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Strategic Information for Anti-RetroViral Treatment Programmes. Workshop WHO and UNAIDS Geneva June 30- July 2 2003. Ties Boerma HIV Department Surveillance, Research and Monitoring & Evaluation. Assess the needs for strategic information in the context of ART programmes - PowerPoint PPT Presentation
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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
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
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
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