Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Implications for Countries: Critical Issues in Service Delivery and Decision Making Dr. Yogan Pillay Deputy Director General National Department of Health, South Africa

Kuala Lumpur, Malaysia, 30 June - 3 July 2013Outline Critical operational/service delivery issues in 2013 guidelines WHO operational/ service delivery recommendations Projected global and country level impact of WHO 2013 recommendations

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 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

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Key WHO Operational and Service Delivery Recommendations Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Expanded testing scenarios Task shifting and decentralization Service integration Adherence support Retention in care

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 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)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 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

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Decentralization: Bringing ART closer to communities WHO 2013 Recommendations: Initiation and maintenance of ART in peripheral primary facilities Initiation of ART in peripheral primary facilities and maintenance at community level between clinic visits. WHO 2013 Recommendations: Initiation and maintenance of ART in peripheral primary facilities Initiation of ART in peripheral primary facilities and maintenance at community level between clinic visits.

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Task shifting: nurses and non-physician clinicians providing care and treatment 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.

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Service integration: Responding to co-morbidities and multiple needs WHO 2013 Recommendations: Initiate and maintain ART in : TB care settings MCH/ANC settings OST settings with linkage to continued HIV care and treatment WHO 2013 Recommendations: Initiate and maintain ART in : TB care settings MCH/ANC settings OST settings with linkage to continued HIV care and treatment

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Scale up of ART in Rwanda Main factors: Strong political commitment Decentralization of ART and integration with primary care services Task shifting for nurses and non-physicians to provide HIV care and ART. Main factors: Strong political commitment Decentralization of ART and integration with primary care services Task shifting for nurses and non-physicians to provide HIV care and ART.

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 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 Mobile phone text messages Nutritional support in food insecure settings 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 Mobile phone text messages Nutritional support in food insecure settings

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Projected impact of the new recommendations Mortality Incidence Cost

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Projected impact: incidence WHO Global ART report, million more infections averted, by 2025, compared to 2010 guidelines

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Projected impact: mortality WHO Global ART report, million more deaths averted by 2025, compared to implementing 2010 guidelines

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Estimated cost of implementing the new recommendations WHO Global ART report, % increase of the billion USD annually for full HIV response

Kuala Lumpur, Malaysia, 30 June - 3 July 2013Acknowledgements Guideline Development Group Co-Chairs Elaine Abrams (International Center for AIDS Care and Treatment Programs, Mailman School of Public Health, Columbia University, USA) Tsitsi Apollo (Ministry of Health and Child Welfare, Zimbabwe) Kevin De Cock (United States Centers for Disease Control and Prevention, USA) Serge Eholie (ANEPA/Treichville Hospital, Abidjan, Côte d’Ivoire) Adeeba Kamarulzaman (University of Malaya, Malaysia) Yogan Pillay (National Department of Health, South Africa) Denis Tindyebwa (African Network for the Care of Children Affected by AIDS, Uganda) Stefano Vella (Istituto Superiore di Sanità, Italy) Special thanks to all the external experts who contributed as members of the Guideline Development Groups, the Peer Review panel and to those who contributed to the GRADE systematic reviews and supporting evidence which informed the guidelines process. WHO Department of HIV Steering Committee Members Andrew Ball Philippa Easterbrook Meg Doherty Eyerusalem Kebede Negussie Nathan Shaffer Lulu Muhe Marco Vitoria Joseph Perriëns Other Contributors