Recommendations for HIV Service Delivery WHO 2013 ARV Consolidated Guidelines

Key service delivery and programme issues  Low testing coverage, and inadequate linkage from testing to care  Delayed diagnosis and treatment initiation, inadequate retention in care  Low treatment coverage among key populations

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Expanded testing scenarios Decentralization and service integration Task shifting Adherence support Key Operational Considerations

onsiderable operational challenges Considerable operational challenges 4 Low testing coverage, and linkage to care

Type date Expanded testing and linkage to care WHO 2013 Recommendations: Generalized epidemics: community- based HIV testing in addition to PITC Concentrated epidemics: community- based HIV testing for key populations in addition to PITC provider-initiated testing and counselling (PITC) Adolescent testing and counselling WHO 2013 Recommendations: Generalized epidemics: community- based HIV testing in addition to PITC Concentrated epidemics: community- based HIV testing for key populations in addition to PITC provider-initiated testing and counselling (PITC) Adolescent testing and counselling Suthar et al, Plos Medicine 2013 (in press)

Experience in home based testing Multiple countries implemented community based testing approaches: supplementing PITC in health facilities provides opportunity to reach individuals tested for the first time provided opportunity for multi disease interventions Multiple countries implemented community based testing approaches: supplementing PITC in health facilities provides opportunity to reach individuals tested for the first time provided opportunity for multi disease interventions Sweat M et al. Community-based intervention to increase HIV testing and case detection in people aged 16—32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study. The Lancet Infectious Diseases, Volume 11, Issue 7, Pages , July RCTS + 8 observational studies (community vs facility based testing in generalised epidemics) Increased rate of first testers and diagnoses CD4 >350 cells 3 studies in key populations Increased uptake, but rate of first testers comparable

onsiderable operational challenges Considerable operational challenges 7 Inadequate retention in care Delayed initiation of ART ARV stock outs

Western Cape Provincial Dept. of Health, South Africa, % lost to care After 5 years 50% lost to care After 5 years Mugglin et al, Trop Med Int Health, % drop out of care at each step from testing to ART Losses along the Continuum of Care

Recommendations: Decentralization of HIV Care And Treatment To Primary Care And Community Settings Recommendations: Decentralization of HIV Care And Treatment To Primary Care And Community Settings RECOMMENDATIONSTRENGTH & QUALITY OF EVIDENCE ART initiation at hospital and maintenance at peripheral health facility. Strong recommendation, Low quality of evidence ART initiation and maintenance at peripheral health facility. Strong recommendation, Low quality of evidence ART initiation at peripheral health facility with maintenance at community level. Strong recommendation and Moderate quality of evidence Moving to more integrated and linked and primary care models of service delivery Impact of decentralization will improve programme outcomes Consider drugs and diagnostics supply, training/supervision of health workers;task-shifting Clinical teams led by nurse or clinical officer Community-based care District hospital Option 1: Option 3: Central/Regional Hospitals Option 2:

Decentralization: Bringing ART closer to communities WHO 2013 Recommendations: Initiation and maintenance of ART in peripheral primary facilities maintenance of treatment at community level between clinic visits. WHO 2013 Recommendations: Initiation and maintenance of ART in peripheral primary facilities maintenance of treatment at community level between clinic visits. 2 observational studies (initiating and maintaining at peripheral sites) Attrition declined at 12 months 2 cluster RCTs (community maintenance) Attrition comparable at 12 months

Recommendations: Service Integration of ART with ANC/MCH Care, TB Care, OST Settings RECOMMENDATION STRENGTH & QUALITY OF EVIDENCE ART initiation and maintenance in pregnant/BF women and their infants in MNCH settings, with link to ongoing HIV care and ART. Strong recommendation, and Very low quality of evidence ART initiation in TB care settings in high TB and HIV burden settings, with linkage to ongoing HIV care and ART. Strong recommendation, Very low quality of evidence TB treatment and diagnosis in HIV care settings in high burden of HIV and TB. Strong recommendation and Very Low quality of evidence ART initiation and maintenance in OST settings. Strong recommendation and Very Low quality of evidence Implementation considerations o Mobilizing and allocating resources o Training, mentoring and supervising health workers o Procuring and managing drugs and other medical supplies o Monitoring and evaluation

TB/HIVService integration: Responding to co-morbidities and multiple needs 19 observational studies – ART delivery in TB settings increased ART uptake and timeliness of ART initiation 5 observational studies – TB treatment in HIV care Decreased mortality 19 observational studies – ART delivery in TB settings increased ART uptake and timeliness of ART initiation 5 observational studies – TB treatment in HIV care Decreased mortality

