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Treatment 2.0 Catalyzing the Next Phase

of Scale-up

Decentralized, Integrated and Community-Centred Service Delivery

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Background

6.6 million on ART13 fold increase in six years

Global coverage ~40%

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Achievements and Challenges

People currently eligible for ART 15 million

People currently receiving ART (2010) 6.6 million

ESTIMATED TREATMENT GAP 9 million

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What is Treatment 2.0

Joint WHO/UNAIDS Initiative

Catalyse the next phase of treatment: achieve and sustain universal access and maximize preventive benefits of ART

Radical simplification and improved efficiencies and effectiveness of all aspects of care and treatment

Continue scale up in cost neutral environment while intensifying advocacy for more resources to end the epidemic

– doing more with less

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Priority Work Streams of Treatment 2.0

1. Optimize drug regimens

2. Promote diagnostics using point of care and other simplified technologies

3. Reduce costs 4. Adapt delivery systems

5. Mobilize communities, protect human rights

TREATMENT2.0

Adapt delivery systems

Mobilize communities

POC and other

simplified monitoring

Optimize drug

regimens

Reduce costs

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What WHO Is Doing

Overall coordination with UNAIDS

Provide support to countries to review and adapt T2.0 principles

Advocacy for commodity price reductions

Anchor all normative work on treatment and care under the Treatment 2.0 umbrella

– Optimization of ART, OI treatment and prevention, testing and counselling, PMTCT– Secondary preventive benefits of ART and primary benefit of ARVs (PrEP)– Adherence and retention in care– Nutrition support – TB/HIV – Reduction in stigma, discrimination, protection of human rights

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Focus on Priority Work Stream 4: Adapting Delivery Systems

1. Optimize drug regimens

2. Promote diagnostics using point of care and other simplified technologies

3. Reduce costs 4. Adapt delivery systems

5. Mobilize communities, protect human rights

TREATMENT2.0

Adapt delivery systems

Mobilize communities

POC and other

simplified monitoring

Optimize drug

regimens

Reduce costs

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The Cost of Treatment

Source UNAIDS 2010

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The cost of late diagnosis and treatment

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Principles for Adapting Delivery Systems Decentralizes

• HIV care into the community

Integrates• Prevention, diagnosis and treatment• Using chronic health care model

Shifts from stand alone ART services• ART delivered in primary care, ANC, MCH, TB and drug dependency services

Expands HIV testing and counseling• Health sector and community • Entry point to treatment and prevention

Strengthens• Procurement and supply systems

Links– Health sector and community-based services

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Decentralization

Sub-Saharan Africa 80% rural communities

Transport to and from clinic difficult– limited or no public transport– roads often impassable

Best way to deliver care – decentralization

Task shifting/sharing is key– WHO global guidelines 2008– slow adoption in many settings

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Integration

Slide courtesy of Emily A. Bobrow, PhD, MPH Senior Research Officer Elizabeth Glaser Pediatric AIDS Foundation

Linking and integrating health services provides people with user-friendly care they need, when they need it

Maximizing retention and health outcomesProviding better value for money

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From evidence to recommendationsThe GRADE process

Mapping

Internal reference group Agreed

outcomes

ExternalGuidelines review group

GRC*Systematic review

Guidelines

GRADE = The Grading of Recommendations Assessment, Development and Evaluation

*GRC WHO Guidelines Review Committee

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Evaluation framework

1. Equity and human rights

2. HIV outcomes

3. Non-HIV outcomes

4. Cost

5. Systems

6. Socio-economic security

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Critical patient & public health outcomes

• Knowledge of status • Earlier uptake/access to ART• Mortality• Cost efficiencies• Quality of care• Morbidity• Retention• Acceptability• Transmission

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HIV testing and counselling PICO

For people living in generalised or concentrated HIV epidemics (P), should community HTC be provided by non-physician providers (I), compared to providing only facility based HTC and PITC (C), to increase knowledge of HIV status linked to access to HIV prevention and treatment (O)?

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Task Shifting PICOS For HIV-infected people eligible for ART in generalised or

concentrated epidemics (P), does initiation of ART by appropriately trained non-physician healthcare workers (I), compared to initiation by physicians (C), result in comparable health and programmatic outcomes (O)?

For HIV-infected people eligible for ART in generalised or concentrated epidemics (P), does the provision of maintenance ART by appropriately trained non-physician healthcare workers (I), compared to the provision of maintenance ART by physicians (C), result in comparable health and programmatic outcomes (O)?

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Integration PICOS (1)

In countries with a high burden of TB/HIV co-infection, (P) does ART and HIV care services provided at the TB clinic (I) compared to referral to specialised HIV clinics (C) result in comparable health and programmatic outcomes (O)?

 

In countries with a high burden of TB/HIV co-infection, (P) does TB diagnosis and treatment at specialised HIV clinics (I) compared to referral to TB clinics (C) result in comparable health and programmatic outcomes (O)?

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Integration PICOS (2)

For pregnant women and infants in generalised epidemics (P) does initiation or maintenance of ART and HIV care services within ANC/MCH clinics (I), compared to referral to specialised HIV clinics (C), result in comparable health and programmatic outcomes (O)?

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Primary care PICOS For HIV-infected people eligible for ART in generalised or

concentrated epidemics, (P), does the initiation of ART and HIV care in clinics providing general services in the community (I), compared to referral to specialised HIV clinics for ART initiation (C), result in comparable health and programmatic outcomes (O)?

  For HIV-infected people eligible for ART in generalised, or

concentrated epidemics (P), does the provision of maintenance ART and HIV care in clinics providing general services in the community (I), compared to referral to specialised HIV clinics for maintenance ART (C), result in comparable health and programmatic outcomes (O)?

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Service delivery pilot in Vietnam

Challenges for VietnamLate treatment initiation common

Mortality high in early phase of ART

Limited access and retention Stigma, discrimination and punitive laws

Large burden of TB and drug dependence high among PLHIV Highly verticalized HIV, TB, MCH programs

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Treatment 2.0 adapted to Vietnam situation

Pilot implementation in two provinces – South– Commitment of provincial authorities for

integrated service delivery– ART-TB-MCH services for IDU

– Northwest– Emerging epidemic – Mountainous geography and ethnic minorities– decentralization critical to ensure access

Vietnam Authority of HIV/AIDS Control

Support from WHO

Can Tho

Dien Bien

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Summary

Decentralized and integrated service delivery – into the community and for the community

Key objectives– earlier initiation of ART– improved retention in care– improved survival– reduction of new HIV and TB infections over time

Increased and sustainable ART coverage with the same money– by increasing efficiency without compromising quality of care

Synergise prevention and treatment

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Acknowledgements

Chris Duncombe

Marco Vitoria

Shaffiq Essajee

Reuben Granich