Targeting Criteria in National ARV Programs: Mexico, Senegal, and Uganda Catherine Chanfreau, MD, MPH Sara Bennett, PhD Abt Associates, Bethesda, USA XV International AIDS Conference Bangkok, July 2004

Presentation objectives Identify explicit factors used to target government-subsidized ART in Uganda, Senegal, and Mexico Review priority criteria used in two national ART programs and one major pilot project

Background Continued gap between access to and need for ART Explicit policy commitment to provide ART to all those in need Not always feasible in the short term: interim targeting is occurring International clinical guidelines on how to scale up ART exists Lack of policy guidance on how best to allocate scarce life-saving resources

Selection process in the proposed Ugandan National ARV Policy HIV+ Individual Meets clinical eligibility criteria Assessment of likely adherence Unlikely to comply: excluded IMMEDIATE ACCESS TO FREE ART Likely to comply: Eligible HIV+ individual Priority eligibility for: Pregnant women (PMTCT) Health workers (PEP) Mothers identified in PMTCT and their HIV infected family members (PMTCT+) Orphans and vulnerable children People enrolled in support activities Participants in research projects Ordinary eligibility ACCESS TO FREE ART

Selection process in the Initiative Sénégalaise dAccès aux ARV (ISAARV) HIV+ Individual Senegalese Residency Meets clinical eligibility criteria Unlikely to adhere: excluded ACCESS TO ART Likely to adhere: Eligible HIV+ individual Determination of patients contribution Social investigation: adherence & ability to pay Likely to adhere: Exempted from payment: HIV/AIDS activists Health workers Patient accepts contribution rate

Selection process in National ARV policy in Mexico HIV+ Individual Meets clinical eligibility criteria Insured Individual ACCESS TO ART Uninsured Individual Meets MoH program for free care (SSA*) eligibility criteria Citizenship Residency Inability to pay for ART Commitment to adhere to treatment Consent to start and Adhere to treatment Priority accorded to those at more acute stage of disease Previously Treated on ART No prior history of ART treatment: Placed on waiting list SSA: Programa de accesso gratuito a tratamiento Antiretroviral para la poblacion no asegurada de bajos recursos economicos

An Anatomy of prioritization Biomedical factors: patients clinical ability to benefit from ART Prospects for adherence to treatment: patients likelihood to comply Prevention-driven factors: focused ART is the matching piece of UNAIDS focused prevention strategy

An Anatomy of prioritization (cont.) Social and economic benefits: positive externalities associated with sub-groups Social and political empowerment: selection based on gender or role that individuals have played in the fight against HIV/AIDS Financial factors: ability/inability to pay for treatment Ethical arguments: poor and vulnerable children

Conclusions Targeting enables the scale-up of universal access to ART using a step by step approach Explicit targeting criteria are used to allocate public subsidies and formulate policy strategies Biomedical criteria are evidence-based Prospects for adherence to treatment and biomedical criteria are used in virtually all settings Social and political empowerment is a recurrent factor Prevention-driven factors are internationally endorsed ( PMTCT plus)

Thanks … Merci Governments of Uganda and Mexico ISAARV team USAID Uganda