Link to Newsletter 2: newsletter-2-21jan09.doc

The EU funded INCO DEV 6th framework project ARVMAC is exploring health and health system consequences of the rapid scale-up of HIV treatment programmes, focusing on maternal and child health outcomes related to the Millenium Development Goals 4 and 5. Seven countries and partners participate in the project, all responsible for different research workpackages related to maternal and child health and HIV: policy, access to care, quality and capacity of health services, human resources for health, morbidity and mortality surveillance:

(1) Division of International Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

(2) Makerere University, School of Public Health,Kampala, Uganda

(3) Swiss Tropical Institute, Basel, Switzerland

(4) Ifakara Health Institute, Ifakara and Dar es Salaam, Tanzania

(5) Institute ofTropical Medicine,Antwerp, Belgium

(6) University of Heidelberg, Hygiene Institute, Department of Tropical Hygiene and Public Health, Heidelberg, Germany

(7) The Centre de Recherche en Santé de Nouna, Kossi, Burkina Faso

1. Country News Section
Since the previous newsletter in January 2008, a series of activities have been conducted by all partners. In the Rufiji Health and Demographic Surveillance System (HDSS), under Ifakara health institute (IHI) in Tanzania, as well as the Iganga-Mayuge Demographic Surveillance Site (DSS), under the Makerere SPH Uganda, and Nouna DSS run by the Centre de Recherche en Santé de Nouna (CRSN), Burkina Faso, various effects of the scaling-up of anti-retroviral treatments on health systems as well as maternal and child health was analysed through data collection and analysis of health policy, human resource, quality of care at health facilities and health service delivery, access to care, ART coverage data and demographic vital registration, the latter continuing as part of the regular household surveys in the DSSs. The DSS teams assisted all other partners in their contacts with the local key informants and population surveys and IHI and CRSN also collected data on as part of their own Workpackages (WPs), WP8 vs WP5 respectively. Specifically, the following activities took place in the three DSSs:

Uganda-Makerere University and Iganga-Mayuge DSS
The Iganga-Mayuge DSS in collaboration with Makerere University continued to collect and analyse data jointly with the different research teams focussing on health policy, human resources, health facility, health service delivery and household information. They hosted several international PhD students who collaborated closely with their Ugandan counterparts and helped organize their presentations for sub-PhD specific IRB presentations for ethical clearance. Iganga-Mayuge DSS also hosted a workshop on verbal autopsy coding for physicians held by the Tanzanian team to which Burkina Faso doctors were also invited. The Ugandan team - including key people from the DSS - also participated in the annual meeting for INDEPTH sites in Dar Es Salaam where the ARVMAC teams also met for the annual progress update in September.Centre de Recherche en Santé de Nouna (CRSN) and Nouna DSS
The Centre de Recherche en Santé de Nouna (CRSN) has conducted a baseline survey on geographic coverage and patient flows in Nouna as well as in the other two sites in Uganda and Tanzania. The CRSN team also assisted the other partners in translation of forms, data collection and data analysis. The Nouna team furthermore helped constructing data masks for data entering to standardize data for joint cross-country analysis. The team organised four national workshops in Nouna and Ouagadougou for planning activities and for sharing preliminary findings with local policy makers to keep them informed about the ARVMAC activities and how our findings could be useful for the country. A burden of disease profile for Nouna district for the year 2005 was also established as part of the ARVMAC morbidity and mortality tracking. Tanzania and Ifakara Health Institute, the Rufiji HDSS
The WP 8 team from IHI established internally consistent mortality monitoring methods across the three countries for use in assessing impact trends as ART scales up. Further details for example on a Burden of Disease (BoD) Profiling Tool are described below in the section on measuring the health impact of scaling-up ART. The work on refining verbal autopsy (VA) tools to include more information on HIV/AIDS related conditions continued by training coders on the new tools, awaiting the new standardized VA tool developed by the INDEPTH network together with the WHO. Four other HDSS sites within Tanzania also benefited from this training. Using standardized VA tools will enable comparison between sites and countries. IHI was also responsible for arranging a one-week course in Verbal Autopsy coding in Uganda.2. Work Package News Section
Consortium management (Karolinska Institutet, WP 1)
Under the frame of the annual INDEPTH meeting, for all demographic surveillance sites, the ARVMAC consortium held a meeting on 21 September in

