The HIV/AIDS Treatment Acceleration Program for Africa

World Bank, Africa Region

Concept Paper

June 2003

Outline

• Introduction

• Challenges

• The Proposed Africa Regional HIV/AIDS Treatment Acceleration Program

The Status of HIV/AIDS Treatment in Africa

• There are 30 million people infected in Africa– Of which six million in need of ART

• Many will be difficult to reach even with the best of effort

• Current treatment target of WHO: 3 million by 2005

• Actual number of people treated: Less than 50,000

Recent Opportunities

• Treatments are becoming much simpler: 2 pills per day rather than 10 to 15

• WTO negotiations allow low income countries to use generic drugs

• Because of competition, cost of first line drugs has dropped to around 20 dollars per month

• Diagnostic techniques options are increasing and prices are falling

Treatment Benefits Now Exceed Treatment Costs

• Prophylaxis of opportunistic infections and Prevention of MTCT have proven cost effective

• Comprehensive treatment including ART can now be made available at less than 500 dollars a year

• Treatment of employees is now a cheaper option for employers than letting them progress to AIDS

• Large scale comprehensive treatment will reduce the growing orphan problem, benefit the health sector, and reduce pain and suffering

HIV/AIDS Treatment: A Continuum of Five Components

• VCT and regular checkups for all who are HIV+• Positive Living and Survival Skills, including

psychosocial support, nutrition, etc.• Prophylaxis and treatment of opportunistic

infections (OI)• Anti-retroviral treatment (ART)• Prevention of Mother to Child Transmission, including

treatment of the mothers and infected family members (MTCT-Plus)

Opportunities Have Not Led to Rapid Expansion of Treatment

• Less than 50,000 people are under treatment in Africa• Current Global Fund grants envisage ART for about

200,000 patients• IDA funds provide for ART, but current plans envisage

treatment of less than 10 000 patients• Promising pilot programs of Medecins Sans Frontières,

Sant’Egidio, AIDS Empowerment and Treatment International, PharmAccess have not attracted adequate funding

Why Has Progress Been So Slow

• Governments are struggling to formulate treatment policies, protocols and programs

• Focus is mostly on medical control rather than on implementation mechanisms for scaling up

• Governments have been reluctant to finance programs outside of the public sector

Key Challenges to Be Addressed

• Rapid adaptation of WHO treatment guidelines and protocols to specific country situations

• Agreement on best delivery and scaling up mechanisms

• Low and declining numbers of heath professionals• Inadequate laboratory infrastructure• Cost-effectiveness and fiscal sustainability• Buy-in of governments

The Centrality of Financial and Fiscal Sustainability

• Even at the reduced costs, treatment cannot be made to be entirely self financing

• Co-finance of treatment by OECD countries and African governments will be needed

• But unless overall costs of treatment decline further, millions cannot be reached even with the expanded resources now becoming available

Sustainability requires investing in the construction of efficient and reliable outreach mechanisms

The Seven Margins of Cost-reduction and Sustainability

• Target treatment subsidies to poor rural and urban patients, and to essential health, education, and agricultural personnel

• Recover costs from those able to afford treatment

• Further reduce cost of the ARVs, OI drugs, diagnostic tests via astute and reliable procurement and distribution systems

• Mobilize drug donations from industry

More Margins

• Encourage and support health insurance initiatives which include HIV/AIDS treatment– in private sector or public/private partnerships

• Enhance the fund-raising capabilities of the community organizations and NGOs involved

• Improve the capability of PLWHAs to co-finance their own treatment by supporting their income generation activities

The Role of National AIDS Council and Ministries of

Health• Develop treatment policies, framework, and

guidelines• Institute national mechanisms for assuring

pharmaceutical and treatment quality• Coordinate and facilitate mechanisms for

monitoring and evaluation, and for sharing of lessons learned

• Facilitate continuous training and upgrading of all involved in treatment

• Facilitate registration, imports, and in some cases production of quality generic drugs

• Facilitate the upgrading and rational use of existing public and private treatment and laboratory infrastructure and competencies

The Proposed IDA Treatment Acceleration Program

Objectives of the Treatment Acceleration Program (TAP)

• Test the scalability of existing HIV/AIDS treatment programs of NGOs and public/private partnerships

• Ensure that the treatment programs are comprehensive, decentralized, cost-effective, equitable, and sustainable

• Monitor, evaluate and learn from these programs • Disseminate the lessons and implementation tools across

Africa rapidly

Components of the TAP

• Country programs to accelerate the scaling up of the five components of holistic HIV/AIDS Treatment (four countries)

• Cross-country facilitation and learning program – Across and from the four countries– To benefit other MAP countries

Links Between Multi-sector HIV/AIDS Program and the TAP

• MAP countries have concentrated on awareness, prevention, and voluntary counseling and testing

• Treatment programs are under preparation in many MAP countries – Financed by several donors, including the MAP– Focusing primarily on the public sector

• MAP countries will draw lessons, mechanisms, and tools from the TAP, and thereby facilitate the use of rapidly increasing donor support

The Country Programs

• Fund scaling up of existing holistic HIV/AIDS treatment programs of NGOs and public/private partnerships which include all five components of treatment

• Institute M&E systems to strengthen the programs and compare the scalability, cost-effectiveness, equity, treatment adherence and quality among programs

• Assist countries treatment coordination capabilities and quality assurance

• Disseminate lessons, prepare for national mainstreaming • Assist countries in improving health insurance systems,

medical benefit plans, and the targeting and administration of treatment subsidies

Eligibility Criteria for the TAP

• Existing treatment programs of domestic or international NGOS, communities, or public/private partnerships, which– include at least treatment components one to three, and preferably

all five component

– innovate on at least four of the seven margins of sustainability

– address low and declining medical personnel, and/or laboratory infrastructure in innovative ways

– foster confidentiality and ethical approaches to treatment

– ensure equitable patient selection in rural and urban areas

• Organizations commit to freely share lessons learned and tools developed

Other Program Characteristics

• Reach into or out from public or private centers of excellence– Through district and local hospitals and health centers– Via NGOs and faith-based organizations– By involving communities and associations of people

living with HIV/AIDS

• Establish and sustain financial accountability• Institutionalize accountability to patients, their

families and communities, associations of people living with HIV/AIDS

Monitoring and Evaluation

• Independent monitoring and evaluation of scalability, treatment quality, equity, and sustainability is essential

• Must include comparison among alternative treatment implementation mechanisms within and across countries

• Therefore the M&E indicators need to be similar or the same all treatment programs

• They must be implemented from the start of the program and include an adequate baseline

• They should generate comparable clinical and economic data for research

Program Duration and Size

• TAP will be a three year program running in four countries

• Lessons will be mainstreamed as soon as they become available during the program and at the end

• Overall costs likely to be US$ 50 million, the bulk of which will be in country programs

TAP Partners

• Likely implementing partners: Sant’Egidio, Columbia University, PharmAccess, AIDSETI, MSF, Red Cross…

• Facilitating partners: International Treatment Access Coalition (ITAC), World Health Organization (WHO), United Nations Economic Commission for Africa (UNECA)