HIV Program Design: Lessons Learned for a Broader Impact Wafaa El-Sadr, MD, MPH International Center for AIDS Care & Treatment Programs (ICAP) Columbia University Mailman School of Public Health 18 July 2009

Rapid scale-up of HIV/AIDS programs 2 The emergency response to HIV required the rapid scale-up of a new type of public-sector health program.  Scale-up of both funding and implementation  An unprecedented expansion of services and systems.

Unique characteristics of HIV/AIDS drive program design Impact throughout lifecycle Affects families, not simply individuals Periods of health and periods of illness Need for laboratory monitoring and secure drug supply High levels of adherence required 3 Families Associated with stigma and discrimination Both HIV prevention and HIV treatment are chronic endeavors

4 Characteristics of HIV DiseaseRequirements Impact throughout lifecycleServices for adults (including pregnant women), infants, children, adolescents Asymptomatic periods, acute episodes of illness, chronic symptoms Health maintenance, continuity care, linkages Multiplicity of clinical & psychosocial needs Multidisciplinary teams, referral systems & partnerships Importance of adherence & retentionRelationship between patients & providers, outreach & tracking Need for clinical & laboratory monitoring, medications & other commodities Infrastructure, medical records/registers, laboratories, procurement systems Transmissible infectionCounseling, antenatal care, family planning and prevention methods

Systems for retention & adherence Innovations from HIV programs can be used in other chronic health systems –Appointment systems (from simple to sophisticated) –Adherence support (counseling, peer education, buddy systems, transportation vouchers) –Co-located, co-scheduled family appointments –Text messaging reminders –Defaulter tracking –Use of retention and adherence as quality indicators 5

Adherence outcomes 6 Mills et al, JAMA, 2006

Health workforce innovations Use of non-physician clinicians –Change in role of nurses –Task-shifting and task-sharing Introduction of new cadres –Lay counselors, peer educators, expert patients, data clerks Mentorship and supportive supervision > > formal didactic training 7

New roles-New appreciation 8 Multidisciplinary teamsTask-shifting MSF Lesotho ICAP-Ethiopia

Stakeholder Engagement PLWHA Communities Civil society CCMs Accountability and transparent target- setting 9

Data innovations drive quality programs Electronic medical records (AMPATH, Open-MRS, other) Aggregate data (site census, GIS) Use of data at site level for systems mentoring and QA Attention to outcomes >> enrollment targets 10

Linkage and Integration of Programs and Services

Systems for HIV- A chronic disease 12

Leading Causes of Burden of Disease (DALYs in millions) GLOBAL BURDEN OF DISEASE Global Burden of Disease, WHO

Burden of Disease 14 Burden of Disease 2004, WHO

Commonalities of Barriers and Challenges MCHTBDiabetes HTNHIV/AIDSBarriers 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 √√√√√√√√√√√√√√√√√√ Mental health

Leveraging HIV programs to strengthen NCD services Adama hospital, Ethiopia –Large HIV/AIDS program (12,635 patients enrolled) –Significant enhancements of infrastructure, lab, pharmacy, medical records throughout facility (not just HIV clinic) funded by PEPFAR –HIV program is the first large-scale chronic disease program at the facility –Tools and approaches developed for HIV will be adapted to support care and treatment of diabetes Appointment systems, peer education, clinical support tools, family enrollment forms, QA/QI, mentoring & supervision, etc. 16

Chronic endeavors needed for prevention of “acute” conditions HIV prevention requires support for chronic behavior change for prevention of repeated exposure Analogous to other chronic and environmental exposures, whose ‘symptoms’ can be misconstrued as isolated acute events Diarrhea (exposure to unsafe water sources) Malaria (exposure to mosquitoes) Lung disease (exposure to cooking smoke) STI (exposure to infections in social network) 17

Vertical Funding Horizontal Implementation

Summary Characteristics of HIV disease have necessitated unique service models Models established necessary for confronting chronic conditions (communicable & non-communicable) Models also appropriate for achieving protective behavior change for acute diseases 19

Conclusion HIV has offered a transformative opportunity for health services unprepared for confronting chronic conditions or achieving ongoing protective behaviors Lessons learned from effective HIV program implementation should guide efforts at health systems strengthening 20

Acknowledgements Governmental and non-governmental partner organizations Persons and families affected by HIV ICAP colleagues Funders 21