SWITCHING FROM MONOTHERAPY AND SCALING UP COMBINATION TREATMENT FOR PMTCT PRESENTATION TO REGIONAL A

1
SWITCHING FROM MONOTHERAPY AND SCALING UP
COMBINATION TREATMENT FOR PMTCTPRESENTATION TO
REGIONAL AND TECHNICAL TEAMS
2
Background

• In May 2009, the Board asked the Secretariat to
• Conduct a review of the Global Fund grant
  portfolio to identify pediatric HIV high-burden
  countries with low coverage rates for PMTCT and
  pediatric HIV care, support and treatment
  services and
• Prepare options for the PIC to use available
  mechanisms to accelerate transitions to more
  efficacious ARV regimens for effective PMTCT.
• Note The scope of work did not include Pediatric
  HIV care, support and treatment

3
Global Fund investment on PMTCT in SSA India
(2)
Source Enhanced Financial Reporting NB
Expenditure for India is almost 60 million
4
Global Fund investment on PMTCT in SSA India (3)

1 Annual need Source WHO, UNAIDS, UNICEF,
2008. Towards universal access scaling up
priority HIV/AIDS interventions in the health
sector. Progress report 2008. Geneva. 2
Expenditure and coverage data are cumulative
since the beginning of Global Fund financing.
Global Fund coverage figures may include service
and commodity deliverables that are co-financed
by others.
5
Further analysis

• Deeper analysis to overcome limitations to the
  data reported
• An in-depth analysis of countries in the Global
  Fund portfolio beyond Africa and India will be
  done to inform a phased roll-out of the of the
  action plan
• Financial analysis will be done to estimate the
  cost for reprogramming (next slide)

6
Framework of Action Re-defining PMTCT SDA

• Work closely with technical partners to define a
  comprehensive PMTCT package
• A Steering Group will lead this work and
  includes
• UNAIDS
• WHO
• UNICEF
• UNFPA
• CIFF and
• Other technical partners
• Work with TRP to translate the PMTCT service
  delivery package into minimum standards for PMTCT
  SDA for new proposals, effective Round 10

7
Framework of Action Advocacy

• Develop an advocacy plan to mobilize CCMs,
  Governments, NGOs and partners to
• Prioritize optimal PMTCT service delivery and
• Strengthen maternal and child health care, SRH
  and PHC services
• The Steering Group will lead the work around
  advocacy plan development
• Advocacy tool to explain the reprogramming plan
  and schedule to countries

8
Framework of Action M E

• Robust monitoring and evaluation of the
  reprogramming is planned
• Steering Group will submit the following reports
• Quarterly reports to Secretariat Management
• Six monthly reports to PIC

9
Critical success factors

• Programmatic challenges
• Securing country support to transition from mono
  to dual/triple therapy in the absence of
  supportive legislative environment.
• Addressing service delivery bottlenecks through
  broad HSS actions
• Service Delivery issues
• Engage with partners on feasible evidence-based
  options for infant feeding.
• Providing PMTCT at non ARV sites
• Enhancing integration and linkages between PMTCT
  and other client-oriented services
• Countries making use of existing HSS grants to
  improve turn-around time for HIV and related test
  results

10
Partnerships

• Partnerships are one of the key pre-requisite
  and success factor
• GF will play a catalytic role, with partners
  playing a leading role
• Harmonization between donors approaches (e.g.
  PEPFAR) to avoid high concentration of resources
  in the same countries.
• Work with technical partners in linking PMTCT and
  RH.
• Working with partners in advocacy and
  coordination of partners activities at country
  level.
• Work with international NGOs during
  implementation and scale up of programs and
  sharing of local knowledge)
• Work with local CSO during implementation and
  scale up of programs, sharing local knowledge and
  advocacy)

11
Reprogramming

• Reprogramming existing grants using a phased
  approach
• 27 out of the 34 countries require switching from
  sd-NVP to dual/triple therapy

• Phase 1
• This phase has begun
• Countries that are ready to switch immediately
• PMTCT guidelines revised
• Available infrastructure
• Integrated services
• Sufficient HR
• Support them switch immediately

• Phase 2
• Preparatory work for this phase is in progress
• Countries that will likely be ready in the short
  term
• PMTCT guidelines revised
• Centralized testing facility
• Sub-optimal HR
• Services not linked
• With partners, develop TA

• Phase 3
• Countries that are not likely to be ready in a
  short term
• Outdated guidelines
• Lack of infrastructure
• Insufficient HR
• Engage partners i.e. UNAIDS RSTs to develop
  extensive TA plan

12
A NEW Framework of Action Priority countries
13
Addressing sub-optimal PMTCT services
Number and percentage of HIV pregnant women
receiving ARV prophylaxis, 2004-2007
68 of Global Burden is in 10 African countries
14
Percentage of HIV positive pregnant women
receiving ARV treatment for PMTCT
Addressing sub-optimal PMTCT services
Source UNAIDS (2008 report)
15
Coverage Analysis
Addressing sub-optimal PMTCT services

• New coverage data will be released by UNAIDS on
  29 September
• This will show higher levels of coverage
• Coverage suffers from the Nevirapine cascade
• The efficacy is sub-optimal
• South Africa coverage masks low efficacy
• High coverage does mean that the infrastructure
  may exist to take the intervention to the next
  level
• The Western Cape experience demonstrates that the
  sd-NVP scale up built the infrastructure for more
  complex programming

16
Addressing sub-optimal PMTCT servicesTen High
Burden Countries
17
Estimated Number of HIV positive Children(014)
in the PMTCT focus countries
Addressing sub-optimal PMTCT services
70
Source UNAIDS (2008 report)
18
Percentage of HIV positive pregnant women
receiving ARV treatment for PMTCT
Addressing sub-optimal PMTCT services
Source UNAIDS (2008 report)
19
Global Fund investment on PMTCT in Ten High
Burden Countries
Grants in detail on GF website Accessed on the
25th July
20
Potential Opportunities for switching PMTCT
Component
Addressing sub-optimal PMTCT services
21
Next steps
Addressing sub-optimal PMTCT services

• Engage Team Leaders and Portfolio Managers
• Discuss with CCMs and PRs
• Define programming and budget gaps
• Renegotiate targets and indicators
• Jointly review regimens and diagnostics together
  with PRs, NACs and CCMs (including technical
  partners UNAIDS WHO UNICEF)
• Build acceleration into disbursement requests
• Reprogramming opportunities with new grants
  (Round 8 and 9, Phase 2, RCC)

22
An Evaluation Framework

• Would we benefit from an evaluation framework
  before we embark on this ambitious project
• Is it possible to have a simple and implementable
  evaluation framework
• What are the essential activities to evaluate
  with limited resources
• What should the time frames be?
• Who should do this evaluation?
• Whats the governance model?

23
23
24
HIV Prevalence Antenatal survey
WC DOH, 2008
25
ANC HIV Prevalence - Metro
26
Example Evolution of PMTCT services in Western
Cape South Africa
(Boulle 2009)
27
PMTCT Results - Western Cape Province
n 108,352
n 103,043