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

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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

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Families

• Associated with stigma and discrimination• Both HIV prevention and HIV treatment are chronic endeavors

Both HIV prevention and HIV treatment are chronic endeavors

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Characteristics of HIV Disease Requirements

Impact throughout lifecycle Services 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 & retention Relationship between patients & providers, outreach & tracking

Need for clinical & laboratory monitoring, medications & other commodities

Infrastructure, medical records/registers, laboratories, procurement systems

Transmissible infection Counseling, 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

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Adherence outcomes

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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

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New roles-New appreciation

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Multidisciplinary teams Task-shifting

MSF Lesotho

ICAP-Ethiopia

Stakeholder Engagement

• PLWHA

• Communities

• Civil society

• CCMs

• Accountability and transparent target-setting

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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

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Linkage and Integration of Programs and Services

Systems for HIV- A chronic disease

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Leading Causes of Burden of Disease (DALYs in millions)

GLOBAL BURDEN OF DISEASE

Global Burden of Disease, WHO

Burden of Disease

14Burden of Disease 2004, WHO

Commonalities of Barriers and Challenges

MCH TB Diabetes HTN HIV/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

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Adapted from Travis, Bennett, et al. Lancet 2004

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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.

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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)

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Ver

tical

Fun

ding

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

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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

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Acknowledgements

• Governmental and non-governmental partner organizations

• Persons and families

affected by HIV

• ICAP colleagues

• Funders

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