1. Scale-up of HIV Programs: A Platform for the Global Health Response Wafaa El-Sadr, MD, MPH Harlem Hospital & Columbia University

2. www.worldmapper.org HIV Prevalence

3. Characteristics of HIV that drive program design Characteristics of HIV DiseaseShaping the Response Impact throughout lifecyclePrograms for adults and children (including pregnant women, infants, children, adolescents) Asymptomatic periods, acute illness, chronic symptoms Chronic disease model (prevention, health maintenance, continuity care, linkages) Multiplicity of clinical & psychosocial needs Multidisciplinary teams (teamwork, referral systems, community resources) Importance of adherence & retentionOutreach & tracking, decentralization Provider-patient relationship Need for clinical & laboratory monitoring, secure supply of medications Medical records and data systems, secure procurement systems Transmissible infectionCounseling, prevention methods (antenatal care, family planning and prevention methods)

4. Number of people receiving antiretroviral therapy in low- & middle-income countries, by region, 2002–2008 WHO, Towards Universal Access, 2009

5. HIV prevalence & Performance of Health Systems UNAIDS 2009 WHO 2000

6. A Healthcare System in Crisis

7. Increased antiretroviral therapy coverage and decrease in all-cause mortality South Africa, 2003–2006 WHO, Towards Universal Access, 2009

8. Estimated number of AIDS-related deaths with and without antiretroviral therapy, globally, 1996–2008 2.5 2.0 1.5 0.5 1.0 3.0 0 Number (millions) Year 1996199820002002200420062008199719992001200320052007 No antiretroviral therapy At current levels of antiretroviral prophylaxis UNAIDS 2009 AIDS Epidemic Update 2.9 M lives saved

9. Support for Systems

10. Mosaic of Services

11. Health System Framework

12. Health System Components and Elements of HIV Scale-up Health System ComponentsElements of HIV scale-up Leadership/GovernanceEngagement of PLWA, coordinated response FinancingMutuelles, performance based financing, user fees Medical products//technologyLaboratories,, drug procurement systems InformationMedical record system, data collection & management systems Health WorkforceNew cadres, task shifting, training/mentorship, interdisciplinary collaboration Service DeliveryContinuity care, linkage and integration (MCH, TB/HIV), family focus, outreach beyond facilities, comprehensive services, behavioral plus biomedical intervention (prevention & treatment)

13. Framework: HIV programs touch each building block of the health system

14. Vertical Funding Horizontal Implementation TARGETS & Outcomes

15. What about other health threats? Mortality Rates in Adults in Africa

16. Disproportionate Disease Burden Land Mass www.worldmapper.orgwww.worldmapper.org 2006 HIV Prevalence 15-49 years Tuberculosis Cases Malaria DeathsChildhood Diarrhea

17. Synergies Antenatal care Postnatal care Male involvement Safe motherhood Maternal mortality Child follow-up Maternal follow-up TB diagnostics Early TB diagnosis ART for TB prevention & improved TB outcomes Use of IPT Adherence & outreach Infection control Maternal follow-up

18. Integration of TB/HIV Programs and Services Traditional TB and HIV Paradigm HIV Services C&T CPT ART OI Dx & Tx Adherence support PWP TB Services Sputum collection DOT Contact tracing IPT National TB Program National HIV Program National TB Program National HIV Program New TB/HIV Paradigm Integration of Services Communication

19. What about other health threats? Mortality Rates in Adults in Africa

20. Commonalities of Barriers and Challenges Maternal health Child health TB Diabetes HIV/AIDS Barriers and challenges Demand-side barriers Inequitable availability Human resources Lack of adherence support Infrastructure, equipment Program management Drug supply / procurement Referral and linkages Community involvement Adapted from Travis, Bennett, et al. Lancet 2004

21. Millennium Development Goals (MDGs). MDG-1: to eradicate extreme poverty and hunger; MDG-2: to achieve universal primary education; MDG-3: to promote gender equality and empower women; MDG-4: to reduce child mortality; MDG-5: to improve maternal health; MDG-6: to combat HIV/AIDS, malaria, and other diseases; MDG-7: to ensure environmental sustainability; and MDG-8: to develop a global partnership for development

22. Push versus Pull Strategy? Investment in HIV Programs Pull Strategy Push Strategy Investment in Health Systems

23. Health System Framework

24. Systems Thinking for Health Systems Strengthening, AHPSR/WHO 2009

25. Synergies

26. Conclusions Significant achievements in HIV program scale-up– but much more needs to be done –Treatment available for only 40% of those in urgent need –Prevention available to 1 in 5 individuals HIV scale-up is a remarkable results- oriented global assistance program – achieving meaningful outcomes – transforming health systems – enabling broad-based benefits

27. Thank you The HIV/AIDS Emergency is Not Over Unfinished Business Remarkable Opportunities