scale-up of hiv programs: a platform for the global health response wafaa el-sadr, md, mph harlem...
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Scale-up of HIV Programs:A Platform for the Global Health Response
Wafaa El-Sadr, MD, MPHHarlem Hospital & Columbia University
www.worldmapper.org
HIV Prevalence
Characteristics of HIV that drive program design
Characteristics of HIV Disease Shaping the Response
Impact throughout lifecycle Programs for adults and children (including pregnant women, infants, children, adolescents)
Asymptomatic periods, acute illness, chronic symptoms
Chronic disease model (prevention, health maintenance, continuity care, linkages)
Multiplicity of clinical & psychosocial needs
Multidisciplinary teams (teamwork, referral systems, community resources)
Importance of adherence & retention Outreach & tracking, decentralizationProvider-patient relationship
Need for clinical & laboratory monitoring, secure supply of medications
Medical records and data systems, secure procurement systems
Transmissible infection Counseling, prevention methods (antenatal care, family planning and prevention methods)
Number of people receiving antiretroviral therapy in low- & middle-income countries, by region, 2002–2008
WHO, Towards Universal Access, 2009
HIV prevalence & Performance
of Health Systems
UNAIDS 2009
WHO 2000
A Healthcare System in Crisis
Increased antiretroviral therapy coverage and decrease in all-cause mortality
South Africa, 2003–2006
WHO, Towards Universal Access, 2009
Estimated number of AIDS-related deaths with and
without antiretroviral therapy, globally, 1996–2008
2.5
2.0
1.5
0.5
1.0
3.0
0
Nu
mb
er
(millio
ns)
Year
1996 1998 2000 2002 2004 2006 20081997 1999 2001 2003 2005 2007
No antiretroviral therapy
At current levels of antiretroviral prophylaxis
UNAIDS 2009 AIDS Epidemic Update
2.9 M
lives
saved
Support for Systems
Mosaic of Services
Health System Framework
Health System Components and Elements of HIV Scale-up
Health System Components Elements of HIV scale-up
Leadership/Governance Engagement of PLWA , coordinated response
Financing Mutuelles, performance based financing, user fees
Medical products//technology Laboratories,, drug procurement systems
Information Medical record system, data collection & management systems
Health Workforce New cadres, task shifting, training/mentorship, interdisciplinary collaboration
Service Delivery Continuity care, linkage and integration (MCH, TB/HIV), family focus, outreach beyond facilities, comprehensive services, behavioral plus biomedical intervention (prevention & treatment)
Framework:HIV programs touch each “building block” of the
health system
Ver
tica
l Fu
nd
ing
Horizontal Implementation
TA
RG
ET
S &
Ou
tcom
es
What about other health threats?Mortality Rates in Adults in Africa
Disproportionate Disease Burden
Land Mass
www.worldmapper.org 2006
HIV Prevalence 15-49 years Tuberculosis Cases
Malaria DeathsChildhood Diarrhea
Synergies
Antenatal care
Postnatal care
Male involvement
Safe motherhood
Maternal mortality
Child follow-up
Maternal follow-up
TB diagnostics
Early TB diagnosis
ART for TB prevention
& improved TB outcomes
Use of IPT
Adherence & outreach
Infection control
Maternal follow-up
Integration of TB/HIV Programs and Services
Traditional TB and HIV Paradigm
HIV Services
• C&T
• CPT
• ART
• OI Dx & Tx
• Adherence
support
• PWP
TB Services
• Sputum collection
• DOT
• Contact tracing
• IPT
National TB
Program
National HIV
Program
National TB
Program
National HIV Program
New TB/HIV Paradigm
Integration of Services
Communication
What about other health threats?Mortality Rates in Adults in Africa
Commonalities of Barriers and Challenges
Maternal healthChild health TB Diabetes HIV/AIDSBarriers and challenges
• Demand-side barriers
• Inequitable availability
• Human resources
• Lack of adherence support
• Infrastructure, equipment
• Program management
• Drug supply / procurement
• Referral and linkages
• Community involvement
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√Adapted from Travis, Bennett, et al. Lancet 2004
Millennium Development Goals (MDGs)
.
MDG-1: to eradicate extreme poverty and hunger;
MDG-2: to achieve universal primary education;
MDG-3: to promote gender equality and empower women;
MDG-4: to reduce child mortality;
MDG-5: to improve maternal health;
MDG-6: to combat HIV/AIDS, malaria, and other diseases;
MDG-7: to ensure environmental sustainability; and
MDG-8: to develop a global partnership for development
Push versus Pull Strategy?
Investment in
HIV Programs
Pull StrategyPush Strategy
Investment
in
Health
Systems
Health System Framework
Systems Thinking for Health Systems Strengthening, AHPSR/WHO 2009
Synergies
Conclusions• Significant achievements in HIV program scale-
up– but much more needs to be done– Treatment available for only 40% of those in urgent
need– Prevention available to 1 in 5 individuals
• HIV scale-up is a remarkable results-oriented global assistance program– achieving meaningful outcomes– transforming health systems– enabling broad-based benefits
Thank you
The HIV/AIDS Emergency is Not Over
Unfinished Business
Remarkable Opportunities