Archive for December, 2009

GOROKA GENERAL HOSPITAL
PAEDIATRIC Department

PAPUA NEW GUINEA DELEGATION TO THAILAND

Paediatric HIV care, Community Network and Paediatric HIV Quality Improvement Program

Just recently in October 2009, I returned from a trip to Thailand where I along with my team mates were able to observe first hand the Paediatric Programme in Bangkok and at the Chiang Rai Regional Hospital.

Forward

The first HIV case in PNG was diagnosed in an adult in 1987.After the first case of HIV was detected in 1987, the number of HIV infections has increased drastically. In 2004, Papua New Guinea became the fourth country in the Asia-Pacific region to declare a generalized HIV&AIDS epidemic. As of 2008, it has the highest HIV prevalence in the Asia-Pacific region at 1.5%. Cases of HIV from Papua New Guinea in turn constitute an increasing proportion of the total cases detected in the Pacific-from 21% of all cases in 1984-1989, to over 98% in 2005-2007. This upwards trend is expected to continue in coming years. (NACS, 2008)

Paediatric HIV has been a long overlooked area of the National HIV Program, although childhood HIV is a preventable disease. The neglect has been particularly due to the focus of the National Aids Council and NDOH on the adult population by promoting preventative aspect of HIV by promoting Abstinence, Faithfulness and the use of Condom. This is more directed to the adult population. The prevention of HIV from passing from an infected adult female to the unborn child through administration of anti-retroviral drug has not been promoted as much by NACS and NDOH as a major preventative option to the unborn child.

Because of the lack of knowledge and experience of care givers and policy makers, Paediatric HIV programs failed to prevent vertical transmission (PMTCT), find and treat children infected with HIV with the consequence that morbidity and mortality for HIV infected children has been very high.

The study tour visit to Thailand to view the health system structure, the Paediatric HIV program coupled with the discussions held with the Paediatric HIV Program implementers has really helped us the PNG contingent to view our own deficiencies and we feel that now we are in a better position to improve our own PMTCT and HIV / ART programs for the children infected with HIV.

We would like to thank the following individuals and organizations for contributing significantly to the study tour: the World Health Organization (PNG) for sponsoring the trip, NDOH Secretary and HIV/STI Team for finding faith in the team and selecting us and the Thailand Ministry of Public Health – United States Center for Disease Control Collaboration (TUC) for organizing the logistics. We also would like to extend our gratitude to the TUC staff especially Dr. Rangsima Lolekha, Ms. Thananda Naiwatanakul and Ms. Worawan Faikratok for their undivided commitment and support to help us understand the concept of PMTCT and Paediatric HIV / ART programs in Thailand. We also really appreciated the discussions we had with the doctors of the respective regional, provincial and community hospitals. Professor Kulkanya and Dr Rawiwan Hansudewechakul of Siriraj Hospital and Pan Hospital respectively were very inspirational.

The experience has motivated all of us to have a positive view on childhood HIV programs. Depending on the circumstances all of us have decided to report to the respective organizations our activity in 6 months time.

Figure 1: The PNG Participants

Participants (from left to right):

1. Dr. Mary Bagita (Obstetrician & Gynaecologist PMGH: In charge of PPTCT in PMGH)
2. Team Leader Dr. Harry Poka (Paediatrician Kundiawa: Paediatric Tuberculosis focal person for PNG)
3. Dr. Paul Wari (Paediatric Registrar Goroka Base: In collaboration with Clinton Foundation/Paediatrician, oversees the Paediatric portion of the PPTCT program in Goroka)
4. Sr. Veronica Kalebe (Paediatric Nurse employed by the Clinton Foundation and works at the PMGH Paediatric unit specifically manages the HIV infected children)
5. Mrs. Esther Kawang ( Health Extension officer at the Angau Memorial Hospital)
6. Sr. Wendy Kunal Aiwa (Antenatal Clinic Nurse of PMGH and employed by the Clinton Foundation: practices PPTCT in the antenatal clinic and labour ward)

Purpose of the Training

1. To learn about a community-based Paediatric HIV treatment and care network model in Thailand
2. To learn Paediatric HIV quality improvement program HIVQUAL-T Model in Thailand.
3. To visit Paediatric HIV treatment and care clinic and discuss with Paediatric infectious disease physicians in Thailand
4. To discuss and plan for adapting the Paediatric HIV care community network and Paediatric HIV quality improvement program in PNG.

Travel and Transportation

The participants (see figure 1) congregated at the Port Moresby Jackson’s International Airport on the 3rd of October 2009. After a short briefing with Ms Doris Kedea of WHO (PNG) at 1400 hrs, we checked in for Air Niugini direct flight to Manila. We arrived in Manila International Airport safely. After customs clearance we seek the WHO Help Desk in the airport. From there, the WHO van picked us up and transferred us to the Euro Apartments were we spent the night. On the 4th of October the next day at 0800hrs we were picked up by the WHO van and transferred to the manila International Airport. We board the Philippines Airlines flight to Bangkok International Airport. The Windsor Hotel shuttle bus transferred us to the hotel.

The travel within Thailand to the different sites of training was very well organized and timely. All in all our travel was uneventful thanks to the WHO (PNG) and especially the Thailand based CDC (South East Asian Headquarters) logistic officer.

