1. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Adult Treatment Technical Workgroup US Office of the Global AIDS Coordinator September 2007

2. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Since 2004, the Emergency Plan for AIDS Relief has helped 15 resource-limited countries initiate ART for about 1.1 million persons Available data suggest that patients, who are enrolled in ART programs supported by the Emergency Plan and adherent to therapy, have had good clinical and immunologic outcomes

3. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months On March 30, 2007, President Bush announced his intention to work with the U.S. Congress to reauthorize the Emergency Plan The 5-year, $30 billion proposal would increase the United States initial 5-year, $15 billion commitment made in 2003 for a total of more than $45 billion over 10 years

4. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months As a result, we will have the opportunity to continue to support HIV care and treatment in these countries for at least another 5 years This presentation highlights recommendations we think should be considered for special emphasis to help strengthen and expand these services during the next 12 months

5. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months These recommendations were developed by the Adult Treatment Technical Workgroup during consultations with Ministries of Health and U.S. agencies and partners in countries participating in the Emergency Plan Since these are generic recommendations for the Emergency Plan, we suggest that each country decide how best to use this information

6. The List of 10 Recommendations 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months

7. Scaling up HIV prevention, care, and treatment at primary health care centers Use of non-physicians to provide ART Integration of HIV clinical services both programmatically and at facilities Regionalization of Emergency Plan support for HIV care and treatment services

8. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Implementation of Basic Care Packages Standardization of reporting of HIV care and treatment services Development of standardized evaluation systems for HIV care and treatment Use of cost analysis and mapping techniques to enhance efficiency of HIV services

9. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Public health evaluation that provides data to demonstrate how HIV care and treatment can best be used to promote HIV prevention and reduce the number of new infections Development of plans to improve the probability of long-term sustainability

10. A Description of the 10 Recommendations 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months

11. Scaling up HIV prevention, care, and treatment at primary health care centers Decentralization of HIV care and treatment services to primary health centers is essential to achieve ART targets improve equitable access to care and ART for patients promote ART adherence over the long term

12. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Scaling up Services at primary health care The current USG-supported approach to decentralizing ART services to peripheral sites emphasizes “down referral”, whereby patients are started at a central health facility and referred to a peripheral site for their ART, after initiation of therapy However, this approach is complicated by the saturation of existing ART sites and, perhaps more importantly, many patients are reluctant to transfer their HIV care to peripheral sites

13. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Scaling up Services at primary health care Thus, we recommend that the USG support expanding access to ART at primary health centers, and to achieve this goal, we recommend: Approval and use of non-physicians to initiate and follow up care and ART at primary health centers Collaboration with WHO to prepare an operations manual to standardize and scale up HIV services at primary health centers Adaptation and implementation of the operations manual in each country

14. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Use of non-physicians to provide ART To expand HIV care and ART for those who need these services, we need to support the use of non-physicians To provide enough non-physicians for HIV services, we recommend that the following options be considered: Approval and implementation of policies to allow nurses & others, ie, medical technicians, provide ART Development of plans and provision of funds for recruitment, training, and placement of non- physicians, especially in rural primary health centers

15. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Use of non-physicians to provide ART To provide enough non-physicians for HIV services, we recommend that the following options be considered: Train existing staff at primary health centers to provide ART and increase their salaries based on performance and the increased workload Train and hire care providers who will provide ART in locations where they are needed and will continue to provide these services for at least several years

16. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Use of non-physicians to provide ART To provide enough non-physicians for HIV services, we recommend that the following options be considered: Consider consolidating training oversight and management to 1 or 2 partners to build on technical expertise, experience, and effective relationships with the MOH and Provincial Health Departments In collaboration with the MOH and Provincial Health Departments, support the creation of a national ART training program to standardize certification and increase the number of persons trained

17. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Integration of HIV clinical services programmatically and at facilities To improve the efficiency and effectiveness of HIV clinical services, including PMTCT, palliative care, ART, and TB/HIV, these services should be integrated at both the programmatic and facility level For example, drug management systems for these services should be integrated nationally and at each site Also, ideally only 1 USG-funded partner should support clinical services at each site; another partner could provide clinical services at a site but as a sub-contractor

18. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Integration of HIV clinical services programmatically and at facilities If possible, PMTCT should be offered at every facility that provides antenatal care and ART services To the extent possible, each facility should provide diagnosis and treatment of TB, primarily because newly diagnosed and reactivated TB are so prevalent in HIV-infected patients, and patients are more likely to complete TB therapy if TB therapy is provided at the same site as ART. Alternatively, TB clinics could provide ART for HIV-infected TB patients

19. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Integration of HIV clinical services programmatically and at facilities Integrated PMTCT and ART programs at sites will help to provide family-based care and improve follow-up of women and children in ART programs after delivery More HIV-infected pregnant women need to be started on ART. About 15-20% of infected pregnant women qualify for ART. These patients should be initiated on ART in prenatal clinics or followed in ART clinics at the same site where they are receiving prenatal care

20. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Regionalization of Emergency Plan support for HIV care and treatment services Our experience in several countries suggests that assigning each USG partner to a geographic area in a country to provide HIV care and treatment is a more efficient use of resources than allowing more than 1 partner to support these programs in the area The size of geographic area and the rationale for selecting a partner for each area varies but over time this process is being adopted and implemented in most countries supported by the Emergency Plan

21. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Regionalization of Emergency Plan support for HIV care and treatment services Where this process is not used in a country or a province or region of a country, duplication of services and inefficiencies, including the inability to create networks for clinical services, are usually readily identified, when evaluating programs Ideally, all clinical services, including PMTCT, palliative care, ART, and TB/HIV should be provided by 1 USG partner in each geographic area

22. “In view of the need to expand ART services to rural and underserved areas, each partner has been assigned care and treatment sites on a geographical grouping. This approach constitutes a marked shift from the current ‘facility-based’ focus that has been implemented by partners to date, to a broader approach that looks to expand the delivery of services to an entire geographical area, across the range of health facilities. In so doing, this would greatly facilitate logistics for programme rollout and service delivery” Letter from Permanent Secretary – 26 September, 2005

23. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Implementation of Basic Care Packages In contrast to the widespread success implementing ART programs, HIV care programs have uniformly been less successful in providing cotrimoxazole and other prevention interventions and in retaining patients in care over the long term One recent report estimated that as many as 75% of patients die within 1 year of qualifying for ART, suggesting that initiating ART as soon as a patient qualifies for ART is essential for survival of many infected patients

24. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Implementation of Basic Care Packages However, our experience suggests that patients on ART are often not receiving these interventions We recommend that programs make patient retention in care a priority by developing and supporting strategies to improve clinical care and follow-up for persons who are enrolled in care but are not on ART Basic care packages should be developed, funded, and implemented in programs supported by the Emergency Plan, and care providers should be educated about the importance of these services

25. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Implementation of Basic Care Packages Develop an essential care package that includes cotrimoxazole, tuberculosis screening, and one or more of the following: safe drinking water and personal hygiene insecticide-treated bed nets disclosure and partner notification nutrition and micronutrient supplementation HIV counseling and testing of family members and other contacts

26. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Implementation of Basic Care Packages Cotrimoxazole is the most cost/benefit medication for HIV-infected persons. A study of cotrimoxazole in Uganda published in Lancet in 2004 by Mermin et al found that cotrimoxazole: Reduced death by 46% Reduced the incidence of malaria by 72% Reduced the incidence of diarrhea by 35% Reduced hospitalizations by 31% Slowed the rate of CD4 decline and the rate of viral load increase

27. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Standardization of reporting of HIV care and treatment services More informative reports about clinical services, including PMTCT, care, ART, and TB/HIV are needed to monitor progress in (a) scaling up services, (b) integrating services, (c) providing assess to services, and (d) evaluating cost of services Without this information, developing plans for programs and providing guidance for funding are difficult, emphasizing how important reporting is for establishing and maintaining clinical services programs

28. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Standardization of reporting of HIV care and treatment services We recommend that USG agencies and partners collaborate closely with the Ministry of Health in each country to develop more informative reporting systems for clinical services, especially for PMTCT, pediatric care and ART, and TB/HIV The number of persons on ART are carefully monitored to the benefit of all of the countries and organizations participating in this effort, but treatment is only one of many successes in our complex, multifaceted programs

29. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Development of standardized evaluation systems for HIV care and treatment ART programs of the size and complexity of those funded by the Emergency Plan need to be evaluated on a periodic basis to assess progress with scaling-up and the quality of the program We recommend that the USG evaluate the quality of USG-funded HIV care and treatment programs overall and at each USG-funded ART site at least annually

30. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Development of standardized evaluation systems for HIV care and treatment We recommend that the USG evaluate the quality of USG-funded HIV care and ART programs by answering the following 5 questions at least annually Of persons who enrolled in ART, what proportions are alive and on ART at 6, 12, and 24 months of therapy? Of those who enrolled in ART but are not currently on ART, what proportions (a) died, (b) stopped therapy, (c) transferred, and (d) were lost to follow- up at 6, 12, and 24 months?

31. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Development of standardized evaluation systems for HIV care and treatment Of persons on ART, what is the median differential between the CD4 + cell count at baseline and the CD4 + count at 6, 12, and 24 months? Of those who are on ART, what proportion have undetectable viral load (<400 cells/µL) at 6, 12, and 24 months? Of persons enrolled in care (i.e., both those receiving and not receiving ART), what proportion is in care and/or on ART at 12 months?

32. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Use of cost analysis and mapping techniques to enhance efficiency of HIV services Cost analyses and mapping techniques will be used with increased frequency for the Emergency Plan to improve efficiency, collaboration, and communication We recommend that cost analyses and mapping be supported and used by countries, USG in-country teams, USG partners, and other organizations supporting clinical services

37. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Public health evaluation that provides data to demonstrate how HIV care and treatment can best be used to promote HIV prevention and reduce the number of new infections Public health evaluation will soon be integrated into the Emergency Plan. Plans are currently being developed to determine how this activity will be implemented. When this activity begins, learning how to prevent new infections should be one of the most important questions we address.

38. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Development of plans to improve the probability of long-term sustainability The USG agencies and partners in each country, in collaboration with the Ministry of Health, should develop a 5-10 year plan that balances a significant scale-up during the next 3 years with the long-term goal of reducing USG programmatic oversight of USG- funded HIV care and treatment programs over time

39. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Development of plans to improve the probability of long-term sustainability The overall goal of the Emergency Plan is to help countries develop national HIV prevention, care, and ART programs that are sustainable over the long term By sustainable, we mean that funding for the programs will continue, but direct USG technical support and fiscal oversight will diminish over time Consequently, we recommend that the USG in each country develop a 5-10 year plan to enhance the probability of long-term sustainability

40. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Development of plans to improve the probability of long-term sustainability We recommend that the plan incorporate a graduation process that includes the following principles: The graduation process should not decrease the quantity or quality of services Graduation should be structured in a stepwise fashion that includes follow-up evaluations at specified times to determine the impact of the process on USG-funded activities, prior to advancing to the next stage of the graduation

41. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Development of plans to improve the probability of long-term sustainability Graduation should have two components: technical and fiscal. In the first phase, technical responsibility should be shifted to treatment sites and Provincial Health Departments, and in the second phase, fiscal responsibility should be shifted to the extent possible The criteria and process of each phase of the graduation process should be standardized in the plan

42. The List of 10 Recommendations 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months

43. Scaling up HIV prevention, care, and treatment at primary health care centers Use of non-physicians to provide ART Integration of HIV clinical services both programmatically and at facilities Regionalization of Emergency Plan support for HIV care and treatment services

44. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Implementation of Basic Care Packages Standardization of reporting of HIV care and treatment services Development of standardized evaluation systems for HIV care and treatment Use of cost analysis and mapping techniques to enhance efficiency of HIV services

45. 10 Recommendations to Help Strengthen and Expand HIV Care and Treatment Services during the Next 12 Months Public health evaluation that provides data to demonstrate how HIV care and treatment can best be used to promote HIV prevention and reduce the number of new infections Development of plans to improve the probability of long-term sustainability