1

Framework for Universal Access to HIV Prevention, Treatment and Care in the

Health Sector

Presented byProfessor Charles Gilks,

Director, Co-ordinator TPS,Department of HIV/AIDS

Technical Meeting for the Development of a Framework for Universal Access to HIV/AIDS Prevention, Treatment and Care in the Health Sector

Geneva 18-20 October 2005

2

Aim of the work presented

Identify the set of core HIV interventions that address HIV prevention, treatment and care in the health sector

Propose a framework for action that can help guide countries as they strive to achieve universal access in the health sector

Adopt a sectoral approach, recognizing that for any national response to be successful it must be developed and delivered in a multisectoral environment

3

Health Sector Definition

"The health sector is wide-ranging and encompasses organized public and private health services (including those for health promotion, disease prevention, diagnosis, treatment and care); health ministries; nongovernmental organizations; community groups; and professional associations; as well as institutions which directly input into the health care system (e.g. the pharmaceutical industry, and teaching institutions)."

Global Health Sector Strategy for HIV/AIDS 2003-2007, WHO

4

Where we are

Successful scale-up is taking place in many countries, with significant experience and lessons being learnt

Scale-up is being done in different ways often using diverse plans and models; complex and inter-related processes are involved - and there may be an unbalanced service delivery

Lack of agreement on what constitutes the core elements of HIV prevention care and treatment services

Difficult to identify what processes are necessary to drive current scale-up services forward to achieve and sustain universal access

Countries are increasingly asking WHO, UNAIDS and other partners for clarity and provide guidance on these issues

5

Rationale for a Framework

The framework is intended to provide a structure for discussion of the proposed elements for Universal Access leading to a shared

understanding for all partners

The framework:

Simplifies complex and interrelated processes Highlights the importance of target-driven approaches Identifies the ingredients for country scale-up Specifies the core prevention, treatment and care interventions Recognises that universal access needs action in all core areas Offers an approach which is flexible to different epidemiology Supports health systems strengthening

The framework is a work in progress.

6

Ou

tpu

t Ou

tcom

e Im

pact

Set of coreinterventions for HIV Prevention,Treatment andCare

A Public HealthApproach

Implementation Locus:•Home action•Community action•Facility action•District action•National action

Prevention, Treatment andCare for:•General population•High risk populations•High risk settings•Special groups

Ingredients and Products for Country Scale-up

•Comprehensive scale-up plan•Strategic Partnerships •Sound management capacity•Involvement of PWAs•PSM for commodities •Health sector planning•Financial resource management•Health information system

•Operational guidance - tools and guidelines - national adaptation

Framework for Universal Access to HIV Prevention, Treatment and Care Within the Health Sector

Cou

ntry

Targ

ets

ESSENTIAL ENABLERS

TRACKING PROGRESS

7

Essential Enablers

An enabling environment is one in which political, economic, social, legal and health structures support scale-up and should include:

Building and maintaining political commitmentGood governance practices and structuresPromotion of a rights-based approach Supportive legislative and regulatory environment

Enablers cut across all sectors and are not solely the responsibility of the health sector

8

Principles of a Public Health Approach for Scale-up of HIV services

A public health approach is necessary to reach as

many people as possible with the required services

Package of priority interventions for prevention, treatment and care

Decentralized service delivery models

Simplified and standardized approaches

Standardized, integrated training

Harmonized tracking and reporting

9

A Target-driven process Targets are set and owned at the national level Progress can be measured against targets and milestones Accountability with achievement of targets on time

Targets across the package of priority interventions Ongoing work to propose a complete set Targets are measurable and relevant Methodologies are clearly stated and defined

Country methodologies and targets are harmonized

Regular (annual) reporting of progress National reports Global reports

Major milestones include 2010 (G8) and 2015 (MDGs)

10

Ingredients for Country Scale-up

Comprehensive, integrated scale-up planEnsuring strategic partnerships Ensuring greater involvement of PLWHAsSound management capacity at all levelsComprehensive health sector planningSuccessful procurement and supply management for commodities Acquisition, management and reporting of financial resourcesHealth Management Information SystemOperational guidance

11

Set of inter-related Core HIV Interventions

Preven

tion

, Treatm

ent, C

are

Basic prevention HIV testing and counseling (client initiated) STI detection and treatment Targeted interventions (MSM, SW, IDU, Others) Positive prevention PEP: non-occupational Occupational health and safety Blood safety PMTCT ART including adherence support TB-HIV co-treatment OI treatment Substitution therapy Provider initiated Testing and Counselling OI prophylaxis Nutritional support Psychosocial support Palliative care: symptom management & end-of-life care

12

Home and Person:•Positive prevention•Universal precautions•ART, TB one-to-one treatment support•Psychosocial support•Home-based palliative care

Community: Above plus:• CHWs: adherence, monitor, refill ART, TB, OI prophylaxis; prevention: safer sex, condoms, FP; nutritional support•HIV testing and counseling (CITC/ VCT)•Targeted interventions (outreach)•Broad-based prevention (emphasis on youth)•Community mobilization for prevention, treatment preparedness, use of services

Health centre: Above plus:•Provider-initiated T&C•PMTCT•STI detection and treatment•Special care: IDU, sex worker; youth-friendly•Initiate first-line ART in uncomplicated patients•TB treatment, TB-HIV Co-management•Treat most OIs

Hospital: Above plus:•Blood safety•ART in complicated patients, second-line, IRIS, severe toxicity•TB: smear negative, extrapulmonary, TB-ART co-management•Complicated OIs

•PEP- occupational, non-occupational•Safe medical injections

•IDU: drug substitution, detox

Locus of interventions

13

Home and Person:•Positive prevention•Universal precautions•ART, TB one-to-one treatment support•Psychosocial support•Home-based palliative care

Community: Above plus:•CHWs: adherence, monitor, refill ART, TB, OI prophylaxis; prevention: safer sex, condoms, FP; nutritional support•Client-initiated T&C (VCT)•Targeted interventions (outreach)•Broad-based prevention (emphasis on youth)•Community mobilization for prevention, treatment preparedness, use of services

Health centre: Above plus:•Provider-initiated T&C•PMTCT•STI detection and treatment•Special care: IDU, sex worker, youth-friendly•First-line ART in uncomplicated patients•TB treatment, TB-HIV Co-management•Treat most OIs

Hospital: Above plus:•Safe blood •ART in complicated patients, second-line, IRIS, severe toxicity•TB: smear negative, extrapulmonary, TB-ART co-management•Complicated OIs

Examples of operational tools from WHO and partners:Integrated Management of HIV/AIDS at Facility with Linked Community Interventions (based on IMAI/IMCI/IMPAC)

•PEP- occupational, non-occupational•Safe medical injections

•IDU: drug substitution, detox

14

Tracking Progress

Need to be strategic in what we measure - and why• Standardised methodologies and agreed indicators• One harmonised M&E system (3 ones)

Improve quality of care and prevention • Local review of results• Continuous quality improvement

Demonstrate progress towards Universal Access• Process and Outputs:

• Service Availability Mapping (SAM) and GIS systems• Outcome and Impact:

• Treatment: STARTOMS• Build consensus on prevention indicators

• National and global reports:• National authorities• Donors and funders

15

Summary

Our premise and the basis for our discussion:

A proposed framework intended to

provide guidance to countries in the use of

a harmonised approach to scaling up HIV

prevention, treatment and care services as

they strive to achieve Universal Access