0
ARV programme overview   SOURCE: South Africa HIV/AIDS response stakeholder interviews; Project team analysis <ul><ul><ul>...
South Africa faces the world’s worst HIV epidemic –HIV prevalence seems to have stabilized, but at a very high level   0 <...
ARV roll-out is driving HIV prevalence up even further   SOURCE: HSRC survey reports; ART-adjusted data: Rehle et al., 201...
South Africa’s treatment program is the largest in the world, but there is need to further slow infections and further exp...
New South Africa guidelines have expanded coverage, but there is still a way to go to align with international standards  ...
Aggressive task shifting and strengthened, centralized procurement capabilities are required to keep costs under control  ...
If new drug purchasing mechanisms and task-shifting are  implemented, costs can be kept under control even with  expanded ...
Summary of patients initiated on ARVs vs. cost under each set of guidelines   7 SOURCE: Total cost and potential cost savi...
There are significant capacity challenges in the programme expansion   n <ul><ul><li>Health System constraints </li></ul><...
Recently, the government has taken steps to address these capacity gaps   n SOURCE: Global Fund; UNAIDS; Press search, NDO...
Coordination complexity archetypes – South Africa (province)   1 Includes provider-initiated VCT SOURCE:  South Africa HIV...
Complexity of the programme   Low Medium High Extreme Funders <ul><ul><li>SAG provides majority (85%) of funding; In Febru...
Structure of the HIV response is complex: ARV example   SOURCE: Interviews 1 HIV/ AIDS, TB and STD director ILLUSTRATIVE A...
Key ART programme players and roles     SOURCE: South Africa HIV/AIDS stakeholders interviews PRELIMINARY Donors and provi...
Landscape of programme execution   SOURCE: South Africa HIV/AIDS stakeholder interviews PRELIMINARY <ul><ul><li>Strategy a...
Funding flows, technical support, and accountability lines flow  through multiple stakeholders in the ARV programme   Fund...
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Arv programme summary

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  1. 1. ARV programme overview SOURCE: South Africa HIV/AIDS response stakeholder interviews; Project team analysis <ul><ul><ul><li>South Africa’s treatment program is the largest in the world </li></ul></ul></ul><ul><ul><ul><li>By the end of 2010, over 1 million people with HIV in South Africa had initiated ARV treatment , however, the total need is 5.7 million </li></ul></ul></ul><ul><ul><ul><li>Additional 300,000 people in need every year </li></ul></ul></ul><ul><ul><ul><li>Government led effort with support from PEPFAR </li></ul></ul></ul>Overview <ul><ul><ul><li>Pre-initiation: Testing conducted by primary health care facilities and clinics, as well as private clinics </li></ul></ul></ul><ul><ul><ul><li>Initiation: HIV+ patients meeting medical criteria (CD4<350) get ARVs </li></ul></ul></ul><ul><ul><ul><li>Maintenance/Adherence: Behaviour aspect driven mainly by NGOs with increasing focus from government </li></ul></ul></ul>Structure <ul><ul><ul><li>Measures taken by DoH to upgrade existing health infrastructure includes upgrading and accreditation of sites, training programs for health-workers to deliver treatment </li></ul></ul></ul><ul><ul><ul><li>Scale up of task shifting to increase the ability of nurses to provide ARV treatment, and ensuring proper supervision/mentorship </li></ul></ul></ul>Implemen-tation model <ul><ul><ul><li>Government provides 85% of funding with some support on technical areas from development partners </li></ul></ul></ul><ul><ul><ul><li>Drugs are purchased centrally and make up roughly 20% of the global market for ARVs ; reduction of the cost of drugs to allow for increased coverage at a reduced cost per patient </li></ul></ul></ul>Financing
