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http Beginnings

The HIV Telehealth Training Program is patterned after the model adopted in Vietnam, which was largely motivated by the University of New Mexico Health Sciences Center’s Department of Internal Medicine’s Extension for Community Healthcare Outcomes (ECHO) or Project ECHO. The latter was developed as an innovative approach to improve access to high quality clinical care among rural and underserved population in New Mexico through capacity building of primary care physicians and other healthcare workers. Project ECHO used videoconferencing technology to bring together multiple community-based primary care physicians with specialists from academic centers for the purpose of co-managing the patients handled by the former. 

Telehealth allowed for providers from multiple locations to connect simultaneously with a central team of experts, allowing for experience sharing and peer-to-peer learning between clinical sites. Learning is exponential, as participants can  also serve as hubs of information of the institutions within their jurisdiction.

Three years after its implementation in Vietnam, the success of telehealth is seen in the establishment of over 17 central hubs in their respective territories, leading to a network of 695 clinical sites, participants from 62 provinces. Certification of healthcare providers in HIV medicine were established through online courses, which was organized by five hubs, enabling 779 providers from 46 provinces to professionalize their services – physicians, physician assistants, nurses, and others.

Evaluation of the program showed improvement of self-assessed confidence in HIV care (mean baseline score 2.9; mean post score 3.9; p<.001), quality of care provided, and reduction of professional isolation.

SHIP Medical Director Dr. Kate Leyritana visited HAIVN to witness this marvel of distance education personally, and with the help of country director Dr. Todd Pollack and the Ho Chi Minh branch support staff, she was able to learn about Telehealth enough to propose it for the Philippines.

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About http

http – HIV Telehealth Training Program

Telehealth is a means of delivering education through telecommunication technologies. Elsewhere in the world, telehealth has made it easier for healthcare workers in remote field settings to obtain guidance from professionals in the diagnosis, care, and referral of patients. Whereas telemedicine serves as the clinical application of technology, telehealth encompasses a broader scope, and aims to enhance both healthcare delivery and health education.

The rapid and consistent increase in the new cases of HIV in the Philippines calls for an equally aggressive response from medical providers to provide adequate care.  One of the current gaps in HIV healthcare is seen in the lack of formally trained providers to man the front lines of the treatment hubs and primary care facilities that cater to over 50,000 patients. The lack of a formal HIV Medicine training program and the paucity of Infectious Diseases specialists have led physicians of all specialties, nurses, social workers, and peer educators to provide primary healthcare as numerous HIV treatment centers are opened each year.

In an effort to augment current practices in HIV healthcare provider training, Sustained Health Initiatives of the Philippines (SHIP) organized the HIV Primary Care Skills upbuilding workshops in 2015. The workshop emphasized management of clinical scenarios, holistic HIV care, and engagement of the network of HIV healthcare providers. The generous feedback of participants in the workshops revealed how continuing medical education of HIV providers is a sound should be provided. However, it presented a significant logistical and financial investment for some.

To engage a greater number of healthcare providers, the power of internet and technology should be leveraged. The potential of a technology-driven learning program can overcome the Philippines’ innate geographical setbacks, and may prove to be a cost effective to provide training. Inspired by the success of the nationwide HIV telehealth training program of HAIVN in Vietnam, the HIV Telehealth Program will engage experts to lead issue-driven case study training and discussion in clinical and system-based care based on existing guidelines, updates on policies, and implementation of quality improvement activities, provide didactic training.

Telehealth allows for providers from multiple locations to connect simultaneously with a central team of experts, allowing for experience sharing and peer-to-peer learning between clinical sites. Learning is exponential, as participants can  also serve as hubs of information of the institutions within their jurisdiction. The three main tenets of telehealth are:

  • Longitudinal co-management of patients with specialists and case-based learning
  • Opportunities to learn from other community-based primary care physicians working in similar settings
  • Short didactic presentations on topics relevant to the case discussions

http aims to achieve the following objectives:

  1. to increase the knowledge base and skillsets of HIV healthcare providers in HIV primary care, management of opportunistic infections and co-occurring diseases, other issues surrounding HIV care
  2. to improve the communication and referral system among hubs and paramedical services
  3. to recommend this program to policy makers in the health ministry for nationwide scale-up                 

This program hopes that building up the knowledge and skill of the HIV healthcare provider will be translated to improved patient outcomes, better patient retention in care, towards the UNAIDS 90-90-90 target (90% of people living with HIV diagnosed-90% on treatment-90% virally suppressed).

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SHIP Featured in DW

http://pulitzercenter.org/reporting/dying-shame-aids-philippines

Dying of Shame and AIDS in the Philippines

May 31, 2016|

DW

BY

ANA P. SANTOS AND VEEJAY VILLAFRANCA

Manila in 2016 is starting to look like San Francisco in the 1980s when the AIDS took the lives of mostly gay men. Image by Veejay Villafranca. Philippines, 2016.

The Facebook posts were becoming so common that it no longer surprised Jayce Perlas, but it still made him sad. Friends were posting messages about the passing of another friend who was “gone too soon.”

