Implications for Countries: Critical Issues in Service Delivery and Decision Making

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1 Implications for Countries: Critical Issues in Service Delivery and Decision Making Dr. Yogan Pillay Deputy Director General National Department of Health, South Africa

2 Outline Critical operational/service delivery issues in 2013 guidelines WHO operational/ service delivery recommendations Projected global and country level impact of WHO 2013 recommendations

3 Key service delivery and programme issues Low testing coverage, and inadequate linkage from testing to care Delayed diagnosis and treatment initiation, inadequate retention in care

4 Key WHO Operational and Service Delivery Recommendations Expanded testing scenarios Task shifting and decentralization Service integration Adherence support Retention in care

Expanded testing and linkage to care Suthar et al, Plos

Generalized epidemics: communitybased HIV testing in

HIV testing for key populations in addition to PITC

5 Expanded testing and linkage to care Suthar et al, Plos Medicine 2013 (in press) WHO 2013 Recommendations: Generalized epidemics: communitybased HIV testing in addition to PITC Concentrated epidemics: communitybased HIV testing for key populations in addition to PITC provider-initiated testing and counselling (PITC) Adolescent testing and counselling

6 Experience in home based testing Multiple countries implemented community based testing approaches: supplementing PITC in health facilities provides opportunity to reach individuals tested for the first time provided opportunity for multi disease interventions

7 Decentralization: Bringing ART closer to communities WHO 2013 Recommendations: Initiation and maintenance of ART in peripheral primary facilities Initiation of ART in peripheral primary facilities and maintenance at community level between clinic visits.

first-line ART and maintain treatment Trained and

8 Task shifting: nurses and non-physician clinicians providing care and treatment WHO 2013 Recommendations: Trained non-physician clinicians, midwives and nurses can initiate first-line ART and maintain treatment Trained and supervised community health workers can dispense ART between clinic visits.

9 Service integration: Responding to co-morbidities and multiple needs WHO 2013 Recommendations: Initiate and maintain ART in : TB care settings MCH/ANC settings OST settings with linkage to continued HIV care and treatment

Scale up of ART in Rwanda 140 000 120 000 100 000 80 000 60 000 40 000 20 000 0 2003 2004 2005

[with range] Main factors: Strong political commitment Decentralization of ART and integration

10 Scale up of ART in Rwanda People receiving treatment People eligible for treatment [with range] Main factors: Strong political commitment Decentralization of ART and integration with primary care services Task shifting for nurses and non-physicians to provide HIV care and ART.

11 Adherence support: combinations of interventions WHO 2013 Recommendations: Combination of interventions Minimizing out of pocket payments Use of fixed-dose combinations Strengthening drug supply system Patient counselling and education Peer support Mobile phone text messages Nutritional support in food insecure settings

12 Projected impact of the new recommendations Mortality Incidence Cost

13 Projected impact: incidence 3.5 million more infections averted, by 2025, compared to 2010 guidelines WHO Global ART report, 2013

14 Projected impact: mortality 3 million more deaths averted by 2025, compared to implementing 2010 guidelines WHO Global ART report, 2013

15 Estimated cost of implementing the new recommendations 10% increase of the billion USD annually for full HIV response WHO Global ART report, 2013

16 Acknowledgements Special thanks to all the external experts who contributed as members of the Guideline Development Groups, the Peer Review panel and to those who contributed to the GRADE systematic reviews and supporting evidence which informed the guidelines process. Guideline Development Group Co-Chairs Elaine Abrams (International Center for AIDS Care and Treatment Programs, Mailman School of Public Health, Columbia University, USA) Tsitsi Apollo (Ministry of Health and Child Welfare, Zimbabwe) Kevin De Cock (United States Centers for Disease Control and Prevention, USA) Serge Eholie (ANEPA/Treichville Hospital, Abidjan, Côte d Ivoire) Adeeba Kamarulzaman (University of Malaya, Malaysia) Yogan Pillay (National Department of Health, South Africa) Denis Tindyebwa (African Network for the Care of Children Affected by AIDS, Uganda) Stefano Vella (Istituto Superiore di Sanità, Italy) WHO Department of HIV Steering Committee Members Andrew Ball Philippa Easterbrook Meg Doherty Eyerusalem Kebede Negussie Nathan Shaffer Lulu Muhe Marco Vitoria Joseph Perriëns Other Contributors

Progress toward Universal ART Access: Innovations and Treatment 2.0. Marco Vitoria World Health Organization September 2013

Progress toward Universal ART Access: Innovations and Treatment 2.0 Marco Vitoria World Health Organization September 2013 The need for scalable, more efficient treatment models Simpler drugs Point of