Examples of integration: South Africa  60% co-infection rate (HIV and TB)  50% of deaths in pregnant women and children associated with HIV  Need for integration is obvious  Since 2010 all PHC facilities that provide TB, sexual & reproductive, ANC and child health services, including school health services, also targeted for HIV services  Currently most public health facilities and over 3500 of 4200 public health facilities offer ART  Many challenges to integration still exist, including infection control! 13

Delivery of ART in settings providing opioid substitution therapy Existing WHO guidance on HIV testing in all drug dependency treatment services Low OST and ART coverage 1 RCT and 3 observational studies Small sample size and variable results Trends for improved viral suppression and reduced mortality

Recommendations: Task Shifting RECOMMENDATIONSTRENGTH & QUALITY OF EVIDENCE Trained non-physician clinicians, nurses, midwives on 1 st line ART initiation. Strong recommendation, Moderate quality of evidence Trained non-physician clinicians, nurses, midwives on ART maintenance. Strong recommendation, Moderate quality of evidence Trained community health workers dispense ARV between clinical visits. Strong recommendation and Moderate quality of evidence Implementation considerations o Enabling policy/regulatory framework o Quality assurance, health workers ongoing professional education, mentoring, supportive supervision, o Sustainability

Task shifting 16 WHO 2013 Recommendations: Trained non-physician clinicians, midwives and nurses can initiate first-line ART and maintain treatment Trained and supervised community health workers can dispense ART between clinic visits WHO 2013 Recommendations: Trained non-physician clinicians, midwives and nurses can initiate first-line ART and maintain treatment Trained and supervised community health workers can dispense ART between clinic visits Sanne et al, Lancet 2010; Fairall et al, Lancet RCTs and 6 observational studies No difference in mortality of LFU at 12 months (non-physicians initiate and maintain on community workers maintain) 3 RCTs and 6 observational studies No difference in mortality of LFU at 12 months (non-physicians initiate and maintain on community workers maintain)

2013 Essential for effective task shifting  Enabling policy/regulatory framework  Quality assurance, ongoing professional education, mentoring, supportive supervision,  Sustainability – Broader strengthening of health systems agenda – Country overall strategy for health workforce planning and management – Political and financial commitment – Need to engage stakeholders, including public service, local government, private sectors and donors

Interventions to support ART adherence: Start before ART initiation and continue throughout treatment Programme Avoid out of pocket payment FDC regimens Prevent ARV stock out Task shifting Linkage with community level interventions Patient and service delivery Patient education & counselling Peer & community support Co-management of substance use disorder Co-management of mental health disorders Nutritional support in food insecure settings Financial support Mobile phone text message Viral load monitoring Pharmacy drug refill records Self-reporting Pill counts ADHERENCE Mobile phone text messages could be considered as a reminder tool for promoting adherence to ART as part of a package of adherence interventions (strong recommendation, moderate-quality evidence). Monitoring

Adherence support: combinations of interventions WHO 2013 Recommendations: Combination of interventions Minimizing out of pocket payments Use of fixed-dose combinations Strengthening drug supply system Patient counselling and education Peer support Nutritional support in food insecure settings Mobile phone text messages WHO 2013 Recommendations: Combination of interventions Minimizing out of pocket payments Use of fixed-dose combinations Strengthening drug supply system Patient counselling and education Peer support Nutritional support in food insecure settings Mobile phone text messages

Psycho-social factors Structural factors Related to knowledge, beliefs and motivations within a given social context (herbal medicine, lack of disclosure, stigma) Underlying economic conditions of daily life (accessibility of care, transportation, work responsibilities, food insecurity) Health care delivery factors Quality of care at the point of contact with the patients (waiting time, conflict with staff, coordination of care, stigma); service inaccessibility (distance from home)

Retention in care: Potential interventions No specific recommendations: multiple interventions necessary to retain patients in care o No single or package of interventions support retention in all context o Service decentralization o Improved patient –provider interaction o Social and peer support o Training of health workers o Programme monitoring and focused evaluation of retention

Summary: operations and service delivery Operational Recommendations Specific Recommendation Recommendation Strength Quality of Evidence Service integration ART initiation and maintenance in pregnant/BF women and their infants in MNCH settings, with link to ongoing HIV care and ART StrongVery Low ART initiation in TB care settings in high TB and HIV burden settings, with linkage to ongoing HIV care and ART StrongVery Low TB treatment and diagnosis in HIV care settings in high burden of HIV and TB StrongVery Low ART initiation and maintenance in OST settings StrongVery Low Decentralization of treatment and care Options of decentralization ART initiation at hospital and maintenance at peripheral health facility StrongLow ART initiation and maintenance at peripheral health facility StrongLow ART initiation at peripheral health facility with maintenance at community level StrongModerate Task shifting Trained non-physician clinicians, nurses, midwives on 1 st line ART initiation StrongModerate Trained non-physician clinicians, nurses, midwives on ART maintenance StrongModerate Trained community health workers dispense ARV between clinical visits StrongModerate