Transcript Strategic Information for Anti-RetroViral Treatment Programmes Workshop WHO and UNAIDS Geneva June 30- July 2 2003 Ties Boerma HIV Department Surveillance, Research and Monitoring & Evaluation.

Strategic Information for
Anti-RetroViral Treatment
Programmes
Workshop
WHO and UNAIDS
Geneva
June 30- July 2 2003
Ties Boerma
HIV Department
Surveillance, Research and Monitoring & Evaluation
OBJECTIVES OF THE MEETING
• Assess the needs for strategic information in the context
of ART programmes
• Share experiences in developing monitoring and
evaluation systems and other strategic information efforts
• Explore methods and techniques that can be considered
for monitoring ART programmes
• Develop a list of priority strategic information issues faced
by national programmes and large-scale projects and
explore ways to address those issues
DEFINING ART PROGRAMMES
Primary goals of ART programmes
- Enhance the length and quality of life of persons with advanced HIV infection
- Reduce HIV transmission as a “non-conventional prevention tool” **
Provision ARV drugs to those who need it
- HIV infected persons with advanced infection
- Public health approach to delivery of drugs
Inclusion of 12 ARVs on WHO Essential Drugs list
Standardised combination ARV in poor settings: first and second-line regimens
Recommend minimum requirements for safe monitoring of therapy
Beginning of a district approach in countries
Other elements and links
HIV Testing and Counselling
Treatment and prophylaxis of opportunistic infections
Link with TB Control, PMTCT and Care&Support programmes
**Blower and Farmer, AIDScience, 2003, 3 (11)
Treatment as a disease control measure
(e.g. tuberculosis)
Effective Case
Management
Case detection, Case treatment
Case holding
Therapeutic
benefits for infected
individuals - cure
Reduced
transmission
ARV Treatment as a disease control
measure
Effective Case
Management
Case detection, Case treatment
Case holding
•
•
•
+
-
•
•
•
More HIV testing & counselling
Stigma reduction
Reduction in infectiousness of
people on treatment
Behavioural disinhibition
Diverting resources from
prevention
Longer duration of
infectiousness
Therapeutic
benefits for infected
individuals
Reduced
transmission
O
T
H
E
R
F
A
C
T
O
R
S
DEVELOPING PROGAMMES
• Different models in different settings
• Models not yet well defined - roadmap
• Strategic information can play an important guiding role in
the development of appropriate and effective programmes
STRATEGIC INFORMATION
WHAT DO WE MEAN BY
STRATEGIC INFORMATION?
DATA
Generating information and
knowledge to influence policy making,
programme action, and research
Analysis
ÎNFORMATION
Understanding
Assessment
KNOWLEDGE
Application
ACTION
WHAT KIND OF INFORMATION DO WE NEED?
Needs, resources, access, coverage
What are and will be the needs for treatment?
What resources are available and what will be needed?
How many have access? Who has access?
Programme Monitoring & Evaluation
Is the programme performing according to plans?
Is the programme able to contain drug resistance development?
Does the programme make a difference? Is it achieving its goals?
How much does it cost and how cost effective is it?
Patient monitoring
Operations Research
How can programme implementation be improved?
What are the best models of implementation?
What can be done to improve health systems?
Research
Can we provide more efficacious and more effective interventions?
What impact do programmes have?
Needs, resources, access, coverage
MEASURE
Evaluation
Carolina Population Center
The University of North Carolina at Chapel Hill
Trends in Number of People Living with HIV
infection 1980 - 2002 by WHO Region
30,000,000
25,000,000
2002
42 mln people living with HIV
5 mln new infections
AFRO
8.8%
3.1 mln deaths
20,000,000
15,000,000
10,000,000
5,000,000
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
0
SEARO
<1%
Heterogeneity in the African epidemic
Median HIV prevalence (%) in antenatal clinics in cities by
subregion in sub-Saharan Africa, 1997-2002
30
25
20
1997-1998
1999-2000
2001-2002
15
10
5
0
Southern
Eastern
Central
Western
Strategic Information - Urban-Rural and Gender
HIV prevalence among 15-54 years by place residence
for men and women, Burundi, 2001
Men
Women
90% of the population
60% of HIV cases
20
15
14
10
7
6
2
3
0
Urban
Semi urban
Rural
Access to ARV Treatment for HIV:
The 3 By 5 goal
3000
(x 1,000)
North Africa / Near East
Eastern Europe & Central
Asia
Latin America & Caribbean
2500
2000
Other Asia & Pacific
1500
India
1000
West & Central Africa
500
Eastern Africa
Southern Africa
0
2002
2003
2004
2005
STRATEGIC INFORMATION ON RESOURCES
Resource availability
•Global Fund
•World Bank MAP
•US Government
Drug prices
GAPS
Health system
capabilities
Resource needs
HOW MANY NOW? (COVERAGE)
• Build national monitoring systems
• Global coverage survey of key informants 2003
• Global district access survey 2004
MONITORING AND EVALUATION
A FRAMEWORK for Monitoring and Evaluation
for ARV Therapy Programmes
Input
Process
Output
Outcome
Services
available
Resources
Staffing
Policies
Training
Logistics
Management
Education
etc.
(testing &
counseling,
ART, lab)
Quality
services
Public
understands
ART
People
on
Treatment
Knowledge
HIV status
Stigma lower
Behavioural
change
Impact
Survival
Quality of
life
HIV/STI
transmission
reduced
DATA COLLECTION for
Monitoring and Evaluation
Input
Process
Output
Outcome
Household
Surveys
Programme Monitoring
