Lessons from Practice in HIV Scale-UpIAS Education Programme

ICASA 2008

Debrework Zewdie

Director

Global AIDS Program

The World Bank

Dakar, SenegalDecember 2, 2008

Overview

Historical context of scale up of treatment in Africa Current challenges to further expansion and

sustainability Operational research garners evidence to ensure

sustainability – examples Role of donors and partners to coordinate and

support research and to promote learning Conclusion

Number of people receiving antiretroviraldrugs in low- and middle-income countries2002−2007

Source: Data provided by UNAIDS & WHO, 2008.

end-2002

end-2004

end-2003

end-2005

0.4

0.8

1.2

1.6

2.2

2.8

Mill

ion

s

Year

2.4

2.6

3.0

0.0

0.2

0.6

1.0

1.4

1.8

2.0

end-2007

end-2006

North Africa and the Middle East

Eastern Europe & Central Asia

East, South and South-East Asia

Latin America and the Caribbean

Sub-Saharan Africa

5.2

Total annual resources available for AIDS 1986–2007

[i] 1996-2005 data: Extracted from 2006 Report on the Global AIDS Epidemic (UNAIDS, 2006); [ii] 1986-1993 data: Mann.&. Tarantola, 1996

Notes: [1] 1986-2000 figures are for international funds only; [2] Domestic funds are included from 2001 onwards

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

US

$ m

illio

n

2921623

8.3 billion

Signing of Declaration of Commitment on HIV/AIDS,

UNGASS

1996 1997 1998 19992000 20012002 2003 2004 200519861987 1990 19911992 1993

Less than US$ 1 million

59212

World BankMAP

launch

Global Fund

PEPFAR

257

UNAIDS

Gates Foundation

2006 2007

10 000 8.9 billion

10 billion

7.1 Source: UNAIDS & WHO unpublished estimates, 2007

Bilateral & multilateral resources available for HIV-related programmes in 2006

GSource: UNAIDS analysis based on OECD/DAC online database (last visited on May 6, 2008), Resource availability UNAIDS 2005, Funders Concerned About AIDS (FCAA), European HIV/AIDS Funders Group (EFG) for Philanthropic sector

Bilateral disbursements to HIV-related programmes in 2006 (OECD/DAC statistics)

Global resources available for HIV-related programmes in 2006 (US$ Billions)

2

5

8

6

7

0

1

3

4

9

10

UN (2%)

GFATM (7%)

Foundations (11%)

Bilaterals (33%)

Domestic Publicand Private (46%)

EC (0.5%)

Canada 2%

Belgium 1%

Netherlands 3%

Other DAC country members 1%

Sweden 3%

Spain 1%

Norway 2%

Australia 2%

Germany 2%

Ireland 3%

United Kingdom 9%

United States 71%

(US

$ B

illio

ns)

Global resources available: US$8.9 Billion Percentage out of the total bilateral disbursementsTotal Bilateral disbursements 2006: US$ 2.9 Billion

The organizational disbursements are different than commitments or obligations, as well as different from in-country expenditures

Heterosexual

SWIDU

MSM

IDUHeterosexual

SWMSM

IDU

Heterosexual

SWIDU

MSM

IDUHeterosexual

SWMSM

IDU

Current challenges (1)

Heterosexual

SWIDU

MSM

IDUHeterosexual

SWMSM

IDU

Heterosexual

SWIDU

MSM

IDUHeterosexual

SWMSM

IDU

The Face of Treatment is Changing… Dr. Mari Kitahata at Univ. of Washington recently

compared patients who started ART with a CD4 below 350 cells/mm3 to those started between 350-500 cells/mm3. The later initiators had a 71% increased risk of death (relative hazard of 1.7; C.I. 1.4 – 2.1).

Reported on October 27 2008 at Interscience Conference on Antimicrobial Agents and Chemotherapy; will appear in Journal of Infectious Disease Dec. 2008

Used 22 U.S. and Canadian cohorts; 8374 “healthy” HIV patients from the International Epidemiology Databases to Evaluate AIDS

Studies are ongoing comparing starting with CD4 > 500 with starting CD 4 = 350 - 500 cells/mm3.