Dar Es Salaam, Tanzania. The meeting allowed us to review and discuss project progress, to conduct the planning of upcoming events and to agree on the publication policy and plans within ARVMAC. The assurance of functioning programmatic and financial reporting structures, which allowed the compilation of the second annual report in December 2008 to the European Commission as well as efficient regular communication mechanisms between partners (monthly telephone conferences, email utilization structures), internal webarchives for joint documents, literature and tools have continued over 2008. Policy analysis of ART scale-up (Swiss Tropical Institute, WP 3)
STI finalized the District Health Accounts tool, and for all three countries i.e.Tanzania,

Uganda and

Burkina Faso completed one round of national policy data collection, one round of district translation data collection, and one round of quantitative district health budgets analysis. Questions focused on the policy environment, processes, networks and actors as they relate to scaling up ART and relation with other policies. For Burkina Faso, two annual rounds of data have been collected allowing in-depth data analysis of the Burkina Faso data to be completed and a draft manuscript has been prepared for publication. Human Resources for Health for ART (

Institute of

Tropical Medicine Antwerp, WP 4)
The focus in 2008 has been on data collection, processing and analysis of human resource for health (HRH) related data at health facility level and on the preparation of the framework and tools for data collection at the national policy level. In parallel the work on country-specific HRH literature reviews continued. In January 2008 the Institute of Tropical Medicine Antwerp organised a joint data analysis workshop together with all European and African partners. Observations and conclusions following the Antwerp workshop could thereafter be integrated into the data analysis. Capacity and integration of health services (Centre de Recherche en Santé de Nouna, WP 5)
Data for 2006 and 2007 on health services and provision of HIV related activities in the DSS areas have been collected to assess health service coverage and patient flows in the study areas. Included in this were quality assessments of the laboratory facilities in the health centres in the DSS areas. The quality assessment involved direct observation of the work place (general environment, work space) samples processing by lab technician; interviews with those in charge of the laboratories and a retrospective assessment of the work done. Quality of health services (Heidelberg University, WP 6)
Data from cross sectional studies focusing on the delivery strategies for Voluntary Counselling and Treatment (VCT) and the Prevention of Mother To Child Transmission (PMTCT) in Burkina Faso, Uganda and Tanzania were analysed. Further activities on the scope and quality of VCT and PMTCT services were conducted, thereby assessed quality of care from different perspectives: sit-in observations, document review, provider and client. One initial finding was that the districts in the three countries vary widely with regard to the ART services. Results are currently being written up and should be available soon.  

Accessibility and equity of health services (Karolinska Institutet, WP 7)
A population-based household survey with questionnaires on care-seeking behaviour for Aids-like symptoms in order to get the denominator of ART need, has been completed in Tanzania (Rufiji) and Burkina Faso (Nouna) and the process of data collection process has begun in Uganda (Iganga/Mayuge). Further, semi-structured interviews were held with pregnant women and HIV positive mothers, exploring barriers and facilitators for their access to HIV testing during antenatal care. Also focus groups were held with men in the community and health providers about their knowledge and attitudes towards HIV testing during antenatal care as well as on barriers and facilitators for access to HIV/AIDS care.

