1. Bridging the Divide Wafaa El-Sadr, MD, MPH Columbia University and Harlem Hospital Vienna, July 20, 2010

2. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening Vienna, July 16-17 Background: HIV scale-up and health systems Meeting objectives and agenda

3. www.worldmapper.org HIV Prevalence Persons Living with HIV/AIDS, 2008 33.2 million (30.6-36.1 million) worldwide

4. Health Systems in Crisis: Infrastructure

5. Health Systems in Crisis: Human Resources

6. Health Systems in Crisis: Laboratory and Pharmacy Systems

7. Antiretroviral Therapy by Region, 2001

8. Unique Characteristics of HIV and its Treatment Drive Programmatic Innovation 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 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)

9. Innovations: Multidisciplinary Teams, Health Workforce Task-shifting Changing role of nurses Linkages with pharmacy Linkages with laboratory New cadres (from peer educators to data clerks) Involvement of PLWHA Mentorship and supportive supervision > formal didactic training Enhanced stewardship and supervision by regional health bureaus

10. Innovations: Family-Focused Services Co-located and co- scheduled appointments Family enrollment forms Linkages Community outreach Couples counseling Prevention counseling Integration with primary care, reproductive health, TB, and malaria services

11. Innovations: Transparent Target- setting, Record Keeping, Data Use Appointment systems On-site medical records File rooms Data clerks Charting tools Enrollment forms Electronic medical records / databases Supportive supervision Data-based clinical systems mentorship Use of data to guide quality initiatives

12. Innovations: Tiered Laboratory Systems, Linkages, Specimen Transport Support for national laboratory plans & guidelines Tiered system strategy Infrastructure Equipment/supplies Training Standardized approach to patient monitoring Decentralization of services Enhanced quality

13. Innovations: Community Participation and Support Mapping of community resources Support of and for community-based organizations Outreach to community leaders and key stakeholders Establishment of organizations of PLWA New models for governance

14. Innovations: Substantial Financing and Financing & Payment Schemes Performance-based payment Inclusion of HIV services in workplace plans, some national health insurance schemes Leveraging the private sector Use of “vertical” funds to support broader efforts (mutuelles in Rwanda, health workforce in Malawi)

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

16. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening Vienna, July 16-17 What is the impact of HIV scale-up?

17. Estimated Impact of ART on AIDS-related deaths, 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

18. ART coverage and all-cause mortality in South Africa, 2003–2006 WHO, Towards Universal Access, 2009

19. Under-two Child Mortality/1000 Live Births Kwa Zulu Natal, South Africa Ndirangu et al. AIDS 2010

20. Impact of HIV Services on Mortality of HIV- uninfected Infants Mortality, Uganda Prospective cohort of 1373 HIV-infected adults and 4601 HIV-uninfected household members ART and cotrimoxazole associated with – 95% reduction in mortality among HIV-infected – 81% reduction in mortality in uninfected children < 10 years of age – 93% reduction in orphanhood Mermin et al, Lancet 2008

21. Effect of PMTCT Programs on Quality of Overall Antenatal Care and Delivery, Cote D’Ivoire Delvaux et al, IAS 2009

22. Effect of ART on Incidence of Malaria Uganda & Zimbabwe Kasirye et al, IAS 2009

23. Impact of ART on worker absenteeism

24. Impact of ART as Prevention: Effect on New HIV Infections Free ART TaiwanBritish Columbia, Canada Wood et al. BMJ 2009;338b:1649 Fang et al. JAIDS 2004;190:879-85

25. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening Vienna, July 16-17 What about other health threats?

26. 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

27. Commonalities of Barriers and Challenges Maternal healthChild healthTBDiabetesHIV/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 27

29. Cape Town 2009: Accelerating the Impact of HIV Programming on Health Systems Strengthening

31. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening Vienna, July 16-17 Meeting Objectives: To foster interdisciplinary partnerships across disciplines To present data and evidence from implementation research, rigorous evaluation and country case studies addressing impact of HIV programming on health systems To discuss options for the future with respect to leveraging HIV programming to improve health systems and other priority health conditions; To highlight a priority research agenda re: HIV and health systems

