HIV Program Design: Lessons Learned for a Broader Impact

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HIV Program DesignLessons Learned for a Broader
Impact
Wafaa El-Sadr, MD, MPH International Center for
AIDS Care Treatment Programs (ICAP) Columbia
University Mailman School of Public Health 18
July 2009
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Rapid scale-up of HIV/AIDS programs

• The emergency response to HIV required the rapid
  scale-up of a new type of public-sector health
  program.
• Scale-up of both funding and implementation
• An unprecedented expansion of
  services and systems.

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Unique characteristics of HIV/AIDS drive program
design

• Impact throughout lifecycle
• Affects families, not simply individuals
• Periods of health and periods of illness
• Need for laboratory monitoring and secure drug
  supply
• High levels of retention and adherence required
• Association with stigma and discrimination
• Both treatment and prevention are chronic
  endeavors

Families
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Both HIV prevention and HIV treatment are chronic
endeavors
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Health Systems in Crisis
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Health workforce innovations

• Use of non-physician clinicians
• Change in role of nurses
• Task-shifting and task-sharing
• Introduction of new cadres
• Lay counselors, peer educators, expert patients,
  data clerks
• Mentorship and supportive supervision gt gt formal
  didactic training
• Multidisciplinary teams

Quality services focused on needs of
patients Effective use of health care
workforce Enhance morale of health workers
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New roles-New appreciation
Multidisciplinary teams
Task-shifting
ICAP-Ethiopia
MSF Lesotho
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Innovations for retention adherence

• Co-located, co-scheduled family appointments
• Appointment systems (from simple to
  sophisticated)
• Adherence support (counseling, peer education,
  buddy systems, transportation vouchers)
• Defaulter tracking
• Use of retention and adherence as quality
  indicators

Responsive services Reaching beyond walls of
facilities
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Stakeholder Engagement

• PLWHA
• Communities
• Civil society
• CCMs
• Accountability and transparent target-setting

Generation of demand Community care Accountability
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Innovations in data collection drive quality
programs

• Aggregate data (site census, GIS)
• Use of data at site level for systems mentoring
  and QA
• Electronic medical records (AMPATH, Open-MRS,
  other)
• Attention to outcomes gtgt enrollment targets

Focus on outcomes Focus on quality Empowering
workforce
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Linkage and Integration of Programs and Services
Focus on individual patient required break down
of silos at program and service delivery levels
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Systems for HIV-A chronic disease Health
systems strengthening
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Burden of Disease
Burden of Disease 2004, WHO
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Leading Causes of Burden of Disease (DALYs in
millions)
GLOBAL BURDEN OF DISEASE
Global Burden of Disease, WHO
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Commonalities of Barriers and Challenges
MCH
TB
Diabetes
HTN
HIV/AIDS
Barriers and challenges
Mental health
v v v v v v v v v
v v v v v v v v v

• Demand-side barriers
• Inequitable availability
• Human resources
• Lack of adherence support
• Infrastructure, equipment
• Program management
• Drug supply / procurement
• Referral and linkages
• Community involvement

v v v v v v v v v
v v v v v v v v v
v v v v v v v v v
v v v v v v v v v
Adapted from Travis, Bennett, et al. Lancet 2004
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Chronic endeavors needed for prevention of
acute conditions

• HIV prevention requires support for chronic
  behavior change for prevention of repeated
  exposure
• Analogous situation with other conditions
  misconstrued as isolated acute events
• Diarrhea (exposure to unsafe water sources)
• Malaria (exposure to mosquitoes)
• Lung disease (exposure to cooking smoke)
• STI (exposure to infections in social network)

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Summary

• Characteristics of HIV disease have necessitated
  unique models for health system organization and
  delivery systems
• Models established necessary for confronting
  chronic conditions (communicable
  non-communicable)
• Models also appropriate for achieving protective
  behavior change for acute diseases

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Conclusions

• HIV programs by their nature require health
  system strengthening
• HIV programs can offer a transformative
  opportunity for health services unprepared for
  confronting chronic conditions or achieving
  ongoing protective behaviors
• Lessons learned from effective HIV program
  implementation should guide efforts at
  implementation of other programs

Build on the HIV Platform
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Proposed Evaluation Framework Primary Results
Chain for HIV/AIDS Interventions
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Linking Primary and Secondary Results Chains
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Review of Literature on HIV/AIDSPrograms
Health Services Key Questions

• Do HIV/AIDS programs contribute to broader health
  systems objectives?
• Do HIV/AIDS programs distort health services away
  from local needs?

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Mixed Effects from Quantitative Studies
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Descriptive Studies

• Many reasonable explanations for both positive
  and negative effects for insiders and
  beneficiaries
• Examples
• HIV/AIDS program supported local policies and
  decision-making processes
• Scarce managerial resources were consumed by
  HIV/AIDS programs
• Duplicate systems for HIV/AIDS programs and other
  services

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Conclusions

• Little scientifically robust evidence for or
  against hypotheses that
• HIV/AIDS programs distort health services away
  from local needs
• HIV/AIDS programs systematically contribute to
  additional health systems objectives
• Examples of both positive negative experiences

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Design Features on How to Better Learn about
HIV/AIDS Effects on Health Services

• Use both quantitative and qualitative methods
• Comparison groups and randomization (or matching)
  where possible
• Prospective tracking of primary and secondary
  results chains
• Collect data on all relevant parts of conceptual
  framework

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What to Measure

• Relevant Initiating Conditions
• Health System and External Environment
• Track primary and secondary Results Chains, and
  How they Connect
• Key Enabling and Inhibiting Factors
• Critical Players, Institutions, Functions
• Intended and Unintended Consequences
• Beneficiaries, Other Parts of Health System

Make results available to managers,
policy-makers, and the public for learning,
re-planning, disclosure
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Conclusion

• HIV has offered a transformative opportunity for
  health services unprepared for confronting
  chronic conditions or achieving ongoing
  protective behaviors
• Lessons learned from effective HIV program
  implementation should guide efforts at health
  systems strengthening
• Research is needed to determine effect of HIV
  programming on the health systems

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A Remarkable Achievement
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Vertical Funding
Urgency Plus Sustainability
Horizontal Implementation
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Acknowledgements

• David Peters
• Rene Ekpini
• IAS
• Rockefeller Foundation