Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Implications for Countries: Critical Issues in Service...

Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Implications for Countries: Critical Issues in Service Delivery

and Decision Making

Dr. Yogan PillayDeputy Director General

National Department of Health, South Africa


Outline

• Critical operational/service delivery issues in 2013 guidelines

• WHO operational/ service delivery recommendations

• Projected global and country level impact of WHO 2013 recommendations


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


Key WHO Operational and Service Delivery Recommendations


• Expanded testing scenarios• Task shifting and

decentralization• Service integration• Adherence support• Retention in care


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

93% 93%87%

82%

59%

0%

25%

50%

75%

100%

IndexN=6

MobileN=9

SelfN=3

House to houseN=18

WorkplaceN=4

Prop

ortio

n ac

cepti

ng H

TC

Suthar et al, Plos Medicine 2013 (in press)


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


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.


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.


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


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.

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 0

20 000

40 000

60 000

80 000

100 000

120 000

140 000

People receiving treatmentPeople eligible for treatment [with range]


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


Projected impact of the new recommendations

• Mortality• Incidence• Cost


Projected impact: incidence

WHO Global ART report, 2013

3.5 million more infections averted, by 2025, compared to

2010 guidelines


Projected impact: mortality


3 million more deaths averted by 2025, compared to implementing 2010 guidelines


Estimated cost of implementing the new recommendations


10% increase of the 22-24 billion USD annually for full HIV response

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Implications for Countries: Critical Issues in Service...

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