Track E: Rapporteur SummaryPierre Barker
Track E: Rapporteur Summary
• Role of health systems in providing high quality care to all who need it
• The financing of health systems that provide HIV care
• Operations Research on quality of care, universal coverage, and financing
Track E
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Track E representation at oral sessions (15 ex 116)
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Track E abstracts accepted (ex 1269 ex 10,145)
Thanks!.....
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Current State– How far are we from universal access (LMIC)?
“gap” = 340,000 new infant infections/year
100%HAART Any ARVs for PMTCT
Current State: ART coverage gap in every region – health system
response is different in each region
Latin America
The Caribbean
Eastern and Southern Africa
East, South and South-East Asia
Western and Central Africa
Europe and Central Asia
North Africa and the Middle East
0% 20% 40% 60% 80% 100%
Current State of Health System Performance – Not just about
numbers! Retention on ARVs
Current State of Health System And then there is finance!
Interaction of Health System Financing and Health System Performance
100%
Financing Access to HAART
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1. Interaction between Health System Financing and Health System Performance?
100%
Financing Access to HAART
? ?
• lobby to replenish Global Fund
• Innovative external fundraising
• LMIC fund raising
• Op research on costing of methodologies
• Reduce drug costs
• Cost-benefit of guideline changes
• More effective care at lower or same cost (efficiencies)
The financial implications of the 2010 WHO recommendations
• CD4 <350 , PMTCT recommendations (plus phasing out d4T): ─ Tripling of costs 2010 to 2015 (US$3.5 billion US$9.5
billion by 2015 - d4T phase out NS)
• Cost per person year on ART is US$800, but… cost per death averted is about US$10,000
Lori Bollinger , Futures Institute
Potential Cost Savings of Implementing WHO PMTCT 2009 (“A”) vs 2006
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Avert x3 more infections
Save money with Option A (significantly less expensive than option “B”)
The 2009 WHO Guidelines with option “A” are:
highly cost effective (ICER <GDPpp)
? cost-saving in 9 of 15 PEPFAR focus countries
15 PEPFAR countries Implementing 2009 WHO Guidelines could….
Auld et al , CDC
Where are the opportunities for cost reduction?
Lori Bollinger , Futures Institute
I. 1st-line NRTI PYD evolution II. Compulsory license of EFV
C Meiners,
Lessons from Brazil: Drug Cost reductions through…negotiations with drug companies, mandatory licensing, local production and international collaboration
Health systems improvement: Cost effectiveness of interventions
Compared incremental cost effectiveness for facility-based vs outreach vs campaign (Uganda)
Static Clinic Campaign Outreach 0
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Cost per Number of people who know their status (US$)
Arinaitwe et al…MSH: Uganda
Compared community based health insurance and performance based financing introduced to Rwanda
CBHI – major impact on improvements in HIV care
PBF – no impact
Both interventions had been rolled out country wide.
Wu Zeng (Brandeis University)
Health systems improvement: Cost effectiveness of HCT interventionsTested cost effectiveness of HCT, malaria, diarrhoea campaign in subdistrict of W Kenya. 30 sites, 7 days
Reached 80% of 51,000 targeted population
Dr. Eric Lugada CHF International Kenya
By Disease
$6.27
$15.80
$9.93
Malaria (nets and training)
Diarrhoea (filters and training)
HIV (test kits, counselling, condoms and CD4 testing)
Per person costs ( $34 USD)
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10,000
20,000
30,000
40,000
Campaign cost(unadjusted)
Averted costs
Cost effectiveness (USD)
What will it take to close the gap between “best case” (RCT)
performance and actual performance?