Study Fellowship Program Component

Our study fellowship tour consisted of two parts:

The first part was based in Bangkok Metropolitan Area

1. TUC: Overview of pediatric HIV care community program / quality program
2. Visit to Bamrasnaradura Hospital, the National Infectious Disease Hospital of Thailand.
3. Visit to Paediatric HIV Clinic at the Siriraj Hospital
4. Site visit to Klong Luang Community Hospital

The second part was based at Chiang Rai, the northern most region of Thailand

1. Site visit to Chiang Rai Regional Hospital. This hospital has a very effective Paediatric HIV Care Community Network and Paediatric HIV Quality Improvement Program and is in-fact the leader in the HIVQUAL-T program in the Western Pacific Region
2. Site visit to the Pan Community Hospital.
3. Site visit to a Health Centre

Siriraj Hospital which is an hour’s drive from Bangkok CBD. This hospital is a University Hospital and is the biggest in Thailand, it has 72 buildings (See figure 2: Siriraj Hospital building complex as indicated by the box). Since it was built by the King of Thailand it is also called the “Hospital of the Kingdom.” It has 2,500 beds, of which 350 beds is allocated for pediatrics.

At the Siriraj Hospital we had a very informative and stimulating session with Professor Kulkanya who highlighted four effective strategies to Prevent Mother to Child Transmission which were:

1. Pregnant HIV mothers should be administered ART in addition to OI prophylaxis
2. ART should be administered to the neonate for PEP. More ART treatment is needed if mother received less treatment
3. Elective caesarean section and
4. No Breast feeding (but if needed, exclusive BF is helpful. Here we learnt that the Thailand Government provides formulae feeds for free to all babies of HIV infected babies. Thus the practice was all expose babies are put on formulae feeds as well as co-trimoxazole prophylaxis from birth.)

Figure 3 – Map of Thailand

From Siriraj Hospital we departed to the Bangkok International Airport and Boarded a flight to Chiang Rai (see figure 3 courtesy of Dr Rawiwan Hansudewechakul) the Northern Most Region of Thailand. Our Hotel Van took us from the Chiang Rai International Airport to the Wangcome Hotel.

On Wednesday the 7th of October, the third day of our visit, we were fortunate to visit the Chiang Rai Regional Hospital. This hospital under the leadership of Paediatrician Dr Rawiwan Hansudewechakul has a very effective and efficient community network system for Paediatric HIV care. Their Paediatric HIV activities are oriented towards improving the adherence to the ART. The hospital is taking the lead in this program. The processes of establishing a well functioning Paediatric HIV program with a good ART adherence rate of 95% and above were basically the following:

1. The hospital adopts best practice in the area of PMTCT and Paediatric HIV
2. Good leadership (Dr Rawiwan herself)
3. Make the system work by drafting policies and guidelines according to the recent available research updates
4. Attitude to work is highly maintained in the team. Workers have good work ethics; they all have a good heart.
5. Hospital mobilizes its staff to form a Paediatric HIV team that consisted of the following
6. Nurses: take history, prepare all documents / records of HIV infected children
7. Pharmacist: provide medicine, check adherence
8. Paediatrician: physical check up, prescribes ARV and medicines for OI
9. NGO / PLHA: do home visits, does pill counts etc

Each of the above staff has specific responsibilities clearly spelt out and they perform their job really well as such there is sharing of workload and everyone enjoys their job.

Once the hospital based PMTCT and Paediatric HIV program organization, structure , policies and procedures are up and running well, then the hospital goes to the next level which is to bring in the health workers from health centers and rural hospitals (known as community hospitals) into the hospital and conduct on-the-job training for them in a day. These community hospital staff feels motivated and have ownership of the programs. After the on-the-job training the Chiang Rai Regional Hospital then refers the Paediatric HIV patients back to the community hospital for follow up and continuation of care is maintained.

These above activities has enabled very good adherence rate (see figure 4 courtesy of Dr Rawiwan Hansudewechakul). Due to their effective PMTCT program which was started in 1997, the vertical transmission rate in PMTCT at the Chiang Rai Hospital has been zero for the past two years (see figure 5 courtesy of Dr Rawiwan Hansudewechakul).

On the 8th of October 2009 we were privileged to visit the Pan Community Hospital in Chiang Rai (equivalent to a rural hospital in PNG). The pediatric HIV care and pediatric HIVQUAL – T are embraced and applied very well.

Several things that stand out were;

1. There is a very good relationship between the Paediatric HIV team (PLHA, NGO, Nurses, doctors, pharmacist, and dentist) of the community hospital with the Chiang Rai Regional Hospital Paediatric HIV team.
2. The regional hospital closely supervises and monitors the pediatric HIV care and pediatric HIVQUAL – T program in the community hospital.
3. The staffs in the community hospital are committed and have a very good work ethics.
4. The administration of the community hospital really supports the program

We than returned to Bangkok, where we debriefed and are now in the process of submitting our report to the WHO/NDOH HIV Team

I would like to thank the NDOH Team for selecting me , WHO for sponsoring the trip and GGH CEO Dr Apa, a/DMS Dr Kendaura and my supervisor Dr Mauta (Paediatrician) for releasing me for this study tour.

Dr Paul WARI
Paediatric Registrar -Participant.