptorships in the associated polyclinics of Balakovo, Engels and Volsk. A final discussion with the Director of the Saratov AIDS Clinic and medical colleagues was conducted on the last day for program recommendations. Local specialists had an opportunity to ask specific questions about cases and share their expertise. American specialists noted that the amount of clinical knowledge gained over the three years has been very impressive. Not only was this evident in the didactic training in Togliatti but also clear during the clinical case
discussions in both Togliatti and Saratov.


Key Achievements in Togliatti



• In December 2006, AIHA conducted the first clinical training on Initiation of ARV for adults within the framework of the VRA in Togliatti. Twelve infectionists and six nurses from four local policlinics participated in a five-day training. Dr. Heiko Karcher from the Institute of Tropical Medicine and International Health, Charité-University Medicine, Berlin, Germany, and John Marangio, an RN from AHF, facilitated the training.
• In February 2007, AIHA’s field coordinator in Togliatti conducted follow up meetings with nine medical doctors and nurses from four Municipal Clinics. The purpose was to receive feedback on the training on “Initiation of ARV for adults” and evaluate the level of support provided by the polyclinics to the PLWH. Representatives of the polyclinics explained how they communicate with the Togliatti AIDS Center and shared data about patients served in the polyclinic settings: Polyclinic No. 1 serves 624 HIV-infected people, including 6 children; Polyclinic No. 2 serves around 2,000 PLWH; Polyclinic No. 3 serves 847
PLWH; and Polyclinic No. 4 serves 1,333 PLWH.
• In March 2007, AIHA conducted the first round of perceptorships for medical workers from four Togliatti polyclinics that participated in the training “Initiation of ARV for Adults” in December, 2006. Fourteen
medical doctors and nurses from polyclinics and two medical doctors from the Togliatti AIDS Center participated in a five-day mentoring. During the mentoring, 37 patients were seen by the mentors jointly
with the local infectionists and nurses in the policlinics and 15 at the AIDS Center. The mentors initiated a working meeting with TB specialists at the Togliatti TB Dispensary to discuss better collaboration with medical institutions which provide care, treatment, and support for PLWH. More than 20 representatives of the Togliatti AIDS Center, Department of Healthcare, and polyclinics participated in the meeting.
• Advanced ARV training was held in May 2007. Two international experts conducted an advanced course designed to strengthen the capacity of Togliatti PHC clinics to provide ARV treatment and care. Care teams from four Togliatti policlinics participated in a five-day clinical training at the city AIDS Center. After the course, the experts followed up with mentoring sessions to ensure proper application of treatment and care.
• Also in May 2007, the Togliatti Healthcare Department issued an order titled, “Establishment of a Pulmonary Commission” and a resolution calling for the expansion of the AIDS Center staff and modernization of trainings and equipment. The role of the commission will be to review complicated cases of TB among HIV infected patients. The order and the resolution were developed based on the recommendations of the Alliance’s international experts who conducted mentoring sessions in Togliatti and visited the Togliatti City TB Dispensary in March of 2007.
• On June 20, 2007 the VRA/Togliatti Medical Director made a presentation on neurological symptoms in HIV/AIDS patients at the Togliatti Regional Neurological Conference. The presentation was supported by a case study and materials provided by AIHA and AHF.
• In July 2007, a patient satisfaction survey was conducted in Togliatti. The aim of the survey was to evaluate patient satisfaction with services provided at the Togliatti AIDS Center and municipal policlinics. A total of 51 patients on ARV treatment were surveyed. The majority of the respondents (60 percent) had been on ARV treatment under six months while only 8 percent were treated for over 12 months. An
impressive 98 percent of respondents felt that the doctors had sufficiently explained their treatment regimen and 56 percent of surveyed patients thought that ART was effective while the rest did not confirm either way.
• In July 2007, a self-support group for patients that are on ARV was initiated by the Togliatti Department of Social Care as a result of efforts by the previous Togliatti/Providence Partnership and close cooperation with the Department of Healthcare. Twenty participants of the group were provided with free premises for their meetings by the Department of Social Care and informational materials, developed by AIHA.
• In September 2007, a US nurse and physician (Monica Rutherford, RN and Scott Howell, MD, USA) provided mentoring sessions for infectious disease specialists from four Togliatti municipal policlinics and the TB dispensary. With 15 physicians and five nurses in attendance, they reviewed 44 clinical cases and provided patients with recommendations.
• In December 2007, a three-day training for community general practitioners was conducted by local experts on VCT, epidemiology and infectious diseases. The purpose of the training was to educate
community physicians about the epidemiological situation of HIV in Togliatti, prepare them to work with PLWH and follow up with patients on ARV treatment. The community physicians are supporting the
Togliatti AIDS Center and the municipal policlinic’s efforts to provide treatment and care for PLWH.
• In April 2008, AIHA conducted an Introductory Pediatric ART for HIV course for care teams from St. Peterburg, Orenburg, Togliatti, and Saratov at the Republican Infectious Disease Hospital (Ust’ Uzhora
Clinical Center for Children and Women with HIV). Russian faculty conducted the training utilizing an international standard curricula adapted for Russia. The lectures and clinical sessions within this course
were based on WHO recommendations for ART for the NIS and focused on a team approach in HIV/AIDS care and treatment in children.
• In April 2008, another three-day training for community physicians and general practitioners was conducted by local experts on VCT, epidemiology and infectious diseases. The purpose of the training
was same as the training in December of 2007.
• In May 2008, a team of a US nurse and a physician provided didactic and clinical training to physicians on HIV/AIDS and the associated co-morbidities in Togliatti and Saratov. The first two days were didactic
lectures on HIV and TB co-infection and pulmonary medicine in HIV-TB integrated rounds. The remainder of the week was spent visiting polyclinics and performing clinical preceptorships on both inpatients and outpatients. The second week the US team worked in Saratov conducting clinical preceptorships in the associated polyclinics of Balakovo, Engels and Volsk. A final discussion with the Director of the Saratov AIDS Clinic and medical colleagues was conducted on the last day for program recommendations. Local specialists had an opportunity to ask specific questions about cases and share their expertise. American specialists noted that the amount of clinical knowledge gained over the three years has been very impressive. Not only was this evident in the didactic training in Togliatti but also clear during the clinical case discussions in both Togliatti and Saratov.
• Four infectious disease doctors from four local polyclinics and three infectious disease doctors from the Togliatti Municipal AIDS Center consulted with AHF trainers in September 2008. They discussed management of patients with TB and/or Hepatitis co-infection, management of side-effects; necessary medical examinations; thorough counseling/education of patients and various issues related to ART (adherence, side effects, safe sex, etc.). Overall, the visit was very effective and covered all the issues that were needed. The participants appreciated the knowledge and expertise of the American colleges and admitted that much of information was new to them.
• In addition to clinical trainings for medical personnel, five children were provided with the full scope of treatment and care, including ARV drugs and case management services. Fifty adults were provided with
OI treatment and case management services in Saratov. The workplan for fiscal year 2007 included provision of ARV treatment for five children and OI management medications for 50 adults registered at the Saratov AIDS Center. A list of 55 patient names with their diagnosis and treatment regimens was developed and provided to the partners of the project.

