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