Targeting Criteria in National ARV Programs: Mexico, Senegal, and Uganda

1. Targeting Criteria in National ARV Programs: Mexico, Senegal, and Uganda XV International AIDS Conference Bangkok, July 2004 Catherine Chanfreau, MD, MPH Sara Bennett, PhD Abt Associates, Bethesda, USA

2. Presentation objectives • Identify explicit factors used to target government-subsidized ART in Uganda, Senegal, and Mexico • Review priority criteria used in two national ART programs and one major pilot project

3. Background • Continued gap between access to and need for ART • Explicit policy commitment to provide ART to all those in need • Not always feasible in the short term: interim targeting is occurring • International clinical guidelines on how to scale up ART exists • Lack of policy guidance on how best to allocate scarce life-saving resources

4. Selection process in the proposed Ugandan National ARV Policy HIV+ Individual Meets clinical eligibility criteria Assessment of likely adherence Unlikely to comply: excluded Likely to comply: Eligible HIV+ individual • Priority eligibility for: • Pregnant women (PMTCT) • Health workers (PEP) • Mothers identified in PMTCT and their HIV infected family members (PMTCT+) • Orphans and vulnerable children • People enrolled in support activities • Participants in research projects Ordinary eligibility ACCESS TO FREE ART IMMEDIATE ACCESS TO FREE ART

5. Selection process in the Initiative Sénégalaise d’Accès aux ARV (ISAARV) HIV+ Individual Senegalese Residency Meets clinical eligibility criteria Social investigation: adherence & ability to pay Likely to adhere: Exempted from payment: HIV/AIDS activists Health workers Unlikely to adhere: excluded Likely to adhere: Eligible HIV+ individual Determination of patient’s contribution Patient accepts contribution rate ACCESS TO ART

6. Selection process in National ARV policy in Mexico HIV+ Individual Meets clinical eligibility criteria Uninsured Individual Insured Individual • Meets MoH program for free care (SSA*) eligibility criteria • Citizenship • Residency • Inability to pay for ART • Commitment to adhere to treatment Consent to start and Adhere to treatment No prior history of ART treatment: Placed on waiting list Previously Treated on ART Priority accorded to those at more acute stage of disease ACCESS TO ART SSA: Programa de accesso gratuito a tratamiento Antiretroviral para la poblacion no asegurada de bajos recursos economicos

7. An Anatomy of prioritization • Biomedical factors: patient’s clinical ability to benefit from ART • Prospects for adherence to treatment: patient’s likelihood to comply • Prevention-driven factors: “focused ART ” is the matching piece of UNAIDS “focused prevention” strategy

8. An Anatomy of prioritization (cont.) • Social and economic benefits: positive externalities associated with sub-groups • Social and political empowerment: selection based on gender or role that individuals have played in the fight against HIV/AIDS • Financial factors: ability/inability to pay for treatment • Ethical arguments: poor and vulnerable children

9. Conclusions • Targeting enables the scale-up of universal access to ART using a “step by step” approach • Explicit targeting criteria are used to allocate public subsidies andformulate policy strategies • Biomedical criteria are evidence-based • Prospects for adherence to treatment and biomedical criteria are used in virtually all settings • Social and political empowerment is a recurrent factor • Prevention-driven factors are internationally endorsed ( PMTCT plus)

10. Thanks … Merci • Governments of Uganda and Mexico • ISAARV team • USAID Uganda