Implications for Countries: Critical Issues in Service Delivery and Decision Making

1. Implications for Countries: Critical Issues in Service Delivery and Decision Making Dr.YoganPillay Deputy Director General National Department of Health, South Africa

2. Outline • Critical operational/service delivery issues in 2013 guidelines • WHO operational/ service delivery recommendations • Projected global and country level impact of WHO 2013 recommendations

3. Key service delivery and programme issues • Low testing coverage, and inadequate linkage from testing to care • Delayed diagnosis and treatment initiation, inadequate retention in care

4. Expanded testing scenarios Task shifting and decentralization Service integration Adherence support Retention in care Key WHO Operational and Service Delivery Recommendations Kuala Lumpur, Malaysia , 30 June - 3 July 2013

5. Expanded testing and linkage to care • WHO 2013 Recommendations: • Generalized epidemics: community-based HIV testing in addition to PITC • Concentrated epidemics: community-based HIV testing for key populations in addition to PITC • provider-initiated testing and counselling (PITC) • Adolescent testing and counselling Suthar et al, Plos Medicine 2013 (in press)

6. Experience in home based testing • Multiple countries implemented community based testing approaches: • supplementing PITC in health facilities • provides opportunity to reach individuals tested for the first time • provided opportunity for multi disease interventions

7. Decentralization: Bringing ART closer to communities • WHO 2013 Recommendations: • Initiation and maintenance of ART in peripheral primary facilities • Initiation of ART in peripheral primary facilities and maintenance at community level between clinic visits.

8. Task shifting: nurses and non-physician clinicians providing care and treatment • WHO 2013 Recommendations: • Trained non-physician clinicians, midwives and nurses can initiate first-line ART and maintain treatment • Trained and supervised community health workers can dispense ART between clinic visits.

9. Service integration: Responding to co-morbidities and multiple needs • WHO 2013 Recommendations: • Initiate and maintain ART in : • TB care settings • MCH/ANC settings • OST settings with linkage to continued HIV care and treatment

10. Scale up of ART in Rwanda • Main factors: • Strong political commitment • Decentralization of ART and integration with primary care services • Task shifting for nurses and non-physicians to provide HIV care and ART.

11. Adherence support: combinations of interventions • WHO 2013 Recommendations: • Combination of interventions • Minimizing out of pocket payments • Use of fixed-dose combinations • Strengthening drug supply system • Patient counselling and education • Peer support • Mobile phone text messages • Nutritional support in food insecure settings

12. Projected impact of the new recommendations Mortality Incidence Cost

13. Projected impact: incidence 3.5 million more infections averted, by 2025, compared to 2010 guidelines WHO Global ART report, 2013

14. Projected impact: mortality 3 million more deaths averted by 2025, compared to implementing 2010 guidelines WHO Global ART report, 2013

15. Estimated cost of implementing the new recommendations 10% increase of the 22-24 billion USD annually for full HIV response WHO Global ART report, 2013