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Track E: Rapporteur Summary Pierre Barker

Track E: Rapporteur Summary Pierre Barker. Track E: Rapporteur Summary. Role of health systems in providing high quality care to all who need it The financing of health systems that provide HIV care Operations Research on quality of care, universal coverage, and financing. Track E.

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Track E: Rapporteur Summary Pierre Barker

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  1. Track E: RapporteurSummary Pierre Barker

  2. Track E: Rapporteur Summary • Role of health systems in providing high quality care to all who need it • The financing of health systems that provide HIV care • Operations Research on quality of care, universal coverage, and financing

  3. Track E Track E abstracts accepted (ex 1269 ex 10,145) Track E representation at oral sessions (15 ex 116) E E Thanks!.....

  4. Current State– How far are we from universal access (LMIC)? HAART Any ARVs for PMTCT 100% “gap” = 340,000 new infant infections/year

  5. Current State: ART coverage gap in every region – health system response is different in each region

  6. Current State of Health System Performance – Not just about numbers! Retention on ARVs

  7. Current State of Health System And then there is finance!

  8. 100% Interaction of Health System Financing and Health System Performance Financing Access to HAART ? ?

  9. 1. Interaction between Health System Financing and Health System Performance? 100% ? ? Access to HAART Financing • Op research on costing of methodologies • Reduce drug costs • Cost-benefit of guideline changes • More effective care at lower or same cost (efficiencies) • lobby to replenish Global Fund • Innovative external fundraising • LMIC fund raising

  10. The financial implications of the 2010 WHO recommendations Lori Bollinger , Futures Institute • CD4 <350 , PMTCT recommendations (plus phasing out d4T): • Tripling of costs 2010 to 2015 (US$3.5 billion US$9.5 billion by 2015 - d4T phase out NS) • Cost per person year on ART is US$800, but… cost per death averted is about US$10,000

  11. Potential Cost Savings of Implementing WHO PMTCT 2009 (“A”) vs 2006 15 PEPFAR countries Implementing 2009 WHO Guidelines could…. Avert x3 more infections Save money with Option A (significantly less expensive than option “B”) The 2009 WHO Guidelines with option “A” are: highly cost effective (ICER <GDPpp) ? cost-saving in 9 of 15 PEPFAR focus countries Auld et al , CDC 11

  12. Where are the opportunities for cost reduction? Lori Bollinger , Futures Institute

  13. Lessons from Brazil: Drug Cost reductions through…negotiations with drug companies, mandatory licensing, local production and international collaboration I. 1st-line NRTI PYD evolution II. Compulsory license of EFV C Meiners,

  14. Health systems improvement: Cost effectiveness of interventions Compared community based health insurance and performance based financing introduced to Rwanda CBHI – major impact on improvements in HIV care PBF – no impact Both interventions had been rolled out country wide. Compared incremental cost effectiveness for facility-based vs outreach vs campaign (Uganda) Cost per Number of people who know their status (US$) Wu Zeng (Brandeis University) Arinaitwe et al…MSH: Uganda

  15. Health systems improvement: Cost effectiveness of HCT interventions Tested cost effectiveness of HCT, malaria, diarrhoea campaign in subdistrict of W Kenya. 30 sites, 7 days Reached 80% of 51,000 targeted population Cost effectiveness (USD) Per person costs ( $34 USD) Dr. Eric Lugada CHF International Kenya

  16. What will it take to close the gap between “best case” (RCT) performance and actual performance? Basic science Proof of concept Large RCT Reliable “real-life” implement-ation Scale-up • Every existing / new drug • Every model for prevention or treatment • “hostage” to our ability to implement and scale up what we know will work

  17. “Real Life” assessment: PMTCT results in PEPFAR supported countries Testing and Counselling ARV prophyaxis target target Caroline Ryan, PEPFAR

  18. Are we setting the right performance goals?? • If PEPFAR met its goals (80% HIV+ women get ARVs) , the model estimates that: • At current targets - MTCT rate would be 15% • 85% coverage - MTCT rate would be 10% • to reach MTCT <5% need a 96% coverage goal Caroline Ryan, PEPFAR

  19. Attrition: challenge of delivering complex interventions over time and places 3,244 HIV positive pregnant women at health centres offering PMTCT services in Cameroon, Côte d’Ivoire, South Africa and Zambia 92% 91% 92% 92% 95% 81% 84% 57% Stringer, E.M., JAMA. 2010 Jul 21;304(3):293-302.

  20. Quality Improvement methodology has become powerful tool to make HIV care processes more reliable, and provides methods for scale spread IAS 2010 >70 abstracts used quality improvement in text >40 organizations represented

  21. Health systems improvement: Local Solutions to Solving Logistics Problem: Low rates of CD4 collection, long turnaround times Solution: Using public transport to carry CD4 lab samples, 6 week pilot Results: Cut CD4 turnaround time from 2 weeks to 5 days Massive increase in number of CD4 counts collected Being scaled up to all clinics in system supported by ICAP Preko et al…ICAP: Swaziland

  22. Using existing capacity: Harmonizing efforts between different NGOs to work with government and districts to scale up effective care Distr office Distr office NGO 5 NGO 1 National and provincial government NGO 4 NGO 2 Distr office NGO 3 Distr office Distr office Kedar Mate, Institute for Healthcare Improvement

  23. Highly reliable PMTCT in low resource public health system, at scale, is possible (9 districts, 151 rural facilities, South Africa) Kedar Mate, Institute for Healthcare Improvement

  24. Closing Gaps – Point of care testing • Rapid testing advances for • HIV testing • CD4 count testing • Viral load testing • TB and resistance testing Eliminates steps in a cascade of sequential care steps

  25. Health systems improvement: Integration of HIV into health system: MCH, general clinic, etc Integrated Care Antenatal care HIV care & support HIV testing CD4 cell count testing Maternal ARV Prophylaxis Antiretroviral therapy 42 27 Maternity Long term follow-up Newborn Prophylaxis Immunizations Maternal Child Health ART Care & Treatment Elaine Abrams, ICAP

  26. Health systems improvement: Integration of HIV into health system HIV-TB integration: “1 patient, 1 doctor, 1 clinic, 1 folder, and 1 program,” Gilles Van Cutsem , MSF Khayelitsha , South Africa • Medecins Sans Frontieres • No difference in outcomes for Vertical vs Integrated HIV programs • Conflict/post-conflict and non-conflict settings • Improved outcomes for TB/HIV integrated settings Days from start of TB treatment to ART treatment 42 27 Before integration After integration

  27. Summary • Health system redesign using new and existing knowledge to close remaining gaps in prevention and care • Modify health system response in view of global financial changes • Pay closer attention to the cost-effectiveness • Design prevention and treatment strategies for “real life health systems” and learn how to scale them up • Better NGO-NGO and funder-funder collaboration to capacitate national health systems to deliver sustainable, cost-effective, high quality HIV care that can be rapidly scaled

  28. Thanks!! Robert Hecht Kedar Mate Patty Webster (with help from Rebecca Hodes) … Kelly O’Connor IAS

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