32. Health Systems Building Blocks

33. Service Delivery Integrated Service Delivery Case Studies Moderator / framing presentation: Rifat Atun Case Study #1: Global Fund Case Study: Kenya – Erin Sullivan (HSPH) Case Study #2: Global Fund Case Study: Malawi – Thyra de Jongh (KIT 25) Case Study #3: GF Case Study: Ghana – Daniel Degbotse (MoH Ghana) Discussant: Yogan Pillay (MOH SA) HIV Scale-Up and Chronic Disease Services Moderator/framing presentation: Kevin De Cock The Growing Global Burden of NCDs – Implications for Health Systems: Joseph-Hubert Perriens (WHO) Integrated Services for HIV, Diabetes, and CVD in Cambodia: Bart Janssens (MSF) Integration of HIV and CVD Services in Kenya: Frank Mwangemi (FHI) Discussant: Peter Lamptey (FHI)

34. Health Workforce Moderator and framing remarks: Wim Van Damme The Future of the CHW – lessons from HIV programs: Eric Buch (UP/NEPAD/GHWA) Expanding the Health Workforce in Ethiopia: Tamrat Assefa (MOH Ethiopia) Leveraging HIV Funding for the Malawi Health Workforce: Frank Chimbwandira (MOH Malawi)

35. Information and Technology Leveraging HIV Scale-up for Health Information Systems Moderators: Kevin Fenton (CDC) and Nosa Orobaton (WHO) Presentation from WHO HIS: John Cutler(WHO) Case Study 1: Charles Nzioka (MoH Kenya) Case Study 2: Michael Graven (Health Metrics Network)

36. Financing and Payments Leveraging Private Sector for Health Moderator: Pamela Rao (USAID) Public Stewardship to Optimize the Role of the Private Sector in Health: Deus Mubangizi (U. of Maryland/Results for Development) Private Sector Engagement in HIV Service Provision in Ethiopia: Tesfai Gabre-Kidan (Abt Associates Inc.) Mobilizing the Private Sector for HIV & Social Health Protection: Joep Lange (Pharm Access) From “Universal Access” to Universal Health Coverage Moderator: Robert Hecht (Results for Development) Financing for Universal Coverage: Are There Generalizable Lessons from Experience? David Evans (WHO) HIV & Social Health Insurance: Overview of Country Experiences: Erik Lamontagne (UNAIDS) HIV Integration and Health Systems Strengthening: Performance-based Financing in Rwanda: Jean Kagubare (MSH) Health Investment and Expenditure Data to assess the Financial Impact of HIV Scale-up Moderator: Charles Holmes (OGAC) Where are the data on health spending and HIV? Understanding the evidence: Anna Vassall (LSHTM) What can we learn from NHA and HIV spending accounts? Jose Antonio Izazola (UNAIDS) HIV and Health Spending Surveys: Jean-Paul Moatti (INSERM-France) Discussant : Susna De (USAID)

37. Leadership and Governance HIV Scale-up and Global Health Moderator: Alan Whiteside, IAS Executive Board Ezekiel Emanuel (USG) Eric Goemaere (MSF) Lynn Freedman (Columbia University) Julian Lob-Levyt (GAVI) Directions For The Future Moderator: Wafaa El-Sadr (ICAP) Key Outcomes: Rifat Atun (Global Fund) Taking Forward Key Outcomes: Eric Goosby (PEPFAR) Taking Forward Key Outcomes: Carissa Etienne (WHO) Taking Forward Key Outcomes: Paul DeLay (UNAIDS) Closing Remarks: Elly Katabira (IAS)

38. Vienna 2010: Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems

39. Bridging the Divide: Interdisciplinary Partnerships for HIV and Health Systems Strengthening Vienna, July 16-17 Build the PartnershipsGenerate the Evidence HIV and Health Systems Strengthening

40. Acknowledgements Steering Committee Sam Adjei, CHeSS Ghana Rifat Atun, The Global Fund Jacqueline Bataringaya, The Global Fund Karl-Lorenz Dehne, UNAIDS Wafaa El-Sadr, ICAP Columbia University Charles Holmes, OGAC Harrison Kiambati, MOH Kenya Jeffrey Lazarus, The Global Fund Sharonann Lynch, MSF Robert Oelrichs, The World Bank Sam Okuonzi, ACHEST Uganda Nandini Oomman, Center for Global Development Gorik Ooms, Yale University Jos Perriens, WHO Estelle Quain, USAID Miriam Rabkin, ICAP Columbia University Subha Raghavan, SAATHI India