Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Implications for Countries: Critical Issues in Service Delivery and Decision Making Dr. Yogan Pillay Deputy.

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 Delivery and Decision Making Dr. Yogan Pillay Deputy.

Documents

community based hiv

care slide

community level

maintenance of art

supplementing pitc

health facilities

line art

pitc concentrated epidemics