Strategic Information forStrategic Information forAnti-RetroViral Treatment Anti-RetroViral Treatment

ProgrammesProgrammes

WorkshopWHO and UNAIDSGeneva June 30- July 2 2003

Ties BoermaHIV Department

Surveillance, Research and Monitoring & Evaluation

OBJECTIVES OF THE MEETING

• Assess the needs for strategic information in the context of ART programmes

• Share experiences in developing monitoring and evaluation systems and other strategic information efforts

• Explore methods and techniques that can be considered for monitoring ART programmes

• Develop a list of priority strategic information issues faced by national programmes and large-scale projects and explore ways to address those issues

Primary goals of ART programmes- Enhance the length and quality of life of persons with advanced HIV infection- Reduce HIV transmission as a “non-conventional prevention tool” **

Provision ARV drugs to those who need it- HIV infected persons with advanced infection- Public health approach to delivery of drugs

Inclusion of 12 ARVs on WHO Essential Drugs list Standardised combination ARV in poor settings: first and second-line regimens Recommend minimum requirements for safe monitoring of therapyBeginning of a district approach in countries

Other elements and linksHIV Testing and CounsellingTreatment and prophylaxis of opportunistic infectionsLink with TB Control, PMTCT and Care&Support programmes

DEFINING ART PROGRAMMES

**Blower and Farmer, AIDScience, 2003, 3 (11)

Treatment as a disease control measure (e.g. tuberculosis)

Reduced

transmission

Effective Case Management

Case detection, Case treatment

Case holding

Therapeutic

benefits for infected individuals - cure

ARV Treatment as a disease control measure

Reduced

transmission

Effective Case Management

Case detection, Case treatment

Case holding

Therapeutic

benefits for infected individuals

• More HIV testing & counselling

• Stigma reduction

• Reduction in infectiousness of people on treatment

• Behavioural disinhibition• Diverting resources from

prevention• Longer duration of

infectiousness

-+

O FT AH CE TR O R S

DEVELOPING PROGAMMES

• Different models in different settings

• Models not yet well defined - roadmap

• Strategic information can play an important guiding role in the development of appropriate and effective programmes

STRATEGIC INFORMATION

WHAT DO WE MEAN BY STRATEGIC INFORMATION?

DATA

KNOWLEDGE

ÎNFORMATION

ACTION

Analysis

Understanding

Application

Generating information andknowledge to influence policy making,

programme action, and research

Assessment

WHAT KIND OF INFORMATION DO WE NEED?

Needs, resources, access, coverageWhat are and will be the needs for treatment?What resources are available and what will be needed?How many have access? Who has access?

Programme Monitoring & EvaluationIs the programme performing according to plans?

Is the programme able to contain drug resistance development?Does the programme make a difference? Is it achieving its goals?

How much does it cost and how cost effective is it?Patient monitoring

Operations ResearchHow can programme implementation be improved?What are the best models of implementation?What can be done to improve health systems?

ResearchCan we provide more efficacious and more effective interventions?

What impact do programmes have?

Needs, resources, access, coverage

MEASUREEvaluation

Carolina Population CenterThe University of North Carolina at Chapel Hill

Trends in Number of People Living with HIV infection 1980 - 2002 by WHO Region

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

AFRO8.8%

200242 mln people living with HIV5 mln new infections

3.1 mln deaths

SEARO<1%

Heterogeneity in the African epidemicMedian HIV prevalence (%) in antenatal clinics in cities by

subregion in sub-Saharan Africa, 1997-2002

0

5

10

15

20

25

30

Southern Eastern Central Western

1997-1998

1999-2000

2001-2002

Strategic Information - Urban-Rural and GenderHIV prevalence among 15-54 years by place residence

for men and women, Burundi, 2001

67

2

1415

3

0

10

20

Urban Semi urban Rural

Men Women

90% of the population60% of HIV cases

Access to ARV Treatment for HIV: The 3 By 5 goal

0

500

1000

1500

2000

2500

3000

2002 2003 2004 2005

(x 1,000) North Africa / Near East

Eastern Europe & CentralAsia

Latin America & Caribbean

Other Asia & Pacific

India

West & Central Africa

Eastern Africa

Southern Africa

Drug prices

Resource availability•Global Fund•World Bank MAP•US Government

Health system capabilities

STRATEGIC INFORMATION ON RESOURCES

Resource needs

GAPS

HOW MANY NOW? (COVERAGE)

• Build national monitoring systems

• Global coverage survey of key informants 2003

• Global district access survey 2004

MONITORING AND EVALUATION

Input Process Output Outcome Impact

A FRAMEWORK for Monitoring and Evaluation for ARV Therapy Programmes

ResourcesStaffingPolicies

TrainingLogistics

ManagementEducation

etc.

