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The HIV/AIDS Treatment Acceleration Program for Africa

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Title: Scaling Up HIV/AIDS Treatment in Africa Author: wb12440 Last modified by: Wilbert Bannenberg Created Date: 1/23/2003 10:31:03 AM Document presentation format – PowerPoint PPT presentation

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Title: The HIV/AIDS Treatment Acceleration Program for Africa


1
The HIV/AIDS Treatment Acceleration Program for
Africa
  • World Bank, Africa Region
  • Concept Paper
  • June 2003

2
Outline
  • Introduction
  • Challenges
  • The Proposed Africa Regional HIV/AIDS Treatment
    Acceleration Program

3
The Status of HIV/AIDS Treatment in Africa
  • There are 30 million people infected in Africa
  • Of which six million in need of ART
  • Many will be difficult to reach even with the
    best of effort
  • Current treatment target of WHO 3 million by
    2005
  • Actual number of people treated Less than 50,000

4
Recent Opportunities
  • Treatments are becoming much simpler 2 pills per
    day rather than 10 to 15
  • WTO negotiations allow low income countries to
    use generic drugs
  • Because of competition, cost of first line drugs
    has dropped to around 20 dollars per month
  • Diagnostic techniques options are increasing and
    prices are falling

5
Treatment Benefits Now Exceed Treatment Costs
  • Prophylaxis of opportunistic infections and
    Prevention of MTCT have proven cost effective
  • Comprehensive treatment including ART can now be
    made available at less than 500 dollars a year
  • Treatment of employees is now a cheaper option
    for employers than letting them progress to AIDS
  • Large scale comprehensive treatment will reduce
    the growing orphan problem, benefit the health
    sector, and reduce pain and suffering

6
HIV/AIDS Treatment A Continuum of Five Components
  • VCT and regular checkups for all who are HIV
  • Positive Living and Survival Skills, including
    psychosocial support, nutrition, etc.
  • Prophylaxis and treatment of opportunistic
    infections (OI)
  • Anti-retroviral treatment (ART)
  • Prevention of Mother to Child Transmission,
    including treatment of the mothers and infected
    family members (MTCT-Plus)

7
Component 1 VCT and Regular Checkups
  • Voluntary Counseling and Testing available at
    treatment centers and in communities
  • Classify patients into stages 1,2,3,4 of HIV
    disease
  • Baseline blood tests, including CD4
  • Prevention and treatment of STDs
  • Provide basic guidance
  • Can be done by a nurse/technician entry point
    to any treatment

8
Component 2 Healthy Living and Survival Skills
  • The patient is the most important co-producer of
    his or her own health
  • Knowledge about HIV/AIDS progression, and
    treatment
  • Psychosocial support, combating depression,
    dealing with addiction, etc
  • Nutrition education, nutritional supplements
  • Immune stimulation by vitamins, minerals and
    aspirin
  • Combat stigma and isolation
  • Encourage participation in prevention, peer
    support, home-based care, and defense of human
    rights Improves, prolongs life at a very low
    cost

9
Component 3 Prophylaxis and Treatment of
Opportunistic Infections
  • Starts when patient reaches stage three
  • Determined by syndromic managementor when CD4
    count drops to 200 or below
  • Start prophylaxis for some common OI
  • Treat remaining OI when they occur, with special
    emphasis on tuberculosis, STDs
  • Adds several years of life
  • at a very low cost
  • but implementation lagging badly

10
Component 4 Anti-retroviral Thearpy (ART)
  • Initiated when CD 4 count falls below 200or
    when patient shows symptoms of AIDS-defining
    opportunistic infections
  • Provide one of several triple therapy regimes
  • Follow up with monthly checkups, blood tests to
    monitor and prevent serious side-effects, then
    quarterly dramatic impact on survival most
    complex and costly component

11
Component 5 Prevention of Mother to Child
Transmission
  • Administration of ARVs at birth to mother and
    baby, and prevention of transmission of virus
    through breastfeeding
  • Care and treatment (including ART) of the mother
    and other infected family members via
  • Family centered care and community support
  • Continuity of care, by a multi-disciplinary team
    of providers
  • Psychosocial support, treatment of depression,
    and interventions to promote treatment adherence
  • Integration with other programs such as Family
    Planning and Reproductive Health, STD prevention
    and treatment

