kuala lumpur, malaysia, 30 june - 3 july 2013 implications for countries: critical issues in service...
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Implications for Countries: Critical Issues in Service Delivery
and Decision Making
Dr. Yogan PillayDeputy Director General
National Department of Health, South Africa
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Outline
• Critical operational/service delivery issues in 2013 guidelines
• WHO operational/ service delivery recommendations
• Projected global and country level impact of WHO 2013 recommendations
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Key service delivery and programme issues
• Low testing coverage, and inadequate linkage from testing to care
• Delayed diagnosis and treatment initiation, inadequate retention in care
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Key WHO Operational and Service Delivery Recommendations
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
• Expanded testing scenarios• Task shifting and
decentralization• Service integration• Adherence support• Retention in care
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Expanded testing and linkage to care
WHO 2013 Recommendations:• Generalized epidemics: community-
based HIV testing in addition to PITC• Concentrated epidemics: community-
based HIV testing for key populations in addition to PITC
• provider-initiated testing and counselling (PITC)
• Adolescent testing and counselling
93% 93%87%
82%
59%
0%
25%
50%
75%
100%
IndexN=6
MobileN=9
SelfN=3
House to houseN=18
WorkplaceN=4
Prop
ortio
n ac
cepti
ng H
TC
Suthar et al, Plos Medicine 2013 (in press)
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Experience in home based testing
• Multiple countries implemented community based testing approaches:• supplementing PITC in
health facilities• provides opportunity to
reach individuals tested for the first time
• provided opportunity for multi disease interventions
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Decentralization: Bringing ART closer to communities
WHO 2013 Recommendations:• Initiation and maintenance of ART in
peripheral primary facilities • Initiation of ART in peripheral primary
facilities and maintenance at community level between clinic visits.
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Task shifting: nurses and non-physician clinicians providing care and treatment
WHO 2013 Recommendations:
• Trained non-physician clinicians, midwives and nurses can initiate first-line ART and maintain treatment
• Trained and supervised community health workers can dispense ART between clinic visits.
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Service integration: Responding to co-morbidities and multiple needs
WHO 2013 Recommendations:Initiate and maintain ART in :• TB care settings• MCH/ANC settings• OST settings with linkage to
continued HIV care and treatment
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Scale up of ART in Rwanda
Main factors:• Strong political commitment • Decentralization of ART and
integration with primary care services
• Task shifting for nurses and non-physicians to provide HIV care and ART.
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0
20 000
40 000
60 000
80 000
100 000
120 000
140 000
People receiving treatmentPeople eligible for treatment [with range]
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Adherence support: combinations of interventions
WHO 2013 Recommendations:Combination of interventions
• Minimizing out of pocket payments• Use of fixed-dose combinations• Strengthening drug supply system• Patient counselling and education• Peer support • Mobile phone text messages• Nutritional support in food
insecure settings
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Projected impact of the new recommendations
• Mortality• Incidence• Cost
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Projected impact: incidence
WHO Global ART report, 2013
3.5 million more infections averted, by 2025, compared to
2010 guidelines
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Projected impact: mortality
WHO Global ART report, 2013
3 million more deaths averted by 2025, compared to implementing 2010 guidelines
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Estimated cost of implementing the new recommendations
WHO Global ART report, 2013
10% increase of the 22-24 billion USD annually for full HIV response