In Senegal, multisectoral concept of ECI was unfamiliar, in that it differed greatly from usual models of addressing social and health problems. ECI was first presented to Senegals National HIV and AIDS Committee leaders and National HIV/AIDS Control Program investigators in order to gain support at the highest levels. These leaders accepted the ECI framework as an effective tool, and welcomed the idea of collaboration despite the probable challenge of motivating potential members to take part in the initiative. The ECI Senegal team has expanded to more than 40 experts including private and public health officials, military physicians, biologists, pharmacists, nurses, midwives, social-workers, economists, lawyers, and representatives from PLWHA organizations. Team members continue to work with the National HIV/AIDS Control Programs (NACP) and, working within three committees on epidemiology, ethics, and economics, in relation to the ECI Ten Areas of Care.
Phase I Situation Analysis
As part of the situation analysis in Senegal, the specific care needs of populations in various areas were considered in the context of the three NACP committees. A national survey was conducted to evaluate the capacity and distribution of public HIV and AIDS health care services. The most important finding from the situation analysis data was the marked disparity in available HIV and AIDS care services between the capital city of Dakar and rural regions. Communities outside Dakar were found to have limited access to voluntary testing and counseling and other related services, and 60% of all health facilities offering HIV testing were concentrated in Dakar. In addition, the Team observed a need to train the health personnel engaged in HIV counseling, HIV testing, and laboratory diagnosis procedures.
Evidence of neglect and violation of human rights and ethical concerns related to PLWHA also caused concern within the team. One issue raised within health care services was the fact that many health professionals neglected proper counseling before and after tests, and sometimes did not inform patients of their test results. Many PLWHA and people seeking VCT experienced discrimination and stigma, and concerns remain over health facilities ability to keep test results confidential. The Team also observed a general lack of knowledge regarding virus transmission and safer sex practices among study respondents. As a result of the situation analysis, the Team identified several main priorities for improving HIV/AIDS care in Senegal. These included increasing access to VCT and treatment in rural areas, expanding programs to prevent mother-to-child transmission, addressing stigma and discrimination, establishing guidelines for care, building lab capacities and training medical personnel to treat patients with HIV/AIDS.
Phase II and III Research and Implementation
Patient Consent and Opportunistic Infections
Interviews with physicians and members of the Senegalese Labor Physicians Association revealed that protocols for patient rights and consent, along with guidelines for treating opportunistic infections (OIs) are also needed areas of focus. The Team visited 35 key health facilities in 3 regions of the country to assess the prevalence of OIs, available diagnostic technologies, and access to medications for treatment. The study found inadequate capacity for diagnosis and treatment of most OIs at a majority of labs, and a lack of appropriate guidelines for OI management.
Based on these findings, the Senegalese Team recommended increased training of physicians in informed consent procedures and the creation of anonymous voluntary HIV testing centers. The Team developed and standardized guidelines for the management of OIs for use in health facilities. Educational posters were printed to illustrate and publicize the opportunistic infection management guidelines, and additional posters regarding post-exposure prophylaxis were distributed to health facilities. Working with policy makers in Senegal, the Team has recommended improved training of health personnel in the management of OIs and palliative care. This effort was supported by the government, which had already prioritized HIV/AIDS care training for physicians with the goal of swiftly improving medical infrastructure.
Urban/rural disparities in HIV and AIDS care
One of the most important findings of the situation analysis was that gaps in medical infrastructure were restricting access to HIV/AIDS testing and care outside of Dakar, Senegals capital city. The focus on disparities in quality and extent of care between rural and urban populations was the result of the ECI approach, which stressed that research should be carried out by multisectoral teams of experts who are familiar with local realities. Following a survey of PLWHA and doctors treating HIV/AIDS patients, the Senegalese Team found that in addition to lack of training, lack of confidentiality of HIV test results inhibited the effectiveness of VCT efforts. Continued attention to the urban/rural divide and evaluation of the costs and cost-effectiveness of HAART emerged as priorities for research.
Cost Analysis of Opportunistic Infection Care in Senegal
Given the gaps in care observed, the Team decided to focus its research on assessment of the resources required for expanding HIV interventions outside of Dakar. A study of the costs of hospital treatment for common opportunistic infections including tuberculosis, dermatoses, and candidiasis was collaboratively undertaken by the Senegalese Team and researchers from the Health Economy Program of the Centre Africain DEtudes Superieures En Gestion . The study consisted of a retrospective review of the costs of treatment for HIV-infected patients who presented to both inpatient and outpatient settings in lHopital Fann for opportunistic infections between 1998 and 2000. Costs of HIV-testing, counseling inpatient care, drugs, and diagnostic tests were evaluated, and the financial impact on hospital budgets was assessed. This initial research convinced the team of the need for more in-depth studies of the costs and cost-effectiveness of AIDS care and treatment in Senegal in the future.
Impact of ECI in Senegal
For many of the Team members in Senegal, ECIs multisectoral approach to local problems was a new approach to dealing with HIV/AIDS. As a result, many hours of planning and work were devoted to the process of convincing representatives of professional circles of the mutual benefits of working side by side as well as with members of community groups. Over time, the team found that defining concrete activities and establishing clear methods of communication were key to maintaining a common motivation to take part in the ECI. With each completed activity, Team members grew more motivated to work together for completion of the next goal.
Although challenging at times, the ECI model of collaboration benefited both the team members and the HIV/AIDS situation within the country. The Teams work to date has highlighted important deficiencies in the care provided to persons living with HIV and AIDS in Senegal. The Team identified critical areas requiring improvement across a spectrum of disciplines that had been neglected in the past. In particular, minimization of urban and rural disparities in access to quality care has been prioritized, and steps have been taken to address these disparities at national and local levels. The Teams efforts also promoted a greater awareness of the need for training and capacity building regarding HIV testing and OI care in the country. The Team continues to work closely with the NACP as it makes decisions regarding future interventions. This collaboration has linked team members to policy makers, and has helped the NACP to set locally-appropriate goals for improving HIV and AIDS care in the country.
Future Plans: Analysis of the Costs and Cost-Effectiveness of Scaling Up HIV Care in Five Sites in Senegal
The Senegal Teams future plans are focused on determining the most cost-effective interventions to scale up access to care in semi-urban and rural sites. Unfortunately, little data currently exists on the costs and cost-effectiveness of HIV and AIDS care in the country as a whole. As a result, the Senegalese Team plans to undertake an economic analysis of HIV and AIDS care, and is currently developing a strategy for extensive evaluation of the costs and cost-effectiveness of expanding HIV interventions to sites outside of Dakar. The study will analyze the costs and cost-effectiveness of management of opportunistic infections, prevention of MTCT, improvement of post-exposure prophylaxis, and improvement of access to VCT in five regions. Computer-modeling simulations will be developed to project the costs and effectiveness of various interventions.
Preliminary data collection and compilation has already commenced regarding health system capacity and costs at specific sites in Senegal. Once analysed, this new data will fill an important gap in the cannon of research on HIV/AIDS in Senegal. Analysis of the Teams data will help identify priorities for resource allocation and lend legitimacy to initiatives for increased availability of antiretroviral therapy.