Health impact of scaling-up ART (Ifakara Health Institute, WP 8)
Cause-specific mortality, including mortality due to HIV/AIDS using standard methods, continued to be monitored in the three ARVMAC sentinel districts in Burkina Faso, Tanzania and Uganda. Collection of all vital events, i.e. birth, deaths, pregnancies, in and out migration, socio-economic variables and verbal autopsies (VA) was done. In addition, WP8 conducted VA training on methodology and field practice using the WHO international verbal autopsy (VA) questionnaires and Sample Vital Registration with Verbal Autopsy (SAVVY) tools developed by MEASURE Evaluation. The main aim of this training was to introduce to the participants the international VA questionnaires and to train them on how to conduct and complete VA interviews based on the new VA standards and SAVVY VA tools. All deaths that occurred in the Rufiji HDSS in 2008 have been assessed using this new interview tool.

Dissemination of findings (Swiss Tropical Institute, WP 9)
At the Geneva Health Forum on “Strengthening health systems and the Global Health Workforce” (May 25^th-28^th 2008) we disseminated material with information to other researchers and policy-makers on key features and results of ARVMAC. The following material is available: (*) three A4 posters providing summary information on ARVMAC for use at market places of international conferences; (*) A flyer summarising key features of ARVMAC for distribution among interested parties; and (*) a PowerPoint slide presentation for use at conferences.

January 2008

The EU funded INCO DEV 6th framework project ARVMAC is exploring health and health system consequences of the rapid scale-up of HIV treatment programmes, focusing on maternal and child health outcomes related to the MDGs 4 and 5. There are seven participating partners in the project:

(1) Division of International Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

(2) Makerere University, Institute of Public Health Kampala, Uganda

(3) Swiss Tropical Institute, Basel, Switzerland

(4) Ifakara Health Research and Development Centre, Dar es Salaam, Tanzania

(5) Institute of Tropical Medicine, Antwerp, Belgium

(6) University of Heidelberg, Hygiene Institute, Department of Tropical Hygiene and Public Health, Heidelberg, Germany

(7) The Centre de Recherche en Santé de Nouna, Kossi, Burkina Faso

1. Country News Section

Uganda
From 19th- 23rd February 2007, the ARVMAC project Consortium conducted an international workshop to officially launch project activities, clarify leadership responsibilities, refine project methodology and strengthen the relationships between the seven collaborating institutions. This workshop brought together 39 participants from all participating institutions. Seven countries were represented. Makerere University Institute of Public Health and the Iganga /Mayuge Demographic Surveillance Site were responsible for the Project Launch Workshop and hosted the event.
Burkina Faso
A national launch meeting was held on 16th May 2007 in Ouagadougou, Burkina Faso. The workshop was organized by the National Center for Research in Nouna and introduced the scope and research activities to interested parties. The workshop was attended by a broad spectrum of stakeholders involved in the control of the HIV/AIDS epidemic in the country: the Permanent Secretary of the national committee for the fight against aids, officials from the Ministry of Health, training centers, multilateral and bilateral partners, NGOs, officials from Association for the fight against AIDS and lastly some professional organizations (midwives, paediatricians, obstetricians).

Tanzania
On 26 October 2007, the national launch workshop was organised in Dar es Salaam by the Ifakara Health Research and Development Centre. During the one day event the objectives and the planned activities were presented to a wide spectrum of persons and institutions attending the event. Emphasis was given to key issues under study such as how the Ministries of Health are coping with the human resource crisis in the frame of the AIDS epidemic and how the new funding for example through Global Health Initiatives potentially may provide an opportunity to strengthen health systems. The launch workshop was attended by representatives of the Ministry of Health, research institutions, NGOs and bi- and multilateral agencies.

2. Workpackage News Section

Workpackage 1. Consortium management
Functioning programmatic and financial structures, which allowed the annual reporting in December 2007 to European Commission as well as efficient regular communication mechanisms between partners (telephone conferences, email utilization structures) have been in established in 2007. Further, a consortium agreement between partners as well as on publication guidelines were elaborated and agreed.

A project website accessible to the public is available at www.arvmac.eu
Workpackage 2. Project launch
The international launch workshop was conducted in February 2007 in Uganda. For further information, please see above in country news section.