12
Treatment Is Complementary to Prevention
  • VTC and counseling lead to reduction of stigma
    and supports behavior change
  • So does training in healthy living and survival
    skills
  • Prevention and treatment of STDs lowers
    transmission of HIV direclty
  • Patients enrolled in treatment programs
    frequently become active in prevention programs
  • ART reduces viral load and therefore infections
    associated with unsafe sex

13
Opportunities Have Not Led to Rapid Expansion of
Treatment
  • Less than 50,000 people are under treatment in
    Africa
  • Current Global Fund grants envisage ART for about
    200,000 patients
  • IDA funds provide for ART, but current plans
    envisage treatment of less than 10 000 patients
  • Promising pilot programs of Medecins Sans
    Frontières, SantEgidio, AIDS Empowerment and
    Treatment International, PharmAccess have not
    attracted adequate funding

14
Why Has Progress Been So Slow
  • Governments are struggling to formulate treatment
    policies, protocols and programs
  • Focus is mostly on medical control rather than on
    implementation mechanisms for scaling up
  • Governments have been reluctant to finance
    programs outside of the public sector

15
Key Challenges to Be Addressed
  • Rapid adaptation of WHO treatment guidelines and
    protocols to specific country situations
  • Agreement on best delivery and scaling up
    mechanisms
  • Low and declining numbers of heath professionals
  • Inadequate laboratory infrastructure
  • Cost-effectiveness and fiscal sustainability
  • Buy-in of governments

16
Consensus on Medical Treatment Protocol for
Resource-limited Settings
  • Developed in pilots by numerous actors over past
    three to four years
  • Patient adherence and treatment results equal or
    better than in developed world
  • Consensus codified in WHO treatment guidelines
  • Additional research focuses on further gradual
    improvements

17
Low and Declining Number of Doctors, Nurses,
Other TechniciansBecause of AIDS Death and
Emigration
  • Stop the dying of HIV-positive medical personnel
    and others involved in treatment
  • Delegate treatment components which do not need
    a doctor, technician or nurse to others
  • Mobilize latent capacities in the private sector,
    NGOs, association of people living with HIV/AIDS,
    etc
  • Improve employment conditions and training
    programs for medical personnel, others involved
    in treatment
  • Mobilize self-financing volunteers from the
    developed World, (example SantEgidio, MSF)

18
Treatment Infrastructureis Inadequate
  • Successful HIV/AIDS-Treatment reduces the demand
    for hospitals, other clinical infrastructure,
    doctors dealing with complex OI and terminal AIDS
    cases
  • The WHO treatment protocol reduces the intensity
    of medical tests and laboratory investment
    requirements
  • New testing techniques do the same and reduce
    costs
  • Much of the required laboratory infrastructure
    can be provided by the private sector, and this
    investment must be promoted .. an important,
    but not very complex issue

19
The Centrality of Financial and Fiscal
Sustainability
  • Even at the reduced costs, treatment cannot be
    made to be entirely self financing
  • Co-finance of treatment by OECD countries and
    African governments will be needed
  • But unless overall costs of treatment decline
    further, millions cannot be reached even with the
    expanded resources now becoming
    availableSustainability requires investing in
    the construction of efficient and reliable
    outreach mechanisms

20
The Seven Margins of Cost-reduction and
Sustainability
  • Target treatment subsidies to poor rural and
    urban patients, and to essential health,
    education, and agricultural personnel
  • Recover costs from those able to afford treatment
  • Further reduce cost of the ARVs, OI drugs,
    diagnostic tests via astute and reliable
    procurement and distribution systems
  • Mobilize drug donations from industry

21
More Margins
  • Encourage and support health insurance
    initiatives which include HIV/AIDS treatment
  • in private sector or public/private partnerships
  • Enhance the fund-raising capabilities of the
    community organizations and NGOs involved
  • Improve the capability of PLWHAs to co-finance
    their own treatment by supporting their income
    generation activities

22
The Role of National AIDS Council and Ministries
of Health
  • Develop treatment policies, framework, and
    guidelines
  • Institute national mechanisms for assuring
    pharmaceutical and treatment quality
  • Coordinate and facilitate mechanisms for
    monitoring and evaluation, and for sharing of
    lessons learned
  • Facilitate continuous training and upgrading of
    all involved in treatment
  • Facilitate registration, imports, and in some
    cases production of quality generic drugs
  • Facilitate the upgrading and rational use of
    existing public and private treatment and
    laboratory infrastructure and competencies