Basic science
Proof of concept
Large RCT
Reliable “real-life”
implement-ation
Scale-up
• Every existing / new drug• Every model for prevention or treatment
“hostage” to our ability to implement and scale up what we know will work
TOTAL
Ethiopia
Nigeria
Vietnam
Cote D'Ivoire
Namibia
Haiti
Rwanda
Tanzania
Kenya
Mozambique
Uganda
Guyana
Zambia
Botswana
South Africa
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%TOTAL
Nigeria
Ethiopia
Vietnam
Cote D'Ivoire
Haiti
Mozambique
Tanzania
Kenya
Namibia
Uganda
Zambia
Rwanda
South Africa
Guyana
Botswana
5% 25% 45% 65% 85% 105%
“Real Life” assessment: PMTCT results in PEPFAR supported countries
Testing and Counselling ARV prophyaxis
target target
Caroline Ryan, PEPFAR
Are we setting the right performance goals??
If PEPFAR met its goals (80% HIV+ women get ARVs) , the model estimates that:
• At current targets - MTCT rate would be 15%
• 85% coverage - MTCT rate would be 10%
• to reach MTCT <5% need a 96% coverage goal
Caroline Ryan, PEPFAR
Attrition: challenge of delivering complex interventions over time and places
3,244 HIV positive pregnant women at health centres offering PMTCT services in Cameroon, Côte d’Ivoire, South Africa and Zambia
Stringer, E.M., JAMA. 2010 Jul 21;304(3):293-302.
92%91%
92%92% 95%
81%
57%84%
Quality Improvement methodology has become powerful tool to make HIV care processes more reliable, and provides
methods for scale spread
IAS 2010
>70 abstracts used quality improvement in text>40 organizations represented
Health systems improvement: Local Solutions to Solving Logistics
Problem: Low rates of CD4 collection, long turnaround times
Solution: Using public transport to carry CD4 lab samples, 6 week pilot
Results: Cut CD4 turnaround time from 2 weeks to 5 daysMassive increase in number of CD4 counts collectedBeing scaled up to all clinics in system supported by ICAP
Preko et al…ICAP: Swaziland
NGO 1
NGO 2
NGO 3
NGO 4
NGO 5
Distr office
Distr office
Distr office
Distr office
Distr office National and
provincial government
Using existing capacity: Harmonizing efforts between different NGOs to work with government
and districts to scale up effective care
Kedar Mate, Institute for Healthcare Improvement
Highly reliable PMTCT in low resource public health system, at scale, is
possible
Kedar Mate, Institute for Healthcare Improvement
(9 districts, 151 rural facilities, South Africa)
Closing Gaps – Point of care testing
Rapid testing advances for • HIV testing• CD4 count
testing• Viral load testing• TB and
resistance testing
Eliminates steps in a cascade of sequential care steps
Health systems improvement: Integration of HIV into health system: MCH,
general clinic, etc
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CD4 cell count testing
Antiretroviral therapy
Long term follow-up
HIV care & support
Integrated Care
Antenatal care
HIV testing
Maternity
Maternal ARV Prophylaxis
Newborn Prophylaxis
Immunizations
Maternal Chi ld Health ART Care & Treatment
Elaine Abrams, ICAP
Health systems improvement: Integration of HIV into health system
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HIV-TB integration: “1 patient, 1 doctor, 1 clinic, 1 folder, and 1 program,” Gilles Van Cutsem , MSF Khayelitsha , South Africa
Days from start of TB treatment to ART treatment
Before integration
After integration
Medecins Sans Frontieres
• No difference in outcomes for Vertical vs Integrated HIV programs
• Conflict/post-conflict and non-conflict settings
• Improved outcomes for TB/HIV integrated settings
Summary
• Health system redesign using new and existing knowledge to close remaining gaps in prevention and care
• Modify health system response in view of global financial changes
• Pay closer attention to the cost-effectiveness• Design prevention and treatment strategies for “real life
health systems” and learn how to scale them up• Better NGO-NGO and funder-funder collaboration to
capacitate national health systems to deliver sustainable, cost-effective, high quality HIV care that can be rapidly scaled
Thanks!!
Robert Hecht
Kedar Mate
Patty Webster
(with help from Rebecca Hodes)
… Kelly O’Connor IAS