Strengthening health systems to expand HIV treatment and advance
country ownership
Francesca Celletti Elizabeth Glaser Pediatric AIDS Foundation
The treatment target
90% 90% 90%
tested on treatment virally suppressed
Defining Country Ownership
When a country
leads, implements &, eventually, finances the
national response to health &
development.
UNAIDS Country Ownership Framework-2012
Global Momentum in Country Ownership
Strengthened Health Systems Are Critical to Advancing Country Ownership
UNAIDS Country Ownership Framework-2012
Leadership/Governance
Health Care Financing
Health Workforce
Medical Products/Technologies
Information & Research
Service Delivery
WHO Building Blocks
90 90 90 Discussion paper
2014
Societal challenges Delivery challenges
Financing
Gap Report 2014
Stigma/discrimination
Criminalization HRH
Service delivery Financing
…
Global Fund Progress report
2012 Human Rights Sustainability
HS equity/efficiency Quality of care
Governance, HRH, SI, …
The challenges to expand access to HIV treatment
HIV/UA
Assessment Report 2009
Financing HRH Commodities Stigma/discrimination Accountability
How do many consider health systems?
An eminent economist “a riddle, wrapped in a mystery, inside an enigma”…quoting Churchill An eminent Health Systems expert - Black hole - Black box - Shopping list
How WHO defines health systems?
The main goals are:
– Improving health and health equity – Responsiveness, financial fairness
and efficiency The intermediate goals are:
– Greater access and coverage – Quality and safety
A health system consist of all organisations, people and actions whose primary intent is
to promote, restore or maintain health
Practical, Evidence-Based Approaches
Country Capacity
WHO Building Blocks
Country Ownership Framework
Broad, Theoretical Concepts
How can we move forward?
Approaches to operationalize health systems strengthening to increase access to ART
Leadership/Governance
Health Care Financing
Health Workforce
Medical Products/Technologies
Strategic InformaAon
Service Delivery
Opera7onaliza7on in HIV Programs
MulA-‐stakeholder governance
IntegraAon and decentralizaAon of HIV
Services
Task ShiGing and CSS
Quality improvement
InnovaAve financing
InnovaAve health products and laboratory
strengthening
WHO Building Blocks Best prac7ces
Service Delivery
Integration of HIV Service Primary Care and HIV treatment
Pfeiffer et al, 2010.
Star7ng ART at 90 days
Total starting ART
Vertical delivery Integrated delivery
0
10
20
30
40
50
60
70
80
90
HIV and Hepatitis C
WHO , 2014
Decentralization of HIV Services and retention on ART
Mutasa-‐Apollo T, 2014
0
20
40
60
80
100
120
1.0 2.0 3.0 4.0 5.0
Primary Health care District/Mission Provincial/Central
Decentralization of HIV Services and increased equity
Mutevedzi, 2009
0
10
20
30
40
50
60
70
80
Western Kakyerere
Central Kakyerere
Eastern Kakyerere
New HIV
New HTN
Leveraging Rapid Community-Based HIV Testing Campaigns for Non-Communicable Diseases
Chamie, 2012
New DM
Human resources for health
Task shifting and quality of care: STRETCH study
Fairall, 2012
Task Shifting and cumulative enrollment of children in ART in EGPAF-supported sites in Mozambique
0
1000
2000
3000
4000
5000
6000
7000
5-‐14 years
Q1/09 - Q4/09 Q1/10 - Q4/10 Q1/11 – Q4/11 Q1/12 –Q4 12
2-‐4 years
0-‐1 years
EGPAF, 2013
Governance
Rwanda: ‘Reining in AIDS, a blueprint for strengthening health systems’
Farmer, 2013
“If you give Rwanda money to save the life of the oldest person today, we will make sure that the infant born tonight benefits too.” Agnes Binagwaho
0
200000
400000
600000
800000
1000000
1200000
2002 2012
870
108 113
In early 2012, Rwanda became one of the first nations to receive direct budget support from
PEPFAR.
EGPAF, 2014
Strengthening national civil society
Health Financing
Asia and Pacific: countries are sharing responsibility as GDP rises
UNAIDS, 2014
Results based financing systems and access to health services
Farmer, 2013
2000
2005
2008
2010
Women using contraception
Deliveries at facility
Children (0-5) using bed nets
Children (0-5) fully immunized
0
10
20
30
40
50
60
70
80
90
100
HIV Commodities
Drugs price and access to ART
WHO, 2014 and WIPO, 2013
Articles
6 www.thelancet.com Published online September 26, 2011 DOI:10.1016/S0140-6736(11)61052-0
lost before completion of staging than younger patients; particularly, loss to follow-up was higher in the age group 15–29 years than in other age groups both before and after the introduction of point-of-care CD4 tests.
