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The HIV/AIDS Treatment Acceleration Program for Africa World Bank, Africa Region Concept Paper June 2003.

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Presentation on theme: "The HIV/AIDS Treatment Acceleration Program for Africa World Bank, Africa Region Concept Paper June 2003."— Presentation transcript:

1 The HIV/AIDS Treatment Acceleration Program for Africa World Bank, Africa Region Concept Paper June 2003

2 Outline Introduction Challenges The Proposed Africa Regional HIV/AIDS Treatment Acceleration Program

3 The Status of HIV/AIDS Treatment in Africa There are 30 million people infected in Africa –Of which six million in need of ART Many will be difficult to reach even with the best of effort Current treatment target of WHO: 3 million by 2005 Actual number of people treated: Less than 50,000

4 Recent Opportunities Treatments are becoming much simpler: 2 pills per day rather than 10 to 15 WTO negotiations allow low income countries to use generic drugs Because of competition, cost of first line drugs has dropped to around 20 dollars per month Diagnostic techniques options are increasing and prices are falling

5 Treatment Benefits Now Exceed Treatment Costs Prophylaxis of opportunistic infections and Prevention of MTCT have proven cost effective Comprehensive treatment including ART can now be made available at less than 500 dollars a year Treatment of employees is now a cheaper option for employers than letting them progress to AIDS Large scale comprehensive treatment will reduce the growing orphan problem, benefit the health sector, and reduce pain and suffering

6 HIV/AIDS Treatment: A Continuum of Five Components VCT and regular checkups for all who are HIV+ Positive Living and Survival Skills, including psychosocial support, nutrition, etc. Prophylaxis and treatment of opportunistic infections (OI) Anti-retroviral treatment (ART) Prevention of Mother to Child Transmission, including treatment of the mothers and infected family members (MTCT-Plus)

7 Component 1: VCT and Regular Checkups Voluntary Counseling and Testing available at treatment centers and in communities Classify patients into stages 1,2,3,4 of HIV disease Baseline blood tests, including CD4 Prevention and treatment of STDs Provide basic guidance Can be done by a nurse/technician …entry point to any treatment

8 Component 2: Healthy Living and Survival Skills The patient is the most important co-producer of his or her own health Knowledge about HIV/AIDS progression, and treatment Psychosocial support, combating depression, dealing with addiction, etc Nutrition education, nutritional supplements Immune stimulation by vitamins, minerals and aspirin Combat stigma and isolation Encourage participation in prevention, peer support, home-based care, and defense of human rights Improves, prolongs life at a very low cost

9 Component 3: Prophylaxis and Treatment of Opportunistic Infections Starts when patient reaches stage three Determined by syndromic management or when CD4 count drops to 200 or below Start prophylaxis for some common OI Treat remaining OI when they occur, with special emphasis on tuberculosis, STDs Adds several years of life …at a very low cost …but implementation lagging badly

10 Component 4: Anti-retroviral Thearpy (ART) Initiated when CD 4 count falls below 200 …or when patient shows symptoms of AIDS- defining opportunistic infections Provide one of several triple therapy regimes Follow up with monthly checkups, blood tests to monitor and prevent serious side-effects, then quarterly dramatic impact on survival …most complex and costly component

11 Component 5: Prevention of Mother to Child Transmission Administration of ARVs at birth to mother and baby, and prevention of transmission of virus through breastfeeding Care and treatment (including ART) of the mother and other infected family members via –Family centered care and community support –Continuity of care, by a multi-disciplinary team of providers –Psychosocial support, treatment of depression, and interventions to promote treatment adherence –Integration with other programs such as Family Planning and Reproductive Health, STD prevention and treatment

12 Treatment Is Complementary to Prevention VTC and counseling lead to reduction of stigma and supports behavior change So does training in healthy living and survival skills Prevention and treatment of STDs lowers transmission of HIV direclty Patients enrolled in treatment programs frequently become active in prevention programs ART reduces viral load and therefore infections associated with unsafe sex

13 Opportunities Have Not Led to Rapid Expansion of Treatment Less than 50,000 people are under treatment in Africa Current Global Fund grants envisage ART for about 200,000 patients IDA funds provide for ART, but current plans envisage treatment of less than 10 000 patients Promising pilot programs of Medecins Sans Frontières, Sant’Egidio, AIDS Empowerment and Treatment International, PharmAccess have not attracted adequate funding

14 Why Has Progress Been So Slow Governments are struggling to formulate treatment policies, protocols and programs Focus is mostly on medical control rather than on implementation mechanisms for scaling up Governments have been reluctant to finance programs outside of the public sector

15 Key Challenges to Be Addressed Rapid adaptation of WHO treatment guidelines and protocols to specific country situations Agreement on best delivery and scaling up mechanisms Low and declining numbers of heath professionals Inadequate laboratory infrastructure Cost-effectiveness and fiscal sustainability Buy-in of governments

16 Consensus on Medical Treatment Protocol for Resource-limited Settings Developed in pilots by numerous actors over past three to four years Patient adherence and treatment results equal or better than in developed world Consensus codified in WHO treatment guidelines Additional research focuses on further gradual improvements

17 Low and Declining Number of Doctors, Nurses, Other Technicians Because of AIDS Death and Emigration Stop the dying of HIV-positive medical personnel and others involved in treatment Delegate treatment components which do not need a doctor, technician or nurse to others Mobilize latent capacities in the private sector, NGOs, association of people living with HIV/AIDS, etc Improve employment conditions and training programs for medical personnel, others involved in treatment Mobilize self-financing volunteers from the developed World, (example Sant’Egidio, MSF)

