Scaling up ART in Sénégal: specifics needs for strategic information Mame Awa Toure MD, MSc AIDS/STI Division, MOH Senegal

Introduction Senegal: a west African country Area: km² Population estimated to 10 millions 11 regions and 30 departments/ provinces. Resources constrained settings: GDP of 500$ US. Concentrated HIV epidemic Low HIV prevalence in general population less than 2% 5-20% in high risk group

The Senegalese Initiative for Access to ARVs : ISAARV A Governmental initiative late 1997 Political commitment : increasing annual subsidy Collaboration of ANRS: technical support, project design First step : Pilot study Building up a model according limited resources Evaluation before extension (collaboration with ANRS) Second step : scale up for nationwide access

Accelerating phase of ISAARV  Political comittement Government subsidy increased Subsidy included to the national budget line Credit IDA : MAP  Expanding Fund and Partnership for ARV program  government,  WB, GF, USAID/FHI, UE, GTZ, UN agencies… Decrease of the of financial participation Increasing demand

Increasing government budget

Financial participation Government subsidy con’t October 2000: ACCESS Program Levels of financial participation SES assessed by a social workers team A package including drugs, CD4 count and viral load Low income: $30- $7 per month Government officers $60- $15 About 80% of patients treated free of charge

ISAARV managerial structures Health facilities level: hospital/treatment centers Medical committees Enrollment and medical follow up PEP documentation and management Psycho-social support committees Adherence support, accompaniment counseling… PLWHA clubs Coordination level: HIV/AIDS Division, MOH Drugs and reagents management committee PMTCT management committee VCT piloting committee

Services delivery package District level : operational level Counseling, certain OI management, * PMTCT services, Referral functional system, Monitoring ARV (next step) Hospital level : district + ARV ARV entry point Rapid functionality of structures

Needs, coverage ISAARV components prior Conditions: HIV testing available/ VCT ARV Treatment Centers Counseling, treatment of OI, use of Cotrimo… Laboratories capacity : CD4, routine exams Training of health personals ARV monitoring committees

Needs, coverage (2) Monitoring ART Adults, Children, PMTCT Post Exposure Prophylaxis Psycho-social and adherence support Supportive research: Monitoring drugs resistance Promoting clinical trials

Chain of distribution National procurement pharmacy Treatment centers Regional procurement pharmacy Fann PharmacyRegional hospital/ Districts HPD, IHS

ISAARV up to date 1350 patients included Period Aout 98 - may out of 11 regions involved Active local sponsorship in process Extension to the remaining regions by end of 2003

How does the data collection work? Patient monitoring Detailed patient data base for the first 100 naives patients enrolled to the pilot phase, Database on 80 patients enrolled in the two clinical trials ANRS1204/ ANRS1206 Few initiatives on the remaining Data not being collected regularly Lack of systematized data collection

Strategic objectives Nationwide access to ARV drugs planned Strenghten capacities in the 11 regions Increasing number of PLWHA treated 7000 patients by 2006  M&E system urgently needed!!! Weak part of the program to be improved

M&E approach M&E system already in place For other priority diseases except HIV/AIDS new strategies (PMTCT, ART..) Building up process for HIV/AIDS: Capacity building** M&E Unit: NACA, MOH, and other ministries Strengthening technical resources: training

M&E approach (2) M&E plan developed Workshop in June 2003: set of indicators for each components ** (UNGASS/MAP) M&E tools and Operational guidelines to be developed training Data collection plan

M&E approach (5)

M&E approach (4) next steps by end of 2003 Workshop series Update and reinforce competencies in M&E within targeted sectors (health, education, youth…) Priority for the Health sector TOT, training series M&E tools development Data collection plan Data collection forms Defining evaluation system and calendar M&E sub- units to be set up at the regional level, Contracting services ???

Specifics needs Lack of technical resources : Urgent need to Strenghten HR capacities in M&E Recruit human resources for M&E units at each level More use of available data Systematisation of information, Regular data collection For patient monitoring and program monitoring

Specifics needs ARV delivery system to be improved Logistical issues Better planning of Evaluations for all ISAARV components Evaluation of the pilot phase (ANRS 02) More in-dept Cost-effectiveness analysis External expertise needed