Framework for Universal Access to HIV Prevention, Treatment and Care in the Health Sector

1. Framework for Universal Access to HIV Prevention, Treatment and Care in the Health Sector Presented by Professor Charles Gilks, Director, Co-ordinator TPS, Department of HIV/AIDS Technical Meeting for the Development of a Framework for Universal Access to HIV/AIDS Prevention, Treatment and Care in the Health Sector Geneva 18-20 October 2005

2. Aim of the work presented • Identify the set of core HIV interventions that address HIV prevention, treatment and care in the health sector • Propose a framework for action that can help guide countries as they strive to achieve universal access in the health sector • Adopt a sectoral approach, recognizing that for any national response to be successful it must be developed and delivered in a multisectoral environment

3. Health Sector Definition "The health sector is wide-ranging and encompasses organized public and private health services (including those for health promotion, disease prevention, diagnosis, treatment and care); health ministries; nongovernmental organizations; community groups; and professional associations; as well as institutions which directly input into the health care system (e.g. the pharmaceutical industry, and teaching institutions)." Global Health Sector Strategy for HIV/AIDS 2003-2007, WHO

4. Where we are • Successful scale-up is taking place in many countries, with significant experience and lessons being learnt • Scale-up is being done in different ways often using diverse plans and models; complex and inter-related processes are involved - and there may be an unbalanced service delivery • Lack of agreement on what constitutes the core elements of HIV prevention care and treatment services • Difficult to identify what processes are necessary to drive current scale-up services forward to achieve and sustain universal access Countries are increasingly asking WHO, UNAIDS and other partners for clarity and provide guidance on these issues

5. Rationale for a Framework • The framework is intended to provide a structure for discussion of the proposed elements for Universal Access leading to a shared understanding for all partners The framework: • Simplifies complex and interrelated processes • Highlights the importance of target-driven approaches • Identifies the ingredients for country scale-up • Specifies the core prevention, treatment and care interventions • Recognises that universal access needs action in all core areas • Offers an approach which is flexible to different epidemiology • Supports health systems strengthening The framework is a work in progress.

6. Framework for Universal Access to HIV Prevention, Treatment and Care Within the Health Sector Output Outcome Impact Country Targets TRACKING PROGRESS Set of core interventions for HIV Prevention, Treatment and Care A Public Health Approach • Ingredients and Products for Country Scale-up • Comprehensive scale-up plan • Strategic Partnerships • Sound management capacity • Involvement of PWAs • PSM for commodities • Health sector planning • Financial resource management • Health information system • Operational guidance • - tools and guidelines • - national adaptation • Implementation • Locus: • Home action • Community action • Facility action • District action • National action • Prevention, • Treatment and • Care for: • General population • High risk populations • High risk settings • Special groups ESSENTIAL ENABLERS

7. Essential Enablers An enabling environment is one in which political, economic, social, legal and health structures support scale-up and should include: • Building and maintaining political commitment • Good governance practices and structures • Promotion of a rights-based approach • Supportive legislative and regulatory environment Enablers cut across all sectors and are not solely the responsibility of the health sector

8. Principles of a Public Health Approach for Scale-up of HIV services A public health approach is necessary to reach as many people as possible with the required services • Package of priority interventions for prevention, treatment and care • Decentralized service delivery models • Simplified and standardized approaches • Standardized, integrated training • Harmonized tracking and reporting

9. A Target-driven process • Targets are set and owned at the national level • Progress can be measured against targets and milestones • Accountability with achievement of targets on time • Targets across the package of priority interventions • Ongoing work to propose a complete set • Targets are measurable and relevant • Methodologies are clearly stated and defined • Country methodologies and targets are harmonized • Regular (annual) reporting of progress • National reports • Global reports Major milestones include 2010 (G8) and 2015 (MDGs)

10. Ingredients for Country Scale-up • Comprehensive, integrated scale-up plan • Ensuring strategic partnerships • Ensuring greater involvement of PLWHAs • Sound management capacity at all levels • Comprehensive health sector planning • Successful procurement and supply management for commodities • Acquisition, management and reporting of financial resources • Health Management Information System • Operational guidance

11. Prevention, Treatment, Care Basic prevention HIV testing and counseling (client initiated) STI detection and treatment Targeted interventions (MSM, SW, IDU, Others) Positive prevention PEP: non-occupational Occupational health and safety Blood safety PMTCT ART including adherence support TB-HIV co-treatment OI treatment Substitution therapy Provider initiated Testing and Counselling OI prophylaxis Nutritional support Psychosocial support Palliative care: symptom management & end-of-life care Set of inter-related Core HIV Interventions

12. Home and Person: • Positive prevention • Universal precautions • ART, TB one-to-one • treatment support • Psychosocial support • Home-based palliative care Locus of interventions • Community:Above plus: • CHWs: adherence,monitor, refill ART, TB, OI prophylaxis; prevention: safer sex, condoms, FP; nutritional support • HIV testing and counseling (CITC/ VCT) • Targeted interventions (outreach) • Broad-based prevention (emphasis on youth) • Community mobilization for prevention, • treatment preparedness, use of services • Health centre:Above plus: • Provider-initiated T&C • PMTCT • STI detection and treatment • Special care: IDU, sex worker; youth-friendly • Initiate first-line ART in uncomplicated patients • TB treatment, TB-HIV Co-management • Treat most OIs • PEP- occupational, non-occupational • Safe medical injections • Hospital:Above plus: • Blood safety • ART in complicated patients, second-line, IRIS, severe toxicity • TB: smear negative, extrapulmonary, TB-ART co-management • Complicated OIs • IDU: drug substitution, detox

13. Home and Person: • Positive prevention • Universal precautions • ART, TB one-to-one • treatment support • Psychosocial support • Home-based palliative care Examples of operational tools from WHO and partners: Integrated Management of HIV/AIDS at Facility with Linked Community Interventions (based on IMAI/IMCI/IMPAC) • Community: Above plus: • CHWs: adherence, monitor, refill ART, TB, OI prophylaxis; prevention: safer sex, condoms, FP; nutritional support • Client-initiated T&C (VCT) • Targeted interventions (outreach) • Broad-based prevention (emphasis on youth) • Community mobilization for prevention, • treatment preparedness, use of services • Health centre: Above plus: • Provider-initiated T&C • PMTCT • STI detection and treatment • Special care: IDU, sex worker, youth-friendly • First-line ART in uncomplicated patients • TB treatment, TB-HIV Co-management • Treat most OIs • PEP- occupational, non-occupational • Safe medical injections • Hospital: Above plus: • Safe blood • ART in complicated patients, second-line, IRIS, severe toxicity • TB: smear negative, extrapulmonary, TB-ART co-management • Complicated OIs • IDU: drug substitution, detox

14. Need to be strategic in what we measure - and why Standardised methodologies and agreed indicators One harmonised M&E system (3 ones) Improve quality of care and prevention Local review of results Continuous quality improvement Demonstrate progress towards Universal Access Process and Outputs: Service Availability Mapping (SAM) and GIS systems Outcome and Impact: Treatment: STARTOMS Build consensus on prevention indicators National and global reports: National authorities Donors and funders Tracking Progress

15. Summary Our premise and the basis for our discussion: A proposed framework intended to provide guidance to countries in the use of a harmonised approach to scaling up HIV prevention, treatment and care services as they strive to achieve Universal Access