  2. 2. South Africa faces the world’s worst HIV epidemic –HIV prevalence seems to have stabilized, but at a very high level 0 <ul><ul><li>National level HIV prevalence data suggest that HIV prevalence has stabilized </li></ul></ul><ul><ul><ul><li>In adults aged 15-49 years, HSRC surveys estimated HIV prevalence at 15.6% (2002), 16.2% (2005), and 16.9% (2008) </li></ul></ul></ul><ul><ul><li>Although HIV prevalence is stable, the total number of PLHIV 1 is rising (~100,000/year) due to population growth and reduction of mortality due to ARVs </li></ul></ul><ul><ul><li>On average, females are infected about five years earlier than males, with 7% of young women aged 15-19, and 14% of pregnant teenage girls, already infected </li></ul></ul><ul><ul><li>Females have a statistically significant, higher HIV prevalence than men, nationally and in 7 of the 9 provinces (not in N Cape and North-West) </li></ul></ul>SOURCE: KYE/KYR reports, 2011; Spectrum estimations and mid-year population estimates from www.statssa.gov.za 92 1990 2008 06 04 02 2000 98 Number (infected, newly infected, died) 96 94 Population Millions AIDS-related deaths Annual new HIV infections People living with HIV Total population 1 People Living with HIV/AIDS
  3. 3. ARV roll-out is driving HIV prevalence up even further SOURCE: HSRC survey reports; ART-adjusted data: Rehle et al., 2010; K Y E/K Y R reports, 2011 <ul><ul><li>ART has begun to have an important effect on HIV preva-lence levels (adding ~2% to HIV prevalence through PLHIV who would already have died in the absence of ART) </li></ul></ul><ul><ul><li>The life-prolonging effect of ART is the chief reason for the observed increases in HIV prevalence in older people. This ‘ART effect’ is estimated to be largest in people in the mid-20s to late 40s </li></ul></ul>HIV prevalence Percent 2002 2006 2008 2008, ART adjusted Pre-2002 level
  4. 4. South Africa’s treatment program is the largest in the world, but there is need to further slow infections and further expand coverage 9 SOURCE: Nathea Nicolay, Summary of provincial HIV and AIDS statistics for South Africa, Metropolitan, 2008; NDOH programme data 2008,2009, <ul><ul><li>Highest uptake on ARV is in the Western Cape (75%) </li></ul></ul><ul><ul><li>Highest number of people on treatment in Gauteng (175,000) </li></ul></ul><ul><ul><li>Largest number of people who are still in need of treatment but not accessing it are in KZN followed by Gauteng and Eastern Cape </li></ul></ul>Provincial distribution of those in need of ARV and those receiving treatment 2008 figures, ‘000 2008 2009 % of those in need of treatment enrolled in the ART programme Children Adults 297 43% 73 71 87 Mpuma-langa 44% Free State 49% North West 44% 92 293 47% Eastern Cape 60% 111 44% Kwazulu-Natal Gauteng Western Cape 55 75% Limpopo Northern Cape 11 55% Total people accessing ART (mid year) Total people in need of ART (mid year)
  5. 5. New South Africa guidelines have expanded coverage, but there is still a way to go to align with international standards Old South African guidelines Eligibility <ul><ul><li>Adults : CD4 <200 cells/mm 3 or WHO Stage 4 </li></ul></ul><ul><ul><li>Children : CD4 15% to 20% or WHO Stage 3 or 4 </li></ul></ul>Regimens <ul><ul><li>Adults : d4T + 3TC + EFV/NVP; AZT + ddI + LPV/r </li></ul></ul><ul><ul><li>Children <3 yrs : d4T + 3TC + LPV/r; AZT + ddI + NVP </li></ul></ul>New South African guidelines Eligibility <ul><ul><li>Adults : CD4 <350 cells/mm 3 for TB/HIV co-infected or pregnant pts ,<200 cells/mm 3 or WHO Stage 4 for all others </li></ul></ul><ul><ul><li>Children : Early Paediatric Treatment </li></ul></ul>Regimens <ul><ul><li>Adults : TDF + 3TC + EFV/NVP for all new initiates; TDF + 3TC + LPV/r if failing d4T- or AZT-containing regimens/ AZT + 3TC + LPV/r if failing TDF-containing regimens </li></ul></ul><ul><ul><li>Children <3 yrs: ABC + 3TC + LPV/r; AZT + ddI + NVP </li></ul></ul>Full WHO guidelines Eligibility <ul><ul><li>Adults : CD4 <350 cells/mm 3 or WHO Stage 4 for all </li></ul></ul><ul><ul><li>Children : Early Paediatric Treatment </li></ul></ul>Regimens <ul><ul><li>As in “New South African Guidelines” </li></ul></ul>SOURCE: Total cost and potential cost savings of the national antiretroviral treatment (ART) programme in South Africa 2010 to 2017; Author: Gesine Meyer-Rath et. al; Date: April 12, 2011
