EXAMPLES OF SCALE UP

1. Scaling up HIV/TB programs The role of Capacity BuildingDr Alex G CoutinhoInfectious Diseases InstituteMakerere University, Kampala, Uganda

2. EXAMPLES OF SCALE UP

3. NUMBER OF PEOPLE RECEIVING ANTIRETROVIRAL THERAPY IN LOW- AND MIDDLE-INCOME COUNTRIES 2002-2007 WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

4. SCALE-UP OF CLINICAL SERVICES FOR SEX WORKERS UNDER THE AVAHAN INDIA AIDS INITIATIVE WHO (2008). Towards Universal Access : Scaling up priority HIV/AIDS interventions in the health sector; progress report 2008

5. Trends in number of person on ART – 2003 - 2007 Source: Republic of Uganda. Ministry of Health. (2007). Annual health sector performance report : Financial year 2006/2007. Kampala: Ministry of Health.

6. SCALING UP – REQUIRES---- • The need – i.e. Disease Burden • The gap in service provision • The will and political/technical leadership • The knowledge on what/how to scale up • The people (with knowledge) to scale up • The policy framework • The financing • The monitoring and evaluation tools to track progress and provide corrective solutions

7. Common Characteristics of “Success Countries” • Top Leadership (sustained) • Grassroots and community engagement, acceptance and involvement • Stigma free environment ( general and for specific groups) • Policies and programs • Resources • Metrics to track response

10. Estimates of New HIV Infections in Eastern and Southern Africa, 2007 (Source UNAIDS RST) ESA new infections, 1.5 million Global new infections, 2.7 million Rest of the world 1.2 million (43%) Eastern & Southern Africa 1.5 million (57%)

14. TB Cases

15. THE GAP

20. THE KNOWLEDGE

21. HIV Prevalence among CSWs (Kampala - 2001 and 2003)

22. Viral Load and Transmission Rates Among Discordant Couples by Gender In Uganda

23. A. Sexual Transmission B. Perinatal Transmission Transmission Rate HIV Viral Load, RNA Copies / mL

25. HIV Acquisition among Male Partners of HIV + Female Partners By Circumcision Status In Rakai 40/137 uncircumcised men (16.7/100 py) vs. 0/50 of circumcised men became infected after two+ years (p = 0.004). Quinn et al NEJM 2000

26. Circumcision and HIV Transmission to Women Male Viral load Of 47 couples in which circumcised male partner was HIV+ AND whose viral load was <50,000 particles, 0 of female partners were infected after two years, vs. 26 of 143 female partners of uncircumcised HIV+ men (9.6/100 py) (p = 0.02). Quinn et al NEJM 2000

27. The Three Trials: Study Results South Africa Uganda Kenya 3128 4996 2784 HIV Incidence MC (N) 0.85 (20) 0.66 (22) 2.1 (22) HIV Incidence Control (N) 2.1 (49) 1.33 (45) 4.2 (47) Percent Protection (ITT)60%* 51%* 53%* As treated76% 60% 60% Adverse Events 54 (3.6%) 178 (7.7%) 21 (1.5%)

28. 1.00 EntebbeCohort DART trial 0.75 0.50 Proportion alive 0.25 0.00 0 1 2 3 4 5 Years from cohort enrolment Survival

29. How can we scale up circumcision while waiting for policy efforts to catch up?

30. Communal drinking in Uganda –an ideal setting for TB infection

33. THE MONEY

37. THE HEALTH SYSTEM

38. Crumbling Health infrastructure in a rural District In Uganda .

39. Capacity building is not just about existing knowledge but also about the pursuit and discovery of new knowledge .

40. LANDMARK RESEARCH FROM UGANDA • PMTCT nevirapine regimen (HIVNET 012 trial) • Male circumcision as an HIV prevention intervention • Basic care package including cotrimoxazole prophylaxis to reduce morbidity • Impact of ART on Mortality and morbidity • Influence of viral load on HIV transmission • HIV incidence in a rural cohort 1990 -2005 • Home based Delivery of ART and HIV testing

41. Number of Uganda and Congo HIV/AIDS Research Publications by Year:1983-2008

42. JUMP • Integrated management • On-site training • Team approach (clinicians, lab and records staff) • Training on smear microscopy and rapid diagnostic tests for fever • Test diagnosis-based targeted treatment • Avoids misdiagnosis, overuse of antimalarials, and delays in treatment of other illnesses

43. The whole district Was trained The whole district was trained Aroi Omugo Wakitaka & Megamaga Oli Orum Adumi Anyeke Alebtong Ogur Nebbi Aber Pakwach Amac Aboke Paya & Kisoko HCW Akokoro Aduku Kibalinga & Apac Kiryandongo Butawata HCII Mukujju Buwenge Mulanda Kasambya Nagongera Iganga Kyenjojo Bugembe Kilembe Walukuba St Paul KIhihi Kabale Rukungiri District HCIIs Kamwezi Exxon IMM Sites trained at IDI Kisoro District HCW The whole district PMI IMM Sites trained at IDI Exxon Cascade IMM sites Exxon RDT sites IDRC RDT sites WHO RDT sites

44. Impact: JUMP On-Site Follow-Up • Developed a monitoring and evaluation system that demonstrates the impact of training and capacity building on improved case management for malaria at health facility level • Improved surveillance systems and data collection in the target health facilities. • QA/QC for 45 Districts by 2013

45. Impact: JUMP On-Site Follow-Up

46. Impact: JUMP On-Site Follow-Up Ssekabira Am J Trop Med Hyg, Dec 2008; 79: 826 - 833

47. Impact of RDT training interventionon anti- malarial prescribing *Generalized estimating equations controlling for history of fever and age, adjustment for repeated measures on the same day.

48. TASO COMMUNITY ART PROGRAMME

49. THE HOLISTIC APPROACH

50. enable effective use of ... enable effective use of ... enable effective use of ... enable effective use of ... require require require require Health System Capacity building : a pyramid as a guide for effective investment ? Tools Skills Staff andInfrastructure Structures, Roles & Systems Cognisance of local context