1 |1 | Treatment 2.0 Catalyzing the Next Phase of Scale-up Decentralized, Integrated and Community-Centred Service Delivery

2 |2 | Background 6.6 million on ART 13 fold increase in six years Global coverage ~40% 6.6 million on ART 13 fold increase in six years Global coverage ~40%

3 |3 | Achievements and Challenges People currently eligible for ART15 million People currently receiving ART (2010)6.6 million ESTIMATED TREATMENT GAP 9 million

4 |4 | What is Treatment 2.0 Joint WHO/UNAIDS Initiative Catalyse the next phase of treatment: achieve and sustain universal access and maximize preventive benefits of ART Radical simplification and improved efficiencies and effectiveness of all aspects of care and treatment Continue scale up in cost neutral environment while intensifying advocacy for more resources to end the epidemic –doing more with less

5 |5 | Priority Work Streams of Treatment Optimize drug regimens 2.Promote diagnostics using point of care and other simplified technologies 3.Reduce costs 4.Adapt delivery systems 5.Mobilize communities, protect human rights TREATMENT 2.0 Adapt delivery systems Mobilize communities POC and other simplified monitorin g Optimize drug regimens Reduce costs

6 |6 | What WHO Is Doing Overall coordination with UNAIDS Provide support to countries to review and adapt T2.0 principles Advocacy for commodity price reductions Anchor all normative work on treatment and care under the Treatment 2.0 umbrella –Optimization of ART, OI treatment and prevention, testing and counselling, PMTCT –Secondary preventive benefits of ART and primary benefit of ARVs (PrEP) –Adherence and retention in care –Nutrition support –TB/HIV –Reduction in stigma, discrimination, protection of human rights

7 |7 | Focus on Priority Work Stream 4: Adapting Delivery Systems 1.Optimize drug regimens 2.Promote diagnostics using point of care and other simplified technologies 3.Reduce costs 4.Adapt delivery systems 5.Mobilize communities, protect human rights TREATMENT 2.0 Adapt delivery systems Mobilize communities POC and other simplified monitorin g Optimize drug regimens Reduce costs

8 |8 | The Cost of Treatment Source UNAIDS 2010

9 |9 | The cost of late diagnosis and treatment

10 | Principles for Adapting Delivery Systems Decentralizes HIV care into the community Integrates Prevention, diagnosis and treatment Using chronic health care model Shifts from stand alone ART services ART delivered in primary care, ANC, MCH, TB and drug dependency services Expands HIV testing and counseling Health sector and community Entry point to treatment and prevention Strengthens Procurement and supply systems Links – Health sector and community-based services

11 | Decentralization Sub-Saharan Africa 80% rural communities Transport to and from clinic difficult –limited or no public transport –roads often impassable Best way to deliver care –decentralization Task shifting/sharing is key –WHO global guidelines 2008 –slow adoption in many settings

12 | Integration Slide courtesy of Emily A. Bobrow, PhD, MPH Senior Research Officer Elizabeth Glaser Pediatric AIDS Foundation Linking and integrating health services provides people with user-friendly care they need, when they need it Maximizing retention and health outcomes Providing better value for money

13 | From evidence to recommendations The GRADE process Mapping Internal reference group Agreed outcomes External Guidelines review group GRC* Systematic review Guidelines GRADE = The Grading of Recommendations Assessment, Development and Evaluation * GRC WHO Guidelines Review Committee

14 | Evaluation framework 1.Equity and human rights 2.HIV outcomes 3.Non-HIV outcomes 4.Cost 5.Systems 6.Socio-economic security

15 | Critical patient & public health outcomes Knowledge of status Earlier uptake/access to ART Mortality Cost efficiencies Quality of care Morbidity Retention Acceptability Transmission

16 | HIV testing and counselling PICO For people living in generalised or concentrated HIV epidemics (P), should community HTC be provided by non-physician providers (I), compared to providing only facility based HTC and PITC (C), to increase knowledge of HIV status linked to access to HIV prevention and treatment (O)?

17 | Task Shifting PICOS For HIV-infected people eligible for ART in generalised or concentrated epidemics (P), does initiation of ART by appropriately trained non-physician healthcare workers (I), compared to initiation by physicians (C), result in comparable health and programmatic outcomes (O)? For HIV-infected people eligible for ART in generalised or concentrated epidemics (P), does the provision of maintenance ART by appropriately trained non-physician healthcare workers (I), compared to the provision of maintenance ART by physicians (C), result in comparable health and programmatic outcomes (O)?

18 | Integration PICOS (1) In countries with a high burden of TB/HIV co-infection, (P) does ART and HIV care services provided at the TB clinic (I) compared to referral to specialised HIV clinics (C) result in comparable health and programmatic outcomes (O)? In countries with a high burden of TB/HIV co-infection, (P) does TB diagnosis and treatment at specialised HIV clinics (I) compared to referral to TB clinics (C) result in comparable health and programmatic outcomes (O)?

19 | Integration PICOS (2) For pregnant women and infants in generalised epidemics (P) does initiation or maintenance of ART and HIV care services within ANC/MCH clinics (I), compared to referral to specialised HIV clinics (C), result in comparable health and programmatic outcomes (O)?

20 | Primary care PICOS For HIV-infected people eligible for ART in generalised or concentrated epidemics, (P), does the initiation of ART and HIV care in clinics providing general services in the community (I), compared to referral to specialised HIV clinics for ART initiation (C), result in comparable health and programmatic outcomes (O)? For HIV-infected people eligible for ART in generalised, or concentrated epidemics (P), does the provision of maintenance ART and HIV care in clinics providing general services in the community (I), compared to referral to specialised HIV clinics for maintenance ART (C), result in comparable health and programmatic outcomes (O)?

21 | Service delivery pilot in Vietnam Challenges for Vietnam Late treatment initiation common Mortality high in early phase of ART Limited access and retention Stigma, discrimination and punitive laws Large burden of TB and drug dependence high among PLHIV Highly verticalized HIV, TB, MCH programs

22 | Treatment 2.0 adapted to Vietnam situation Pilot implementation in two provinces –South –Commitment of provincial authorities for integrated service delivery –ART-TB-MCH services for IDU –Northwest –Emerging epidemic –Mountainous geography and ethnic minorities –decentralization critical to ensure access Vietnam Authority of HIV/AIDS Control Support from WHO Can Tho Dien Bien

23 | Summary Decentralized and integrated service delivery –into the community and for the community Key objectives –earlier initiation of ART –improved retention in care –improved survival –reduction of new HIV and TB infections over time Increased and sustainable ART coverage with the same money –by increasing efficiency without compromising quality of care Synergise prevention and treatment

24 | Acknowledgements Chris Duncombe Marco Vitoria Shaffiq Essajee Reuben Granich