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Treatment 2.0 Catalyzing the Next Phase of Scale-up Decentralized, Integrated and Community-Centred Service Delivery. Background. 6.6 million on ART 13 fold increase in six years Global coverage ~40%. Achievements and Challenges. People currently eligible for ART 15 million

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Treatment 2.0Catalyzing the Next Phase of Scale-upDecentralized, Integrated and Community-Centred Service Delivery


Background
Background

6.6 million on ART

13 fold increase in six years

Global coverage ~40%


Achievements and challenges
Achievements and Challenges

  • People currently eligible for ART 15 million

  • People currently receiving ART (2010) 6.6 million

  • ESTIMATED TREATMENT GAP 9 million


What is treatment 2 0
What is Treatment 2.0

  • Joint WHO/UNAIDS Initiative

  • Catalyse the next phase of treatment: achieve and sustain universal access and maximize preventive benefits of ART

  • Radical simplification and improved efficiencies and effectiveness of all aspects of care and treatment

  • Continue scale up in cost neutral environment while intensifying advocacy for more resources to end the epidemic

    • doing more with less


Priority work streams of treatment 2 0
Priority Work Streams of Treatment 2.0

Optimize drug regimens

Mobilize communities

POC and other simplified monitoring

TREATMENT

2.0

Adapt delivery systems

Reduce costs

  • Optimize drug regimens

  • Promote diagnostics using point of care and other simplified technologies

  • Reduce costs

  • Adapt delivery systems

  • Mobilize communities, protect human rights


What who is doing
What WHO Is Doing

  • Overall coordination with UNAIDS

  • Provide support to countries to review and adapt T2.0 principles

  • Advocacy for commodity price reductions

  • Anchor all normative work on treatment and care under the Treatment 2.0 umbrella

    • Optimization of ART, OI treatment and prevention, testing and counselling, PMTCT

    • Secondary preventive benefits of ART and primary benefit of ARVs (PrEP)

    • Adherence and retention in care

    • Nutrition support

    • TB/HIV

    • Reduction in stigma, discrimination, protection of human rights


Focus on priority work stream 4 adapting delivery systems
Focus on Priority Work Stream 4: Adapting Delivery Systems

Optimize drug regimens

Mobilize communities

POC and other simplified monitoring

TREATMENT

2.0

Adapt delivery systems

Reduce costs

  • Optimize drug regimens

  • Promote diagnostics using point of care and other simplified technologies

  • Reduce costs

  • Adapt delivery systems

  • Mobilize communities, protect human rights


The cost of treatment
The Cost of Treatment

Source UNAIDS 2010



Principles for adapting delivery systems
Principles for Adapting Delivery Systems

  • Decentralizes

    • HIV care into the community

  • Integrates

    • Prevention, diagnosis and treatment

    • Using chronic health care model

  • Shifts from stand alone ART services

    • ART delivered in primary care, ANC, MCH, TB and drug dependency services

  • Expands HIV testing and counseling

    • Health sector and community

    • Entry point to treatment and prevention

  • Strengthens

    • Procurement and supply systems

  • Links

    • Health sector and community-based services


  • Decentralization
    Decentralization

    • Sub-Saharan Africa 80% rural communities

    • Transport to and from clinic difficult

      • limited or no public transport

      • roads often impassable

    • Best way to deliver care

      • decentralization

    • Task shifting/sharing is key

      • WHO global guidelines 2008

      • slow adoption in many settings


    Integration
    Integration

    Linking and integrating health services provides people with user-friendly care they need, when they need it

    Maximizing retention and health outcomes

    Providing better value for money

    Slide courtesy of Emily A. Bobrow, PhD, MPH Senior Research Officer Elizabeth Glaser Pediatric AIDS Foundation


    From evidence to recommendations the grade process
    From evidence to recommendationsThe GRADE process