18 Treatment “Infrastructure”is Inadequate Successful HIV/AIDS-Treatment reduces the demand for hospitals, other clinical infrastructure, doctors dealing with complex OI and terminal AIDS cases The WHO treatment protocol reduces the intensity of medical tests and laboratory investment requirements New testing techniques do the same and reduce costs Much of the required laboratory infrastructure can be provided by the private sector, and this investment must be promoted ……..an important, but not very complex issue

19 The Centrality of Financial and Fiscal Sustainability Even at the reduced costs, treatment cannot be made to be entirely self financing Co-finance of treatment by OECD countries and African governments will be needed But unless overall costs of treatment decline further, millions cannot be reached even with the expanded resources now becoming available Sustainability requires investing in the construction of efficient and reliable outreach mechanisms

20 The Seven Margins of Cost-reduction and Sustainability Target treatment subsidies to poor rural and urban patients, and to essential health, education, and agricultural personnel Recover costs from those able to afford treatment Further reduce cost of the ARVs, OI drugs, diagnostic tests via astute and reliable procurement and distribution systems Mobilize drug donations from industry

21 More Margins Encourage and support health insurance initiatives which include HIV/AIDS treatment – in private sector or public/private partnerships Enhance the fund-raising capabilities of the community organizations and NGOs involved Improve the capability of PLWHAs to co- finance their own treatment by supporting their income generation activities

22 The Role of National AIDS Council and Ministries of Health Develop treatment policies, framework, and guidelines Institute national mechanisms for assuring pharmaceutical and treatment quality Coordinate and facilitate mechanisms for monitoring and evaluation, and for sharing of lessons learned Facilitate continuous training and upgrading of all involved in treatment Facilitate registration, imports, and in some cases production of quality generic drugs Facilitate the upgrading and rational use of existing public and private treatment and laboratory infrastructure and competencies

23 Lessons From MAP Implementation Implementation support has focused on making the money flow to implementing agencies, and enabling them to procure goods and services Management attention to making an impact on the ground is essential and still growing The pace of disbursements is therefore accelerating significantly Key lesson: A concerted effort will bring results Treatment is complex and progress under the MAP is too slow. Therefore an additional program is needed

24 The Proposed IDA Treatment Acceleration Program

25 Objectives of the Treatment Acceleration Program (TAP ) Test the scalability of existing HIV/AIDS treatment programs of NGOs and public/private partnerships Ensure that the treatment programs are comprehensive, decentralized, cost-effective, equitable, and sustainable Monitor, evaluate and learn from these programs Disseminate the lessons and implementation tools across Africa rapidly

26 Components of the TAP Country programs to accelerate the scaling up of the five components of holistic HIV/AIDS Treatment (four countries) Cross-country facilitation and learning program –Across and from the four countries –To benefit other MAP countries

27 Links Between Multi-sector HIV/AIDS Program and the TAP MAP countries have concentrated on awareness, prevention, and voluntary counseling and testing Treatment programs are under preparation in many MAP countries –Financed by several donors, including the MAP –Focusing primarily on the public sector MAP countries will draw lessons, mechanisms, and tools from the TAP, and thereby facilitate the use of rapidly increasing donor support

28 The Country Programs Fund scaling up of existing holistic HIV/AIDS treatment programs of NGOs and public/private partnerships which include all five components of treatment Institute M&E systems to strengthen the programs and compare the scalability, cost-effectiveness, equity, treatment adherence and quality among programs Assist countries treatment coordination capabilities and quality assurance Disseminate lessons, prepare for national mainstreaming Assist countries in improving health insurance systems, medical benefit plans, and the targeting and administration of treatment subsidies

29 Eligibility Criteria for the TAP Existing treatment programs of domestic or international NGOS, communities, or public/private partnerships, which –include at least treatment components one to three, and preferably all five component –innovate on at least four of the seven margins of sustainability –address low and declining medical personnel, and/or laboratory infrastructure in innovative ways –foster confidentiality and ethical approaches to treatment –ensure equitable patient selection in rural and urban areas Organizations commit to freely share lessons learned and tools developed

30 Other Program Characteristics Reach into or out from public or private centers of excellence –Through district and local hospitals and health centers –Via NGOs and faith-based organizations –By involving communities and associations of people living with HIV/AIDS Establish and sustain financial accountability Institutionalize accountability to patients, their families and communities, associations of people living with HIV/AIDS

31 Monitoring and Evaluation Independent monitoring and evaluation of scalability, treatment quality, equity, and sustainability is essential Must include comparison among alternative treatment implementation mechanisms within and across countries Therefore the M&E indicators need to be similar or the same all treatment programs They must be implemented from the start of the program and include an adequate baseline They should generate comparable clinical and economic data for research

32 Monitorable Targets to Be Developed During Preparation Most importantly the number of patients treated, and number of locations in where treatment takes place The health outcomes and patient satisfaction –Including survival, treatment failure, adherence, and drop- out rates, side effects The mobilization of latent capacities The success of other innovative features The cost-effectiveness and sustainability of the program The spillover effects to prevention

33 Program Duration and Size TAP will be a three year program running in four countries Lessons will be mainstreamed as soon as they become available during the program and at the end Overall costs likely to be US$ 50 million, the bulk of which will be in country programs

34 TAP Partners Likely implementing partners: Sant’Egidio, Columbia University, PharmAccess, AIDSETI, MSF, Red Cross… Facilitating partners: International Treatment Access Coalition (ITAC), World Health Organization (WHO), United Nations Economic Commission for Africa (UNECA)


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