  6. 6. Aggressive task shifting and strengthened, centralized procurement capabilities are required to keep costs under control 5 SOURCE: Total cost and potential cost savings of the national antiretroviral treatment (ART) programme in South Africa 2010 to 2017; Author: Gesine Meyer-Rath et. al; Date: April 12, 2011 2,245 New guidelines 1,161 2,994 Old guidelines 1,055 2010/11 2016/17 1,969 1,504 8,180 9,946 -33 -35 Change on old GL (full cost) Percent 10 33 -29 -12 -18 – Full WHO guidelines 1,415 3,494 2,345 12,077 -33 Change on old GL (full cost) Percent 34 56 12,200 15,251 25 18,125 49 -0.1 – <ul><ul><li>The total cost of the programme increases by 25% and 49%, respectively, for the new guidelines and full WHO guidelines scenarios, as a result of increased eligibility and higher drug cost for TDF-containing regimens </li></ul></ul><ul><ul><li>If new drug purchasing mechanisms and task-shifting are implemented, the cost of the new guidelines is below, and the cost of the full WHO guidelines the same as the cost of the old guidelines </li></ul></ul>$ Millions, 2009 Reduced cost (with task-shifting and cheaper fixed-dose combinations) Total Full cost (staffing and drug cost as current) Total Scenario Change on full cost Percent -11 4
  7. 7. If new drug purchasing mechanisms and task-shifting are implemented, costs can be kept under control even with expanded guidelines s Full WHO guidelines New guidelines Old guidelines SOURCE: Total cost and potential cost savings of the national antiretroviral treatment (ART) programme in South Africa 2010 to 2017; Author: Gesine Meyer-Rath et. al; Date: April 12, 2011 [BUDGET REVIEW 2010, NATIONAL TREASURY 2012/13 2011/12 2010/11 Full WHO guidelines New guidelines Old guidelines % Percentage of budget at full cost Percentage of budget at reduced cost (TS and RL/FDC)
  8. 8. Summary of patients initiated on ARVs vs. cost under each set of guidelines 7 SOURCE: Total cost and potential cost savings of the national antiretroviral treatment (ART) programme in South Africa 2010 to 2017; Author: Gesine Meyer-Rath et. Al; Date: April 12, 2011 Total cost USD millions Total patients 12,077 Full WHO guidelines New guidelines 15,251 Old guidelines Total cost (full cost) Total cost (reduced cost) Total patients initiated on ART
  9. 9. There are significant capacity challenges in the programme expansion n <ul><ul><li>Health System constraints </li></ul></ul><ul><ul><li>>300,000 patients per year, h owever, significant capacity challenges in expansion including human resources, infrastructure and drug supply </li></ul></ul><ul><ul><li>Need for greater decentralisation of ARV treatment services, and greater recruitment and retention of health workers in the public health sector </li></ul></ul><ul><ul><li>Estimating need for ART treatment is difficult </li></ul></ul><ul><ul><li>Even with the best systems in place, calculating number enrolled in ARV programs can be difficult </li></ul></ul><ul><ul><li>South Africa’s ART program lacks one unified, centrally coordinated patient monitoring system </li></ul></ul><ul><ul><ul><li>Hard to collate accurate figures of those receiving treatment or survival rates </li></ul></ul></ul><ul><ul><ul><li>DoH currently piloting an IT system in the Western Cape </li></ul></ul></ul><ul><li>Other challenges </li></ul><ul><ul><li>Monitoring capacity of patients </li></ul></ul><ul><ul><li>Numbers of doctors to provide ARV therapy </li></ul></ul><ul><ul><li>Communication by leaders to communities to overcome stigma and confusion regarding efficacy of ARV treatment relative to traditional medicines </li></ul></ul>SOURCE: Global Fund; UNAIDS; Press search, NDOH programme data 2008/09 Key challenges scaling up the ARV programme
  10. 10. Recently, the government has taken steps to address these capacity gaps n SOURCE: Global Fund; UNAIDS; Press search, NDOH programme data 2008/09 Key actions taken by the government <ul><ul><li>Increasing coverage of facilities </li></ul></ul><ul><ul><li>Increase in number of patients reflects ongoing expansion as service points accredited, counselling and testing, HR and lab infrastructure put into place </li></ul></ul><ul><ul><li>Rapid increase in number of HIV, CD4 and viral load tests performed by National Health Laboratory Service </li></ul></ul><ul><ul><li>Measures taken by DoH to upgrade existing health infrastructure includes upgrading and accreditation of sites, training programs for health-workers to deliver treatment </li></ul></ul><ul><ul><li>Implementation </li></ul></ul><ul><ul><li>In February 2010, the national ART budget was