    Mapping

    Internal reference group

    Agreed outcomes

    External

    Guidelines review group

    GRC*

    Systematic review

    Guidelines

    *GRC WHO Guidelines Review Committee

    GRADE = The Grading of Recommendations Assessment, Development and Evaluation


    Evaluation framework
    Evaluation framework

    • Equity and human rights

    • HIV outcomes

    • Non-HIV outcomes

    • Cost

    • Systems

    • Socio-economic security


    Critical patient public health outcomes
    Critical patient & public health outcomes

    • Knowledge of status

    • Earlier uptake/access to ART

    • Mortality

    • Cost efficiencies

    • Quality of care

    • Morbidity

    • Retention

    • Acceptability

    • Transmission


    Hiv testing and counselling pico
    HIV testing and counselling PICO

    • For people living in generalised or concentrated HIV epidemics (P), should community HTC be provided by non-physician providers (I), compared to providing only facility based HTC and PITC (C), to increase knowledge of HIV status linked to access to HIV prevention and treatment (O)?


    Task shifting picos
    Task Shifting PICOS

    • For HIV-infected people eligible for ART in generalised or concentrated epidemics (P), does initiation of ART by appropriately trained non-physician healthcare workers (I), compared to initiation by physicians (C), result in comparable health and programmatic outcomes (O)?

    • For HIV-infected people eligible for ART in generalised or concentrated epidemics (P), does the provision of maintenance ART by appropriately trained non-physician healthcare workers (I), compared to the provision of maintenance ART by physicians (C), result in comparable health and programmatic outcomes (O)?


    Integration picos 1
    Integration PICOS (1)

    • In countries with a high burden of TB/HIV co-infection, (P) does ART and HIV care services provided at the TB clinic (I) compared to referral to specialised HIV clinics (C) result in comparable health and programmatic outcomes (O)?

    • In countries with a high burden of TB/HIV co-infection, (P) does TB diagnosis and treatment at specialised HIV clinics (I) compared to referral to TB clinics (C) result in comparable health and programmatic outcomes (O)?


    Integration picos 2
    Integration PICOS (2)

    • For pregnant women and infants in generalised epidemics (P) does initiation or maintenance of ART and HIV care services within ANC/MCH clinics (I), compared to referral to specialised HIV clinics (C), result in comparable health and programmatic outcomes (O)?


    Primary care picos
    Primary care PICOS

    • For HIV-infected people eligible for ART in generalised or concentrated epidemics, (P), does the initiation of ART and HIV care in clinics providing general services in the community (I), compared to referral to specialised HIV clinics for ART initiation (C), result in comparable health and programmatic outcomes (O)?

    • For HIV-infected people eligible for ART in generalised, or concentrated epidemics (P), does the provision of maintenance ART and HIV care in clinics providing general services in the community (I), compared to referral to specialised HIV clinics for maintenance ART (C), result in comparable health and programmatic outcomes (O)?


    Service delivery pilot in vietnam
    Service delivery pilot in Vietnam

    Challenges for Vietnam

    • Late treatment initiation common

      • Mortality high in early phase of ART

  • Limited access and retention

    • Stigma, discrimination and punitive laws

  • Large burden of TB and drug dependence high among PLHIV

    • Highly verticalized HIV, TB, MCH programs


  • Treatment 2 0 adapted to vietnam situation
    Treatment 2.0 adapted to Vietnam situation

    • Pilot implementation in two provinces

      • South

      • Commitment of provincial authorities for integratedservice delivery

      • ART-TB-MCH services for IDU

      • Northwest

      • Emerging epidemic

      • Mountainous geography and ethnic minorities

      • decentralizationcritical to ensure access

    • Vietnam Authority of HIV/AIDS Control

    • Support from WHO

    Dien Bien

    Can Tho


    Summary
    Summary

    • Decentralized and integrated service delivery

      • into the community and for the community

    • Key objectives

      • earlier initiation of ART

      • improved retention in care

      • improved survival

      • reduction of new HIV and TB infections over time

    • Increased and sustainable ART coverage with the same money

      • by increasing efficiency without compromising quality of care

    • Synergise prevention and treatment


    Acknowledgements
    Acknowledgements

    • Chris Duncombe

    • Marco Vitoria

    • Shaffiq Essajee

    • ReubenGranich


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