By now, the updates took on a certain template. The deceased was usually male, in his 20s or 30s, openly or secretly gay, his sudden demise simply explained as “hard-core pneumonia” or tuberculosis – infections that could normally be treated by antibiotics.

The virtual but connected universe of Facebook provided a safe haven for final good-byes, an outlet for grief that could not be expressed at hushed and hurried funerals.

At its worst, Perlas, an entrepreneur, has read about three deaths in one week. At the funerals of close friends, he says, there is always a profound grief and sadness, but there is something else, too.

“In every funeral I have attended, the air is thick with the unspoken thought: Could it be one of us next?”

San Francisco in the 80s

The Philippines is one of three countries in the Asia-Pacific Region described as having an “expanding epidemic.” In 2000, one new HIV case every three days was reported. By the end of 2013, that number had increased to one new HIV case every two hours.

To those who witnessed it and still remember, the current situation is reminiscent of San Francisco in the 1980s when mostly gay men got infected and began dying due to what was later identified as AIDS.

HIV activist Tona Benfield, 53, still remembers the early days of AIDS. HIV had yet to be discovered as its cause and men were dying from what was then called the “gay cancer.”

“I lost many friends then. It offends and angers me that I continue to lose friends today,” said Benfield, shaking in outrage.

As a trained HIV counselor at an HIV testing facility subsidized by the Department of Health (DOH), Chris Lagman sees many cases and many stages of HIV. Some come in to get tested for the first time while some who get tested are already showing early signs of opportunistic infections.

Like Perlas, Lagman sees Facebook posts about death of friends and acquaintances. The reasons are cryptic, but from the cases he sees in the clinic, Lagman senses it is most likely a death caused by HIV-related complications – a death that could have been prevented with early diagnosis and treatment.

Early signs

Since 1984, when the Philippines reported its first case of HIV, the island nation of more than 100 million has always been a low-incidence country. Less than 1 percent of its general population is infected with HIV.

Around 2009, things began to change. The main mode of transmission of the virus shifted to men having sex with men (MSM), and new infections among a small group of injecting drug users were reported.

More than 25,000 new HIV infections – around 85 percent of the total 30,356 recorded infections in the country – were reported from 2010-2015. An estimated 81 percent of total HIV infections cluster around MSM, with more than half of the cases belonging to the 25-34 age group.

Data released by the DOH last November showed that HIV infections increased by close to 800 percent in the 15 to 24 age group from 2001 to 2015.

The DOH forecasts that total HIV infections could reach 133,000 by 2022 if the current trend continues.

“To reverse the increase in infections, we need to increase condom use and bring it up to the levels of 80 percent. We need to get people tested and get them on treatment,” said Dr. Genesis Samonte, DOH HIV surveillance head.

Increasing condom use among MSM from its current level of 44 percent will require addressing social, religious and legal obstacles, starting with updating the HIV/AIDS Prevention Law of 1998, which prohibits minors from getting an HIV test without parental consent, hampering early diagnosis and subsequent treatment.

“We need to allow young people to access HIV testing. We need harm reduction programs [for people who inject drugs]. We need to overhaul our legal framework on HIV,” said Jonas Bagas, an HIV activist who has been lobbying for amendments to the HIV law.

“The current law is designed for general population epidemics. Awareness activities are not targeted to inform important sub-populations about prevention and where they could get treatment,” argued Bagas.

The proposed amendments to the HIV law include eliminating the need for parental consent for 15-17-year olds to get an HIV test, strengthening grievance mechanisms for cases of discrimination and allocating more of the budget to information and education drives.

The DOH HIV and AIDS Unit has about 600 million pesos ($13 million) for HIV treatment and prevention from this year’s budget. About 400 million pesos of that will go to providing free antiretroviral (ART) treatment to the more than 12,000 Filipinos who are currently enrolled in the program. The rest will go to purchasing condoms and testing kits, and information materials.

Samonte admits it is not enough and part of the DOH’s interventions will be to find ways to augment this budget.

Stigma and shame

The DOH HIV/AIDS Registry shows 415 AIDS related deaths from January to November 2015. But Samonte recognizes that this number is grossly understated as many deaths are quietly passed off as pneumonia or meningitis. “Some go undiagnosed,” said Samonte.

“The Philippines could look like San Francisco in the 80s, during the height of the AIDS scare. But back then, life-saving ARV treatment was not available. Now, ARV treatment is available and free. No one should have to die from HIV-related infections in 2016.”

“Back then, we called it what it was. ‘He died of AIDS,’ we would say. Here, they say, ‘Oh, it was hard-core pneumonia.'”

But some still do. Kate Leyritana, a doctor at an HIV testing clinic, recalls one incident where she lost one of her patients just a few months after diagnosis. “His mother only knew her son had HIV in his last days. She asked me, ‘Why am I the last to know? I am his mother. I should be the first one he can talk to.’ I had no words.”

The mother still texts Leyritana each December on the anniversary of her son’s 2012 death to say she misses him.