23
Lessons From MAP Implementation
  • Implementation support has focused on making the
    money flow to implementing agencies, and enabling
    them to procure goods and services
  • Management attention to making an impact on the
    ground is essential and still growing
  • The pace of disbursements is therefore
    accelerating significantly
  • Key lesson A concerted effort will bring results
  • Treatment is complex and progress under the MAP
    is too slow. Therefore an additional program is
    needed

24
The Proposed IDA Treatment Acceleration Program
25
Objectives of the Treatment Acceleration Program
(TAP)
  • Test the scalability of existing HIV/AIDS
    treatment programs of NGOs and public/private
    partnerships
  • Ensure that the treatment programs are
    comprehensive, decentralized, cost-effective,
    equitable, and sustainable
  • Monitor, evaluate and learn from these programs
  • Disseminate the lessons and implementation tools
    across Africa rapidly

26
Components of the TAP
  • Country programs to accelerate the scaling up of
    the five components of holistic HIV/AIDS
    Treatment (four countries)
  • Cross-country facilitation and learning program
  • Across and from the four countries
  • To benefit other MAP countries

27
Links Between Multi-sector HIV/AIDS Program and
the TAP
  • MAP countries have concentrated on awareness,
    prevention, and voluntary counseling and testing
  • Treatment programs are under preparation in many
    MAP countries
  • Financed by several donors, including the MAP
  • Focusing primarily on the public sector
  • MAP countries will draw lessons, mechanisms, and
    tools from the TAP, and thereby facilitate the
    use of rapidly increasing donor support

28
The Country Programs
  • Fund scaling up of existing holistic HIV/AIDS
    treatment programs of NGOs and public/private
    partnerships which include all five components of
    treatment
  • Institute ME systems to strengthen the programs
    and compare the scalability, cost-effectiveness,
    equity, treatment adherence and quality among
    programs
  • Assist countries treatment coordination
    capabilities and quality assurance
  • Disseminate lessons, prepare for national
    mainstreaming
  • Assist countries in improving health insurance
    systems, medical benefit plans, and the targeting
    and administration of treatment subsidies

29
Eligibility Criteria for the TAP
  • Existing treatment programs of domestic or
    international NGOS, communities, or
    public/private partnerships, which
  • include at least treatment components one to
    three, and preferably all five component
  • innovate on at least four of the seven margins of
    sustainability
  • address low and declining medical personnel,
    and/or laboratory infrastructure in innovative
    ways
  • foster confidentiality and ethical approaches to
    treatment
  • ensure equitable patient selection in rural and
    urban areas
  • Organizations commit to freely share lessons
    learned and tools developed

30
Other Program Characteristics
  • Reach into or out from public or private centers
    of excellence
  • Through district and local hospitals and health
    centers
  • Via NGOs and faith-based organizations
  • By involving communities and associations of
    people living with HIV/AIDS
  • Establish and sustain financial accountability
  • Institutionalize accountability to patients,
    their families and communities, associations of
    people living with HIV/AIDS

31
Monitoring and Evaluation
  • Independent monitoring and evaluation of
    scalability, treatment quality, equity, and
    sustainability is essential
  • Must include comparison among alternative
    treatment implementation mechanisms within and
    across countries
  • Therefore the ME indicators need to be similar
    or the same all treatment programs
  • They must be implemented from the start of the
    program and include an adequate baseline
  • They should generate comparable clinical and
    economic data for research

32
Monitorable Targets to Be Developed During
Preparation
  • Most importantly the number of patients treated,
    and number of locations in where treatment takes
    place
  • The health outcomes and patient satisfaction
  • Including survival, treatment failure, adherence,
    and drop-out rates, side effects
  • The mobilization of latent capacities
  • The success of other innovative features
  • The cost-effectiveness and sustainability of the
    program
  • The spillover effects to prevention

33
Program Duration and Size
  • TAP will be a three year program running in four
    countries
  • Lessons will be mainstreamed as soon as they
    become available during the program and at the
    end
  • Overall costs likely to be US 50 million, the
    bulk of which will be in country programs

34
TAP Partners
  • Likely implementing partners SantEgidio,
    Columbia University, PharmAccess, AIDSETI, MSF,
    Red Cross
  • Facilitating partners International Treatment
    Access Coalition (ITAC), World Health
    Organization (WHO), United Nations Economic
    Commission for Africa (UNECA)
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