Workpackage 3. Policy analysis
A literature review of all documents relevant to the scaling up of ART including both peer reviewed and grey literature was done in 2007 to assemble and synthesize the global evidence and global policy positions. This was used to define important issues to follow up in the countries. The number of references from peer-reviewed and grey literature potentially relevant to the subject and currently included in a reference database is 882. Of these, a selection of 63 more recent and relevant documents was used to conduct a review of the international and national literature and documents relevant to ART scale-up in the three study countries. In order to share this documentation on-line with all ARVMAC collaborators, an Internet-based archive was set up to structure, archive and disseminate documents and information relevant to the ARVMAC administration, country studies, sentinel districts and workpackages. In September and October 2007, the policy analysis baseline field work was conducted in Burkina Faso.

Workpackage 4. Human Resources for Health
In June 2007, the field-testing of the methods and tools on human resource related issues was carried out in Iganga, Uganda. The field-testing provided many insights regarding the applicability of the instruments and led to substantial revision. Subsequently the first data collection phase has been initiated in Uganda in November/December 2007.

Workpackage 5. Capacity and integration of health services
Research questionnaires were finalized and baseline data collection on Mother and Child and HIV services has been completed in Nouna and Iganga sites and is ongoing at Rufiji. A laboratory control quality protocol is currently being developed and a protocol for HIV quality control has been finalized.
Workpackage 6. Quality of health services
A cross sectional study focusing on the delivery strategies for Voluntary Counselling and Treatment (VCT) and the Prevention of Mother To Child Transmission (PMTCT) in Nouna, Burkina Faso was conducted in May and June 2007. The survey used both quantitative and qualitative methods and indicated that PMTCT and VCT services are generally available. Various specific elements in relation to these services were studied in more detail. Complementary activities on the scope and quality of VCT and PMTCT services in Iganga and Rufii have also been conducted.

Workpackage 7. Accessibility and equity of health services
A situation analysis on the accessibility and equity of MCH and HIV/AIDS related health services was performed through a review of literature, existing guidelines, policies and programmes. Focus group discussions and in-depth interviews with men and women of different age groups in the study sites in Uganda (Iganga-Mayuge DSS) and Tanzania (Rufiji DSS) were performed to explore knowledge, perceptions and beliefs around HIV/ART. This was complemented by a study exploring barriers and enabling factors for access to MCH and HIV care in Tanzania. In late 2007, a large household survey with questionnaires on care-seeking behaviour for HIV/AIDS symptoms and care-seeking behaviour during pregnancy, including antenatal clinic (ANC) attendance, has been started in Tanzania and Burkina Faso and will continue in Uganda during 2008.

Workpackage 8. Health impact
Internally consistent mortality monitoring methods across the three countries and base-line data for trend analysis were established in 2007. Consequently it is now possible to monitor cause-specific mortality, including mortality due to HIV/AIDS using standard methods. These data are available for all three ARVMAC sentinel districts in Burkina Faso, Tanzania and Uganda for the years 2006 and 2007. This information will allow assessment of impact and trends as ART scales-up. In collaboration with WP3, analytic tools for burden of disease analysis were developed and disseminated to all sites in a training workshop in June 2007.

3. Announcements
ARVMAC Data Analysis Workshop

This internal workshop from 28 January to 1 February 2008 in Antwerp, Belgium, will focus on the processing of the data, and related issues such as data presentation, analysis, triangulation.

Geneva Forum: Towards Global Access to Health

In the period 25 to 28 May 2008, the second forum will take place and focus on “Strengthening Health Systems and the Global Health Workforce”. For further information consult:

http://genevahealthforum.hug-ge.ch

Abstract can be submitted up to 15 January 2008 at:

http://genevahealthforum.hug-ge.ch/abstract_themes.html
For further information please contact:

Anna Mia Ekström, MD, MPH, PhD

Scientific coordinator

Division of International Health, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden

anna.mia.ekstrom@ki.se