Current challenges (2)

Attribution: Dr. Jon Simon, Boston University

Other Major Challenges

Funding increases cannot be infinite, donor dependence makes these unpredictable

Late enrollment and early mortality

Treatment failure and the expense of second line therapy

Limited integration with other treatment services (especially TB)

The role of research in sustaining HIV Treatment programs

Discovery of better drugs

Understanding our epidemics

Operational Research

Cost-effectiveness research

Operational Research in Treatment Programs

Evidence is vital for good strategic planning

Research can be an engine of excellence and capacity building

Research for activism and ownership

Clinical research – an essential tool to support programs

The Sydney Declaration

“Ten per cent of all resources dedicated to HIV programming should be used for research

towards optimizing interventions utilized and health outcomes achieved”

Optimizing Treatment approaches and effectiveness

Integration of services

Greater understanding of social, political and cultural barriers

Integration of new therapies, technologies and guidelines

Sustainability. success and cost effectiveness

Priority Research Needs

Treatment Acceleration Project (1)

Goal – pilot strategies for strengthening countries’ capacity to scale-up care and treatment programs that are efficient, affordable and equitable

Piloted in Ghana, Burkina Faso and Mozambique, 2004-2008

3 components: Test approaches to scaling-up AIDS care and treatment

Strengthen institutional capacity for AIDS care and treatment

Facilitate regional learning

Technical support from WHO, UNECA (UN Economic Commission on Africa)

The TAP included a strong operational research / learning component, with regular meetings to share findings and resolve common challenges

Impact evaluations explored: Factors that affect adherence

Impact of increased treatment access on prevention and risk behavior of patients, family members, and society

Impact of ART on individual and family well-being (health expenditures, assets, incomes, life expectancy, poverty, living standards, childrens’ schooling & nutrition

Impact of AIDS funding on quality and access to other health services (facililty and patient surveys)

Treatment Acceleration Project (2)

Addressing Knowledge Gaps in the Public Health Approach to Delivering Antiretroviral Therapy and Care

Two day consultation, March 2008 convened by WHO and cosponsored by IAS, World Bank and GFATM

Clinicians, community advocates, programme managers, researchers, donors and normative agency representatives

To identify gaps in policy relevant and operational research, barriers and opportunities: ART, non-ART care, Lab Services and Health Systems

Emphasis on Treatment through the Public Health Approach

WHO ConsultationResearch Gaps - ART

When is the optimal time to initiate treatment? What are the most effective strategies for improving adherence and the durability of first-line

regimens? When is the optimal time for switching to second-line regimens? What role should laboratory monitoring play in clinical management? What is the potential impact of new drugs/drug classes on first and second-line regimens? What is the impact of ART and other care/treatment interventions on preventing HIV

transmission? Delivering care and treatment to special populations, such as injecting drug users Pediatric ART Integration of TB and HIV treatment programs

WHO ConsultationResearch Gaps - Health Systems

Optimal service delivery approaches for HIV treatment and care interventions

What is the impact of HIV ART care and treatment on the overall health care system?

How can the public health approach to delivering HIV interventions strengthen health care systems?

What costing, and cost-effectiveness analyses, are required to inform the optimal preventive and therapeutic service delivery strategies?

WHO ConsultationResearch Gaps - Challenges

Lack of political commitment

Weak links between researchers and policymakers to help set a policy-relevant research agenda

Lack of funding

The lack of adequately trained staff with research expertise

Poor physical research infrastructure

Slow adoption and implementation of new technologies

WHO ConsultationResearch Gaps - Opportunities

Invest in building research capacity (human resources and infrastructure) Strengthen health information systems to capture information that will be used for

decision-making; Consider developing regional "centres of excellence" to foster and support regional

and national research; Expand north/south and south/south research collaboration and networks Strengthen links between researchers and policymakers, possibly with a national

coordinating body, to help set a policy-relevant research agenda Invest in community engagement -- define and support a role for the community in

designing and implementing research; Strengthen coordination between granting agencies and HIV programmes.

WHO Consultation Partner Commitments

WHO, World Bank, GFATM, IAS agreed to advocate for:

Funding and implementation of Operations Research

Collaboration with countries to encourage greater investment in policy-relevant research

Collaboration with international agencies and countries to develop the research capacity of low- and middle-income countries and to use the results of this research

Contribute resources in co-sponsoring a session on research in Mexico and a follow-up summit in Vancouver in Feb 2009

Conclusion

Treatment sustainability is not assured

Evidence is essential to preserve and expand our gains and operational research can provide this evidence

Research – especially operational research, which uses tools from epidemiological, social and clinical research – can deliver this evidence, but requires substantially increased support

Thank youThank you