 

Unfortunately, due to drug supply regulations and the complexity of donating medication to the Russian Federation, specific medications were not provided for the Saratov patients. At the same time, the Saratov AIDS Center was able to secure appropriate treatment options on the local level and received funding from the regional budget to cover OI management medications, including the 55 patients selected for the project. Provision of the supplies and medications originally intended within the project were therefore ultimately not included in the program.


In September 2008, AIHA completed the VRA initiative that was implemented under the Global Development Alliance and managed jointly with AHF in Saratov Oblast and the city of Togliatti. The Closing Conference was held at the Togliatti Municipal Healthcare Department. Ekaterina Toreeva (Deputy Head, Togliatti Department of Healthcare); Arsen Kubataev (Regional Director of AIHA in the Russian Federation); Dina Rosen (MD, AIDS Healthcare Foundation, Los Angeles, CA, USA); Monica Rutherford (ACRN, AIDS Healthcare Foundation, Positive Healthcare, USA), and heads of Togliatti Municipal Healthcare Institutions took part in the Conference as well as infectious disease doctors involved in the project in Togliatti and Saratov.

Participants of the Alliance presented reports on strengthening the system of treatment, care, and support for PLWH in Togliatti through the implementation of the project. The following topics were presented: the results of patient satisfaction surveys (2007-2008), operational challenges and problems in HIV care system delivery faced by medical professionals before the project started, the interaction between the AIDS Center and municipal polyclinics in management of PLWH, perspectives of practitioners, political will and the commitment
of the Togliatti Department of Healthcare to improve the system of treatment, care and support for PLWH in Togliatti, and outcomes of the project. Journalists representing the local TV channel (VAZ TV), the radio channel (Lada FM), and local newspapers (Gorodskie vedomosty, Togliatti revue) were also present at the Conference.


For additional information, please see the Volga River AIDS Alliance Project Overview (PDF). 



Related Article(s):

Volga River Alliance Project Focuses on Human Resource Development in Russia’s Samara and Saratov Oblasts (Connections, Spring 2007)




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