1. Antiretroviral Treatment (ART) & Human resources Wim Van Damme Department of Public Health ITM, 17 October 2006

2. Programme today 1. Scale-up ART in developing countries 2. Human resources as bottleneck

3. AIDS = most prominent disease on political scene

11. Why?

12. HIV prevalence in adults in sub-Saharan Africa, 1990−2005

13. Deaths in South-Africa (a model for of future AIDS and non-AIDS Deaths)

14. Deaths at ages 15-34 South Africa: 1980-2025 (Estimated and projected ) 0 400 800 1,200 1,600 2,000 Deaths (thousands) Without AIDS With AIDS 1980-19851985-19901990-19951995-20002000-20052005-20102010-20152015-20202020-2025

15. Disease

16. Dead

19. Changes in life expectancy in selected African countries with high and low HIV prevalence: 1950-2005 with high HIV prevalence: Zimbabwe South Africa Botswana with low HIV prevalence: Madagascar Senegal Mali 30 35 40 45 50 55 60 65 Life expectancy (years) 1950– 1955 1955- 1960 1960- 1965 1965- 1970 1970- 1975 1975- 1980 1980- 1985 1985- 1990 1990- 1995 1995- 2000 2000- 2005

20. AIDS orphans in South Africa

21. Orphans

22. AIDS = political issue… Because AIDS in Southern-Africa = dramatic –Demographic impact –Economic impact –Social impact Reduction in life expectancy  “social involution” “AIDS = Unprecedented health crisis” (!! ??) “AIDS = development crisis” “AIDS = potential security threat”(??)

23. AIDS get a lot of attention worldwide. What are the consequences?

24. International reactions International political reactions –to raise awareness & –financial commitments International policy reactions aiming at operational results: prevention, treatment & care, impact mitigation

25. Political reactions … leading to increased donor funding & international Aids policies. Donor funding –World Bank: MAP –Creation Global Fund –Private foundations: Gates & Clinton –Bush Plan (=PEPFAR) International Aids policies –UNAIDS –WHO: ‘3-by-5’

26. Number of people on antiretroviral therapy in low- and middle-income countries, 2002–2005 North Africa and the Middle East Europe and Central Asia East, South and South-East Asia Latin America and the Caribbean Sub-Saharan Africa Source: WHO/UNAIDS (2005). Progress on global access to HIV antiretroviral therapy: An update on “3 by 5.” 0 200 400 600 800 1000 1200 1400 End 2002 Mid- 2003 End 2003 Mid- 2004 End 2004 Mid- 2005 End 2005 People receiving therapy (thousands) 7.1

27. People in sub-Saharan Africa on antiretroviral treatment as percentage of those in need, 2002–2005 2002 2003 2004 2005 7.2 Source: WHO/UNAIDS (2005). Progress on global access to HIV antiretroviral therapy: An update on “3 by 5.”

28. Tanzania21,500 (7%) Zimbabwe24,500 (8%) Mozambique20,000 (9%) Malawi33,000 (20%) South Africa206,500 (21%) Zambia48,500 (27%) Rwanda19,000 (39%) Uganda75,000 (51%) Thailand81,500 (60%) Brazil174,000 (83%) Botswana72,000 (85%) Estimated people on ART (Dec 05)

29. Human Resources for Health (HRH) in times of AIDS AIDS: which consequences for health staff?

30. Who will do the job?

31. 3 steps in HRH 1. HRH shortages & imbalances 2. Impact of AIDS on HRH 3. HRH needs for ART

32. Countries Nurses per 100 000 population Physicians per 100 000 population South Africa 38869 Swaziland32017 Botswana24128 Zimbabwe5415 Zambia1137 Malawi251 Mozambique202 Belgium1074418 UK496166 USA772549 Source: WHO, 2004 (last update 26 Oct 2004) HRH shortages

34. Impact of AIDS on HRH Increased disease burden (OIs, incl. TB, Malaria?)  Increased demand for care  More consultations  More hospitalisations  Longer hospital stays  “crowding-out effects”

36. AIDS  Increased health worker attrition & absenteeism  Health workers our dying from AIDS  Increased absenteeism due to  own illness  illness of family members  funerals Consequences for the remaining carers Increased workload Compelled to work longer hours, see more patients, assume more tasks  “Burn-out”  “Burn-out” Workplace security (perceived?) risk of HIV infection

37. Acceleration of HRH flows ??

38. HRH crisis in sub-Saharan Africa  Absolute shortages & mal- distribution  Worsened by AIDS  workload ↑↑↑  (?) Accelerated flows & Brain drain

39. ART = labour intensive South-Africa: team of 11 staff for 500 patients on ART: 1 doctor, 2 nurses, 5 counsellors, … WHO review: 5 to 7 staff for 1000 patients Usually doctor-based models

40. PLWHAs per medical doctor PLWHAs per nurse Cambodia7520 Thailand306 Brazil27 Health workers & PLWHAs (2004 data: UNAIDS & WHO)

41. PLWHAs per medical doctor PLWHAs per nurse Botswana67681 Uganda39737 South Africa 17130 Cambodia7520 Thailand306 Brazil27

42. PLWHAs per medical doctor PLWHAs per nurse Malawi7,435286 Mozambique3,446328 Zimbabwe2,337260 Tanzania2,164117 Rwanda1,490142 Zambia1,21675 Swaziland1,13564 Botswana67681 Uganda39737 South Africa 17130 Cambodia7520 Thailand306 Brazil27

43. “Emergency HRH plans” TTR = treat – train - retain Treat health workers Investment in HRH / health systems Need for more HRH through Training?Retention?Importation?

44. Innovative solutions for ART delivery –“Task shifting”… … from MDs to clinical officers to nurses to … ‘lay providers’? Or community health workers? Simplification of treatment protocols? Group treatment?? – peer treatment?? (expert patients?) Implications: legal – financial – mentality - … “Need for a paradigm shift”??

46. In conclusion AIDS in high-prevalence countries = –dramatic for society –dramatic for health system To tackle AIDS needs important investment ($/€) – but: feasible Money = becoming available (Global Fund – PEPFAR) But: capacity constraints: Who will do the job?  investment needed in health system, including human resources + adaptation of treatment models