1. Implementing operational research for HIV treatment scale-up in resource-limited settings TB/HIV Research Priorities in Resource-Limited Settings Expert Consultation - Geneva, 14-15 February 2005 Yves Souteyrand, Strategic Information and Research Unit HIV/AIDS Department

2. 2 Operational Research for scaling up treatment and prevention  Learning by doing: an incomplete evidence base should not be a barrier to start scaling up the rapid identification of strategic evidence and application of the new knowledge and successes is critical the development and implementation of an appropriate OR agenda is a key component of the scale-up strategy  Priority to OR that: support the scaling up process document and evaluate public health approach (simultaneous efforts to scale-up treatment and accelerate prevention; scale-up in the context of primary chronic disease management; effective and equitable treatment provision) is relevant, responsive to and can inform programmes is embedded in national programmes

3. 3 Role of WHO and TDR  Comparative advantages Presence in countries Collaboration with and support to Ministries of Health and National programmes Experience in implementation of research in multiple settings for multiple health problems Network of stakeholders and professionals in the field Trust in the Organization's stewardship  Catalyze and promote collective efforts involving countries and key partners (but not implementing)

4. 4 Operational research: WHO & TDR achievements (1)  Global framework established : Expert consultation (Geneva, July 2004) Priorities identified in the key areas (clinical, socio economic, behavioural and health system issues) : Improving treatment and uptake to those in need Dispensing ARVs and supporting adherence Optimizing consequences of treatment for individuals and communities Strengthening health systems

5. 5 Priority areas for Operational Research  Individual, community and social factors Inequity in access to treatment Quality of services Demand and uptake of testing and care services Treatment impact on prevention and stigma Community involvement in treatment programmes  Economic issues Role of incentives to influence providers and patients Impact of treatment on household economics Cost and cost effectiveness of clinical guidelines, care, strategies and interventions

6. 6 Priority areas for Operational Research  Scale up of clinical regimens Optimization of treatment initiation and management Performance of clinical guidelines in different contexts Determinants of resistance to treatments Scaling up testing and counselling  Health systems issues Identification of bottlenecks to scaling up Effect of different models of ART delivery and financing on patient outcomes, efficiency and sustainability Determinants of good and poor treatment outcomes Impact of ART roll out on the health system

7. 7 Operational research: WHO & TDR achievements (2)  Country ownership and action: Kampala workshop (December 2004) Five countries: Burkina, Malawi, Tanzania, Uganda, Zambia Country teams: national programmes, implementers, scientists Partners: bilaterals (USG, ANRS, DFID), multilaterals (UNAIDS, GFATM, the World Bank), scientists, NGOs Outcomes Country first priorities identified and first drafts available Agenda to implement country programmes established

8. 8 Country first priorities in operational research Burkina: how to improve coordination between public and private health structures and with NGOs implementing treatment. Strengthening continuum of care and articulation between stakeholders Malawi: factors affecting health care providers for sustaining VCT and treatment programmes, including perception of their own stakes Tanzania: development of tool for measuring adherence in resource limited settings Uganda: how to better integrate prevention into ART delivery services Zambia: strategies to increase ART provision among TB and PMTCT facilities

9. 9 Operational research: WHO & TDR planned activities (1) With partners:  Jointly coordinate oversight and support to countries to implement, evaluate and follow up proposals ( process for evaluating and implementing proposals: Programme Development Team; first meeting April 2005) to generate capacity that can be further utilised (e.g. through applications to USG, GFATM)  Promote cross country learning and collaboration  Establish OR culture and capacity within national programmes  Establish real-time knowledge sharing and utilisation  Expand the process to other countries

10. 10 Operational research: WHO & TDR planned activities (2)  Develop generic tools to address questions that are common across countries to develop tools that will facilitate the country OR implementation and the comparative approach linking treatment and prevention measuring and promoting adherence comparing costs and cost effectiveness of interventions quantifying resistance determinants

11. 11  Operational Research Programme Robert Ridley, TDR Carla Obermeyer, HIV Department Philip Onyebujoh, TDR