increased by 96%, providing care for up to 2.3 million patients by the end of 2012/13 </li></ul></ul><ul><ul><li>To increase coverage, a HCT campaign was started in April 2010, aiming at testing 15 million South Africans by June 2011 </li></ul></ul><ul><ul><li>Treatment guidelines expanded to include all pregnant women and patients with a CD4 >350 </li></ul></ul><ul><ul><li>Recommended improvements to the programme </li></ul></ul><ul><ul><li>New treatment guidelines in April 2010, adhering to WHO recommendations to initiate ARV at a CD4 count of <350 cells/mm 3 </li></ul></ul><ul><ul><li>New drug purchasing system : ARV drugs at prices set in reference list mechanism issued for 2010 tender, ultimately decreasing the cost of drugs by 26% and saving ~$120 million </li></ul></ul><ul><ul><li>Task shifting : ARV initiation and management by nurses under physician supervision; ARV dispensing by pharmacy assistants under pharmacist supervision </li></ul></ul><ul><ul><li>Programme cost (including new drug purchasing and task shifting under new guidelines) would be 25% less than under the Old Guidelines, while reaching 15% more patients 1 </li></ul></ul>1 See next slide for cost breakdown
  11. 11. Coordination complexity archetypes – South Africa (province) 1 Includes provider-initiated VCT SOURCE: South Africa HIV/ AIDS stakeholder interviews Medium High Low Extreme Intervention type (primary) <ul><ul><li>Clinical </li></ul></ul><ul><ul><li>Clinical </li></ul></ul><ul><ul><li>Clinical/ Behavioural </li></ul></ul><ul><ul><li>Behavioural </li></ul></ul>Number of funders <ul><ul><li>0-2 </li></ul></ul><ul><ul><li>3-5 </li></ul></ul><ul><ul><li>>10 </li></ul></ul><ul><ul><li>3-5 </li></ul></ul>Number of implementers <ul><ul><li>1 </li></ul></ul><ul><ul><li>2-10 </li></ul></ul><ul><ul><li>11-25 </li></ul></ul><ul><ul><li>>25 </li></ul></ul>Examples of programs in archetype <ul><ul><li>N/A </li></ul></ul><ul><ul><li>N/A </li></ul></ul><ul><ul><li>PMTCT </li></ul></ul><ul><ul><li>ART </li></ul></ul><ul><ul><li>MMC </li></ul></ul><ul><ul><li>VCT </li></ul></ul><ul><ul><li>OVC </li></ul></ul><ul><ul><li>BCC </li></ul></ul>
  12. 12. Complexity of the programme Low Medium High Extreme Funders <ul><ul><li>SAG provides majority (85%) of funding; In February 2010, the national ART budget was increased by 96%, providing care for up to 2.3 million patients by the end of 2012/13 </li></ul></ul><ul><ul><li>Drugs are purchased centrally and make up roughly 20% of the global market for ARVs </li></ul></ul><ul><ul><li>43% of CDC funding is directed towards ARV treatment, and 46% of the total from USAID </li></ul></ul>Implementers <ul><ul><li>ARV’s are dispensed only from accredited primary health care facilities and clinics </li></ul></ul>Size <ul><ul><li>Over 1 million HIV positive people are currently on ARV treatment, however, the total need is 5.7 million </li></ul></ul><ul><ul><li>Additional 300,000 people in need every year </li></ul></ul><ul><ul><li>Measures taken by DoH to upgrade existing health infrastructure includes upgrading and accreditation of sites, training programs for health-workers to deliver treatment </li></ul></ul><ul><ul><li>Scale up of task shifting to increase the ability of nurses to provide ARV treatment, and ensuring proper supervision/mentorship </li></ul></ul><ul><ul><li>Reduction of the cost of drugs to allow for increased coverage at a reduced cost per patient </li></ul></ul>Capabilities required SOURCE: South Africa HIV/AIDS stakeholder interviews
  13. 13. Structure of the HIV response is complex: ARV example SOURCE: Interviews 1 HIV/ AIDS, TB and STD director ILLUSTRATIVE ART lead Provincial National District SANAC Treatment Task Team ART lead Implementers District AIDS council DG=>MoH=> HIV Director Directorate for Treatment Premier=>MEC=> Head of department District HAST Director Provincial HAST 1 director ART lead Provincial AIDS council NGOs NGOs NGOs Gvt clinics/ hospitals NGOs NGOs NGOs NGOs (provide TA/ mobile CT) NGOs NGOs NGOs National NGOs NGOs NGOs NGOs Treatment leads National & provincial ART leads meet quarterly to exchange ideas & information NGOs NGOs NGOs Treatment leads NGOs NGOs NGOs Treatment leads NGOs NGOs NGOs National NGOs NGOs NGOs NGOs International donors
