Differentiated Service Delivery for People Displaced by Violence & Emergencies in Northern Nigeria

Dr. Olawale FadareTechnical Director | RISE Nigeria

ICAP at Columbia University 8th December 2020

Presentation Outline

• RISE Nigeria Program• Security situation update: Adamawa & Niger States• Impact on ART services delivered through DSD• Innovative strategies measures to ensure uninterrupted DSD in FY20• Novel initiatives targeting displaced populations in FY21

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RISE Program Implementation In Nigeria

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30 Local Government Areas 90 Health Facilities

Supported4 SupportedStates

Security Situation Update: Adamawa & Niger States

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NIGER STATE:Tx_Curr = 21,800 (RISE = 10,015)(~17% of RISE Tx_Curr in security prone areas) Security Report:• Responsible – bandits, marauding

herdsmen• Recurring cases since 2014/15

with escalation in 2019/20• Est. mortalities = est. 750

Other Factors:• Largest state (landmass) in Nigeria• Very poor road network• Movement restrictions and hike in

transport costs due to COVID19

ADAMAWA STATE:Tx_Curr = 26,292 (RISE = 8,980)(~60% of RISE Tx_Curr are in high-risk areas)Security Report:• Responsible – Boko Haram, Ansaru,

ISWA• Earliest cases in 2010/2011• Est. mortalities = est. 20,000 in

Adamawa/Borno axis

Other Factors:• Extensive border with Cameroon

(relatively safer)• Poor road network• Movement restrictions and hike in

transport costs due to COVID19

Situation Analysis

• Limited access to affected communities (armed escort often needed)

• Difficulty convening meetings/support groups

• Increased costs – transport, phone services, safe locations for trainings and meetings• Difficulty finding and retaining HRH willing to live and work in

communities

• Pivot to IT constrained by difficulty eliciting & finding contacts

• Increased mental health burden

• Increased missed appointments and treatment interruption

• Challenges collecting performance reports/data5

Maintain ART Refill Services &

Adherence Support

Maintain Clinical Monitoring

Services

Program Support Systems

RISE Nigeria: Analysis of Reasons for LTFU

1280

890

694

316 308

106 92 88 35 26 25 20 19 16 16 7 5 4 2 2

32%

23%

18%8%

8%3% 2% 2% 1% 1% 1% 1% 0% 0% 0% 0% 0% 0% 0%

0%0%

5%

10%

15%

20%

25%

30%

35%

0

200

400

600

800

1000

1200

1400

Distance

/economic r

easons

Forgo

t appointm

nent

Travelin

g/busy

with w

ork

Spirit

ual/cultu

ral belie

fs

Lack

of family

support

Hard drugs

Pill burden

Stigma

Waiting t

ime at

clinic

Domestic V

iolence

Side effe

cts of d

rugs

Alcohol

Others (N

ot Specif

ied)

Unsure how to

take

drugs

Shari

ng drugs

Conduct of s

taff c

linic

Health/death of re

lative/fa

mily

Receiving d

rugs fro

m…

Taking herbs

Non disclosure/ f

ear to disc

lose/self…

Community ART clients

Clients in employmentSingle Clients

10 – 24-year-olds

Clients enrolled in facilities

Clients not resident in LGAs

of treatment site

Vulnerability Profile

Clients enrolled in Private Facilities

80% of Reasons for LTFU

Related to impact of insecurity

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct Nov Dec Jan Feb Mar Apr May Jun< 3 Months 3 - 5 Months 6 Months+

MMD transition among children and adolescents (0 - 19 years)

16%

30%

77%81%

71%

80%85%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0

200

400

600

800

1000

1200

1400

1600

1800

May 22 May 29 Jun 5 Jun 12 June 19 Jun 26 July 03

VL Samples Collected

# Eligible # VL Collected Gap % Uptake

Weekly VL Collection and Viremia Clinic Enrollment (0-19 yrs)

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Viral Load Suppression: Q1 vs Q3 (0 – 24 years)

100%

43% 42%53%

64%70%

100%

51%57%

71%77%

84%

0%8%

15% 18%13% 14%

0%

20%

40%

60%

80%

100%

120%

<1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24

VL Suppression

Quarter 1 Quarter 3 Change in Suppression

Supporting Unsuppressed Adult Clients (Viremia Clinic & EAC Profile)

EAC boosted by virtual (phone) counselling using standardized

scripts

Key Strategies:

Strategic response to maintain DSD rested on:

• Open communication with high-risk locations

• Security training & low profile field operations

• Deploying ad hoc personnel to access high risk locations (including collaboration with trusted community and religious leaders)

• Regular, multi-channel data review systems (Zoom, phone, WhatsApp, SMS)

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The CQUIN Project 4th Annual Meeting | December 7-10, 2020

Innovative Strategies to Ensure Uninterrupted DSD

HIV Retention

• “Menu” approach - patients choose from different pickup options

• Structured adherence support (remote adherence calendar & scripts for adherence support)

• MMD for longer ART refills (>90% of patients on MMD3 and MMD6)

• “ARV frontloading” for patients with upcoming appointments if a crisis is anticipated

• Strengthening orthodox and unorthodox clinic settings for ART pickup

HIV Viral Load Monitoring

• Optimized sample collection through:• Phlebotomists embedded in

community teams• DSD model for VL (during home visits,

unsupported clinical platforms)• PPEs and training on COVID19

prevention• Sample storage and logistic systems • Digital technology for VL result

transmission

HIV Case Finding

• Index testing communicated as best practice for case finding (low prevalence in both states)

• Train community embedded ad hoc teams to drive Index HTS

• GIS-guided HTS that focused on high prevalence facilities and communities

Planned Initiatives Targeting Displaced Populations for FY21

•PEPFAR-driven inter-agency ARV delivery network• Safe Zones to facilitate deliveries during insurgencies• Backup ARV pickup centers guided by geo-spatial analysis• Religious leaders to deliver ARVs to insurgent controlled or

militarized locations

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“One thing that has helped us is the integrated model we applied…….We worked as a team, and every contact with the patient, whether by a lab scientist or case manager, was an opportunity to provide services and build capacity“.

~ Friday Abbah(Lab Advisor, ICAP Nigeria)

This presentation was made possible with support from the U.S. President's Emergency Plan for AIDS Relief, through the United States Agency for International Development funded RISE program, under the terms of the cooperative agreement

7200AA19CA00003. The contents are the responsibility of the RISE program and do not necessarily reflect the views of USAID or the United States Government.

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Thank You For Listening