Volga River AIDS Alliance

AIHA and AIDS Healthcare Foundation (AHF) implemented the Volga River AIDS Alliance from December 2006 through December 2008. This public-private partnership was designed to scale up primary level care and treatment for PLHIV in Russia’s Samara and Saratov oblasts. It was supported by USAID through its Global Development Alliance Initiative.

The project built on the many accomplishments of AIHA’s USAID-funded partnerships linking institutions in Saratov with a community-based health consortium in Bemidji, Minnesota, and health facilities in the Russian city of Togliatti with counterparts in Providence, Rhode Island. Both these partnerships were established in 2004 to create model HIV/AIDS care, treatment, and support programs that could be replicated throughout Russia.

As the implementing partner, AIHA led the training and monitoring and evaluation components, while AHF provided expertise in clinic operations and management, as well as professional mentors and faculty.

The Volga River AIDS Alliance’s capacity building strategy focused on clinical training and mentoring for primary level infectious disease specialists, HIV/AIDS care teams, and general practitioners.

Clinicians underwent rigorous, comprehensive training that prepared them to accurately assess the condition of HIV-infected patients, initiate and manage antiretroviral therapy, and diagnose and manage opportunistic infections that commonly afflict people living with HIV or AIDS. The project provided additional training on topics such as case management, establishing an effective referral system, and palliative care.

The Volga River AIDS Alliance project also conducted “HIV 101” courses designed to give community-based and primary care practitioners an accurate overview of the disease and the epidemic in their region, and to strengthen their patient communication and counseling skills. These courses helped combat stigma and discrimination while at the same time arming a larger healthcare workforce with the knowledge and skills they need to assist Russia’s efforts to combat HIV/AIDS.

With an eye toward the future, AIHA and AHF worked with regional health authorities to build institutional training capacity within the Volga region to support ongoing capacity building efforts beyond the funding period of the Volga River AIDS Alliance project.

Key Outcomes

This project helped the Togliatti AIDS Center and three AIDS centers in Saratov Oblast to:

Establish new management systems based on operational efficiency and improved clinical outcomes;
Improve the case management system by using an integrated disease management model;
Establish AIDS Information and Learning Resource Centers with internet connectivity to further expand access of health professionals to evidence-based information;
Develop in-patient palliative care units and provide caregiver training in palliative care and pain management for AIDS patients;
Provide essential opportunistic infection prophylaxis and treatment and build clinical capacity in the management of infections, including PCP, fungal (candida), and viral (CMV, herpes);
Address immediate challenges related to the provision of pediatric ART, namely lack of GF support for pediatric ARVs and the fact the national program only provides several drugs that cannot be combined in regimens and has not made public any plans about provision of pediatric ARVs in the future; and
Address the Hepatitis B and C co-infection issue and look into ways of providing direct support.

Key activities 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. U.S. 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 U.S. 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 polyclinics and the AIDS Center in treatment, care, and support of PLHIV.
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 PLHIV on ARV treatment in Volsk. Specialists from both cities were previously trained through the project.
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 activities 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 PLHIV; Polyclinic No. 3 serves 847 PLHIV; and Polyclinic No. 4 serves 1,333 PLHIV.
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 polyclinic’s efforts to provide treatment and care for PLHIV.
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 PLHIV 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.