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