Facility
surveys
Patient
monitoring
Impact
HIV/STI
surveillance,
surveys
Patient
monitoring
M&E of ARV treatment programmes
(with examples of indicators)
Input
Process
Existence of
national policies
on ARV
(UNGASS)
Output
Access
% of districts / facilities
with ARV treatment
services
(% of people in need of
ARV with access within
one hour travel time)
Quality
% of designated
facilities providing ARV
treatment in line with
national standards
(trained person, drugs in stock,
treatment register used, treatments
correct, lab support)
Outcome
Impact
Coverage
% of people with
advanced HIV infection
receiving ARV
combination therapy
(UNGASS)
Impact
Survival rates among
HIV infected (at 2 years)
Percent of people with advanced HIV infection
receiving ARV combination therapy (UNGASS)
Number of
people receiving
treatment at the
start of the year
+
Number of
people who
commenced in
the last 12
months
-
Number of
people who
discontinued
treatment in the
12 months
*
Number of people with advanced HIV infection
(based on estimated number of deaths in the same and
following year)
Access to ARV through: private sector, NGOs, employers, research community, public sector
100
Way Forward: development of guidance and
tools to countries in developing M&E system
• Patient monitoring
Programme monitoring
• Treatment register: (Starting treatment, Substitute
drugs because of toxicity, Switch regimen because of
treatment failure, Stopping treatment) and link this to
the supply of drugs
– Individual? Electronic? Facility records?
• Adherence to therapy
• Assess treatment outcomes: morbidity and mortality
reporting (AIDS case definitions, survival analysis)
Way Forward: development of guidance and
tools to countries in developing M&E system
• Develop reporting simple systems to monitor at the
facility, district, regional/provincial and national levels
• Develop a simple tool for a facility survey to assess
availability & quality, including laboratory support
• Develop a simple tool to assess community and client
preparedness perspectives on ARV treatment
(including interaction care-prevention) - operational
research
Operations Research
Building Programmes:
Pilot Study Model
PROGRESSION TO AIDS/DEATH
% of patients progressing
30
Research proves
intervention works
25
No therapy
20
Mono-therapy
15
Dual-therapy
10
Triple therapy
5
0
0
1
2
3
4
5
6
Months
7
8
9
10
11
12
13
14
15
JAMA 1998 & CMAJ 1999
Pilot studies
Develop programmes
Building Programmes:
Scale Up Model
Research proves
intervention works
Lesson learned
in other countries
Develop programmes
Operational
research
Operations research issues:
examples
 Integrated systems to track patients, drugs and fees at point of
delivery
 Appropriate human resource planning for ARV programmes
 Working with the private sector – the franchising approach
 Setting and supervising/regulating health standards in ART
programmes
 Equity of access to ART programmes
 Measurement of costs of implementing ART programmes
 Assessment of community preparedness and readiness
 Measurement of stigma and discrimination in the context of
ART programmes
 Strategies to maximize long-term adherence (chronic disease
model)
 Delivering and sustaining ART in drug-using communities
Research
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CLINICAL
When to start treatment
What therapies to be used
What methods for patient monitoring
Operations research? Clinical trials, also observational designs
and comparative cohort studies may be used
 OUTCOME
 Survival, health, quality of life of patient but also children, family,
community
 PREVENTION
 Longitudinal studies with trends in behaviour, stigma, risk
perception etc.
Global partnerships and
major initiatives
Session 2
Pulling together and using strategic information
Stop TB
PMTCT+
TAP World Bank
WHO IAS Resistance monitoring network
Global Fund
WHO’s role - Building Evidence for Effective ART
programmes (The Build Up Initiative)
• WHO to assist health sector in building effective progammes,
link research and programmes
FUNCTIONS
•
•
•
•
Focus on coordination of programme oriented research that is
conducted while programmes are being developed
Initiate and guide multi-country operational research initiatives
Support to in-depth research studies (clinical, outcome, prevention)
Ensure rapid and wide use of results for policies and programmes in
countries and globally
OPERATIONAL FEATURES
•
•
•
•
Partnership with donors and countries - steering committee
Linking with networks (drug resistance, ITAC, clinical research etc.)
Secretariat at WHO
OR multi-country research initiatives
Agenda
Session 3 Assessment of needs and programme inputs
Session 4 Assessment of programme outcome (clinical and economic)
Session 5 Country and project experiences in M&E systems
and strategic information efforts
Session 6 Using technology to monitor ART programmes
Session 7 Monitoring individual and community knowledge,
attitudes and behaviours
Session 8 Developing the priority strategic information issues
for national programmes and large-scale projects
EXPECTED OUTCOMES

Consensus on a list of priority strategic information issues and how to
address these issues - A clear picture of immediate and mid-term country
strategic information needs

Increased understanding and partnership globally with strong input from
countries to support the development of sound monitoring and evaluation
systems for ART programmes