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

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ive

prop

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pat

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sw

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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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