The HIV/AIDS Treatment Acceleration Program for Africa

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 managementor 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 200or
  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, SantEgidio, 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 TechniciansBecause 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 SantEgidio, MSF)

18
Treatment Infrastructureis 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
  availableSustainability 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 ME 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 ME 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 SantEgidio,
  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)