Service Integration in the Context of PEPFAR Programming David Hoos September 2010

1. Service Integration in the Contextof PEPFAR ProgrammingDavid HoosSeptember 2010

2. Continued increase in number of ICAP-supported facilities and enrollment in HIV care and treatment 652 facilities Swaziland Cote d’Ivoire Zambia Nigeria, Kenya 861,280 ever enrolled in care Lesotho, Rwanda, S. Africa, Tanzania Number of facilities Number of patients Ethiopia Mozambique 430,876 ever initiated ART

3. Demand and Uptake of HIV care and treatment continues to increase Number of new patients Note: *New enrollment includes transfers

4. Can Efforts Related to Millennium Development Goal 6 Support MDG 4 and 5 MDG-1: to eradicate extreme poverty and hunger; MDG-2: to achieve universal primary education; MDG-3: to promote gender equality and empower women; MDG-4: to reduce child mortality; MDG-5: to improve maternal health; MDG-6: to combat HIV/AIDS, malaria, and other diseases; MDG-7: to ensure environmental sustainability; and MDG-8: to develop a global partnership for development

5. PEPFAR implementing partners work throughout the health facility Number of sites Note: Some sites offer more than one activity

6. Service Integration: HIV testing continues to increase in TB clinics Percent of patients TB patients with unknown HIV status n=5,992 n=6,397 n=8,416 n=8,750 n=8,907 n=10,003 n=7,613

7. Service Integration: TB testing continues to increase in HIV clinics Percent of patients New HIV patients n=38,025 n=37,234 n=28,630 n=22,037 n=38,379 n=44,612

8. PHC: HIV care is not a vertical program: care provided by same staff for same patients leads to increased retention (an opportunity for MDG 4 and 5)

9. Systems for HIV Care and other Health Issues Face Common Barriers and Challenges TB Diabetes Barriers and challenges: Maternal health Child health HIV/AIDS • Demand-side barriers • Inequitable availability • Human resources • Lack of adherence support • Infrastructure, equipment • Program management • Drug supply / procurement • Referral and linkages • Community involvement √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ Adapted from Travis, Bennett, et al. Lancet 2004

10. Establishment of HIV-related support services offers opportunity for generalization of essential services Percent of facilities

11. PEPFAR reporting requires HMIS: an opportunity to support an overall chronic care model Rates 9.1% per year on ART Lost to Follow-up 4.7% per year on ART Reported Dead Reported stopped ART 3% .44% per year on ART Source: ICAP URS March 2010 Notes: *Includes patients who transferred out while on ART.

12. Mapping can assist in utilization of PEPFAR supported HIV care sites for other public health needs

13. Interrelationship of MDGs 4, 5 and 6 *Women and health: today's evidence tomorrow's agenda, WHO, 2009 • HIV and maternal conditions are the two leading causes of mortality in women age 20-59 in low income countries and worldwide* • 17.7+ million women and girls living with HIV worldwide • Over 530,000 women die in pregnancy or childbirth yearly • An estimated 200 million women in the developing world want to space or limit childbearing but are not using family planning, which contributes to 25% of maternal and child deaths • Women who are HIV-infected have rates of maternal mortality up to 5-times that of uninfected women

14. Effect of HIV Treatment on Incidence of Malaria in HIV-infected PatientsUganda & Zimbabwe Kasirye et al, IAS 2009

15. Effect of PMTCT Programs on Quality of Overall Antenatal Care and Delivery - Cote D’Ivoire Delvaux et al, IAS 2009

16. Potential Impact on < 2 Child Mortality Kwa Zulu Natal, South Africa Ndirangu et al. AIDS 2010

17. PEPFAR-2 Offers Opportunity for Service IntegrationGuidance on PMTCT/MCH/FP Integration Where feasible and appropriate to the epidemic support should be provided for: • Integrating PMTCT with MCH services as an entry point to other HIV services. • Linkages and wrap around with family planning services • e.g., co-locating and linking PMTCT and family planning services , training FP clinical providers on PMTCT, counseling HIV+ women in PMTCT • Safe Motherhood and child survival interventions : • Emergency Obstetric Care and neonatal resuscitation could be integrated into PMTCT training where feasible. • Linkages should be strengthened between key initiatives such as PEPFAR and PMI, which focus on pregnant women and children

18. Causes of Maternal Deaths • Direct (69%) • Obstructed/prolonged labor=21% • Ruptured uterus =22% • Severe pre-eclampsia =20% • Abortion= 10% • PPH= 10% • APH=9% • Indirect causes (21%) • Malaria 35% • Anemia 25% • HIV/AIDS related 21% • Other 19% • Unknown (10%)

19. But WHY Do These Women Die? Three Delays Model • Delay in decision to seek care – increased uptake of PMTCT may impact • Poor uptake of ANC • Lack of understanding of complications that can be prevented by facility-based births • Delay in reaching care – expansion of level of HIV care at PHC may improve access for other diseases • Transport • PHC not equipped to handle complications • Inadequate /unskilled care at facilities – Training opportunities funded through PEPFAR may support • Shortages of supplies and staff • Inadequately trained staff • Finances

20. Challenges • Perception that treatment and prevention are dichotomous choices • How to identify efficiencies within development funding? • Flat or decreased funding will limit options • Perception that disease specific funding will cannot strengthen health systems