DiscussionThe introduction of point-of-care CD4 tests was associated with increased retention of patients and increased ART initiation. The improvements were probably because of a reduction in the time taken to stage patients—from more than 1 month to 3 days—which reduced the opportunities for loss to follow-up and increased the number of treatment-eligible patients who progressed to treatment. For some patients, a point-of-care CD4 test might have simply postponed loss to follow-up to a later time; longer-term studies are needed to assess this possibility. Nevertheless, clinics could counsel and treat patients who would have been lost to follow-up earlier, which might help to reduce subsequent attrition.
The revised WHO antiretroviral therapy guidelines24 for resource-limited settings recommend ART initiation at a CD4 cell count of 350 cells per µL. Untreated patients with CD4 cell counts below this value are at high risk of HIV-related morbidity and mortality,19,25 and patients who start treatment closer to this threshold have decreased mortality with ART.20,26 However, median CD4 cell counts at ART initiation are low; for example, median CD4 cell count was 136 cells per µL in a study of eight sub-Saharan countries.27 Point-of-care CD4 tests might enable more patients to initiate ART with cell counts closer to 350 cells per µL by increase of the number of patients who are successfully staged and by reduction of pretreatment loss to follow-up. Modelling results show that expansion of access to ART initiation below CD4 cell counts of 350 cells per µL is cost-eff ective and provides a substantial survival
advantage compared with other WHO ART recom-mendations.28 In our study, if the threshold of 350 cells per µL had been used for patients aged older than 15 years the proportion of patients eligible for ART would have increased from 45% to 64% in the baseline cohort, and from 42% to 59% in the point-of-care CD4 cohort.
The retrospective, observational, and non-randomised nature of our study is a limitation and hence the results should be interpreted with caution. We took steps to reduce sources of bias; however, our fi ndings might have been subject to confounders for which we did not control in our adjusted analysis. Although the study was done at clinics with well organised data management systems, inaccurate records might have aff ected the study outcomes. The time between study cohorts might have allowed secular changes, for example in clinic operations or the population of patients, to contribute to the observed outcomes. However, characteristics of patients, enrolment rates, and clinic procedures (other than point-of-care CD4 tests) were similar in both study groups. Patients’ characteristics and rates of loss to follow-up and ART initiation at these clinics had not changed in the 12 months before the start of the study. The study clinics were broadly representative of health centres in Mozambique in terms of numbers of patients, staff structures, clinic systems, and HIV management algorithms (based on WHO ART guidelines, which are widely adopted in resource-limited countries). Baseline loss to follow-up was also similar to that reported in other sub-Saharan countries.15–21 A study in Mozambican primary health clinics reported a 23% loss to follow-up between enrolment and CD4 staging, and 69% between staging and initiation.18 Studies in South Africa reported 37% loss to follow-up between diagnosis and CD4 staging,21 and 39% loss to follow-up between staging and ART initation.17 The study clinics might not have been representative of rural health centres because only one site (Mafambisse) was rural, and they were not representative of clinics with on-site conventional CD4 laboratories, which might deliver test results quickly and have less loss to follow-up than clinics without these facilities. Lastly, the new point-of-care CD4 test device might have misclassifi ed eligibility for ART. However, this technology had been previously assessed in Mozambique and found to be accurate compared with laboratory-based CD4 tests.29 Misclassifi cation at the 250 cells per µL threshold was less than 6%, mainly in favour of ART, which is similar to misclassifi cation by conventional laboratory CD4 cell count instruments.
Point-of-care CD4 tests are not a solution for all causes of pretreatment loss to follow-up. Although our study did not assess patient losses between diagnosis and enrolment into HIV care, another study in Mozambique estimated that about 44% of diagnosed patients did not enrol for care.18 Off ering of a point-of-care CD4 test immediately after HIV diagnosis might help to reduce this loss. Second, even after receiving point-of-care CD4 tests,
Cum
ulat
ive
prop
ortio
n of
pat
ient
sw
ho st
arte
d AR
T
Time since enrolment (days)
Odds ratio 2·05 (95% CI 1·42–2·96)
Number at riskWithout POC CD4 492 485 469 452 441 435
With POC CD4 437 389 351 344 344 343
0·50
00 20 40 60 80 100
0·25
Without POC CD4With POC CD4
Figure !: Kaplan–Meier estimate of time from enrolment into HIV care to initiation of antiretroviral therapy before and after the use of POC CD4 for immunological staging at primary health care clinics (p=0·0001)ART=antiretroviral therapy. POC CD4=point-of-care CD4 cell count.
LTF CD4 – ART fell from 64% to 33% Proportion initiating ART doubled from 12-22% Median time to ART initiation reduced from 48 to 20 days Median time to complete CD4 staging reduced from 32 to 3 days
• LTFU between CD4 staging and ART iniAaAon fell from 64 to 33%
• ProporAon starAng ART doubled 12 to 22%
• Median Ame to ART start fell by half
Introduction of POC CD4 and impact on HIV treatment cascade
Jani, 2013
• Country-tailored approaches • National leadership • Country ownership approach • Evidence-based interventions • Community systems strengthening • Cross-sector collaboration • Quality improvement • Strategic metrics ]\
Happy families are all alike, every unhappy family is unhappy in its own way
Anna Karenina, Lev Tolstoy
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