Services available

(testing &counseling, ART, lab)

Qualityservices

Publicunderstands

ART

Peopleon

Treatment

Knowledge HIV status

Stigma lowerBehavioural

change

SurvivalQuality of

life

HIV/STI transmission

reduced

Input Process Output Outcome Impact

DATA COLLECTION for Monitoring and Evaluation

HIV/STI surveillance,

surveys

Patientmonitoring

HouseholdSurveys

Facility surveys

Patient monitoring

Programme Monitoring

Input Process Output Outcome Impact

M&E of ARV treatment programmes(with examples of indicators)

Existence of national policieson ARV (UNGASS)

Access% of districts / facilities with ARV treatment services(% of people in need of ARV with access within one hour travel time)

Quality% of designated facilities providing ARV treatment in line with national standards(trained person, drugs in stock, treatment register used, treatments correct, lab support)

Coverage% of people with advanced HIV infection receiving ARV combination therapy(UNGASS)

ImpactSurvival rates among HIV infected (at 2 years)

Percent of people with advanced HIV infection receiving ARV combination therapy (UNGASS)

Number of people receiving treatment at the start of the year

+ Number of people who

commenced in the last 12

months

- Number of people who

discontinued treatment in the

12 months

Number of people with advanced HIV infection (based on estimated number of deaths in the same and

following year)

* 100

Access to ARV through: private sector, NGOs, employers, research community, public sector

Way Forward: development of guidance and tools to countries in developing M&E system

• Patient monitoring Programme monitoring

• Treatment register: (Starting treatment, Substitute drugs because of toxicity, Switch regimen because of treatment failure, Stopping treatment) and link this to the supply of drugs– Individual? Electronic? Facility records?

• Adherence to therapy• Assess treatment outcomes: morbidity and mortality

reporting (AIDS case definitions, survival analysis)

Way Forward: development of guidance and tools to countries in developing M&E system

• Develop reporting simple systems to monitor at the facility, district, regional/provincial and national levels

• Develop a simple tool for a facility survey to assess availability & quality, including laboratory support

• Develop a simple tool to assess community and client preparedness perspectives on ARV treatment (including interaction care-prevention) - operational research

Operations Research

Building Programmes:Pilot Study Model

Research proves

intervention works

Pilot studies

Develop programmes

PROGRESSION TO AIDS/DEATHPROGRESSION TO AIDS/DEATH

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Months

% o

f pat

ient

s p

rogr

ess

ing

JAMA 1998 & CMAJ 1999JAMA 1998 & CMAJ 1999

No therapyMono-therapy

Dual-therapy

Triple therapy

Building Programmes:Scale Up Model

Research proves

intervention works

Lesson learned

in other countries

Develop programmes

Operational

research

Operations research issues: examples

Integrated systems to track patients, drugs and fees at point of delivery

Appropriate human resource planning for ARV programmes Working with the private sector – the franchising approach Setting and supervising/regulating health standards in ART

programmes Equity of access to ART programmes Measurement of costs of implementing ART programmes Assessment of community preparedness and readiness Measurement of stigma and discrimination in the context of ART

programmes Strategies to maximize long-term adherence (chronic disease model) Delivering and sustaining ART in drug-using communities

Research

CLINICAL When to start treatment What therapies to be used What methods for patient monitoring Operations research? Clinical trials, also observational designs and

comparative cohort studies may be used

OUTCOME Survival, health, quality of life of patient but also children, family, community

PREVENTION Longitudinal studies with trends in behaviour, stigma, risk perception

etc.

Global partnerships and major initiatives

Session 2Pulling together and using strategic informationStop TBPMTCT+TAP World BankWHO IAS Resistance monitoring networkGlobal Fund

WHO’s role - Building Evidence for Effective ART programmes (The Build Up Initiative)

• WHO to assist health sector in building effective progammes, link research and programmes

FUNCTIONS• Focus on coordination of programme oriented research that is

conducted while programmes are being developed

• Initiate and guide multi-country operational research initiatives

• Support to in-depth research studies (clinical, outcome, prevention)

• Ensure rapid and wide use of results for policies and programmes in countries and globally

OPERATIONAL FEATURES• Partnership with donors and countries - steering committee

• Linking with networks (drug resistance, ITAC, clinical research etc.)

• Secretariat at WHO

• OR multi-country research initiatives

Agenda

Session 3 Assessment of needs and programme inputs

Session 4 Assessment of programme outcome (clinical and economic)

Session 5 Country and project experiences in M&E systems and strategic information efforts

Session 6 Using technology to monitor ART programmes

Session 7 Monitoring individual and community knowledge, attitudes and behaviours

Session 8 Developing the priority strategic information issues for national programmes and large-scale projects

EXPECTED OUTCOMES

Consensus on a list of priority strategic information issues and how to address these issues - A clear picture of immediate and mid-term country strategic information needs

Increased understanding and partnership globally with strong input from countries to support the development of sound monitoring and evaluation systems for ART programmes