  14. 14. Key ART programme players and roles SOURCE: South Africa HIV/AIDS stakeholders interviews PRELIMINARY Donors and providers of technical assistance <ul><ul><li>Provides analysis on resource needs </li></ul></ul><ul><ul><li>Facilitates planning </li></ul></ul><ul><ul><li>Provide TA </li></ul></ul><ul><ul><li>Supports imple-mentation </li></ul></ul><ul><ul><li>Monitors program </li></ul></ul><ul><ul><li>Lead evaluations </li></ul></ul><ul><ul><li>Sets global guidance and provides TA to government </li></ul></ul>Civil society organisations <ul><ul><li>Advocates for resources </li></ul></ul><ul><ul><li>Plan for service delivery </li></ul></ul><ul><ul><li>Implement programs (ART , home based care, follow up) </li></ul></ul><ul><ul><li>Report on programs </li></ul></ul><ul><ul><li>Lead evaluations </li></ul></ul><ul><ul><li>Advocates for PLWHA policies </li></ul></ul><ul><ul><li>Allocates domestic resources </li></ul></ul><ul><ul><li>Negotiates with donors </li></ul></ul><ul><ul><li>Forecast treatment needs and allocates resources </li></ul></ul><ul><ul><li>Monitors programs </li></ul></ul><ul><ul><li>Reports to donors </li></ul></ul><ul><ul><li>Distributes ART to clinics </li></ul></ul><ul><ul><li>Trains clinicians </li></ul></ul>Private sector <ul><ul><li>Allocates resources to treat workers </li></ul></ul><ul><ul><li>Develops workplace programs </li></ul></ul><ul><ul><li>Provides treatment to workers and families </li></ul></ul><ul><ul><li>No formal mecha-nisms in place </li></ul></ul><ul><ul><li>No formal mecha-nisms in place </li></ul></ul><ul><ul><li>Input through SANAC </li></ul></ul>Strategy/ Policy Resource allocation (budgeting) Planning Implement-ation Monitoring & reporting Evaluation <ul><ul><li>Conduct and participate in evaluations </li></ul></ul><ul><ul><li>Sets national ART policy and guidelines </li></ul></ul>Government
  15. 15. Landscape of programme execution SOURCE: South Africa HIV/AIDS stakeholder interviews PRELIMINARY <ul><ul><li>Strategy and policy is set at the national level, and guidelines are communicated effectively down to the implementing level </li></ul></ul><ul><ul><li>Communication often in the form of media e.g. recently guidelines adopted from President Zuma’s speeches </li></ul></ul><ul><ul><li>Generally done well, implementing agencies have taken ownership </li></ul></ul><ul><ul><li>However, policies are often set without taking into account capacity constraints </li></ul></ul><ul><ul><li>Resource allocation done at provincial level based on district health plans </li></ul></ul><ul><ul><li>Districts allocate to hospitals and facilities according to funding requests </li></ul></ul><ul><ul><li>However, a lot of bureaucracy/ complexity relating to budgeting </li></ul></ul><ul><ul><li>Lack of trained resources with financial management skills at all levels results in inaccurate budget allocation </li></ul></ul><ul><ul><li>Issues around drug supply from the depot </li></ul></ul><ul><ul><li>Operational planning is done at the facility level </li></ul></ul><ul><ul><li>Plans are tied in with the budget which are then sent to district, and subsequently to provincial level </li></ul></ul><ul><ul><li>Poor under-standing of plans and lack of management capability results in funds being returned to the treasury at the year end or running out mid year </li></ul></ul><ul><ul><li>Lack of evidence of ‘forward thinking’ in planning e.g. taking into account growth </li></ul></ul><ul><ul><li>Implementation is carried out by government hospital and facilities at the sub district level </li></ul></ul><ul><ul><li>There are a number of public private partnerships where NGO support is given to government hospitals </li></ul></ul><ul><ul><li>Initiation of task sharing/shifting from doctors to trained nurses </li></ul></ul><ul><ul><li>Need to increased system efficiency e.g. booking/ queue management </li></ul></ul><ul><ul><li>DoH chosen IT system to pilot </li></ul></ul><ul><ul><li>There is no centralised IT system for monitoring and reporting </li></ul></ul><ul><ul><li>Currently, 3 sets of indicators requested from district office (planning and procurement), DORA (finance) and internal reporting </li></ul></ul><ul><ul><li>Donor specific reports requested from funded partners </li></ul></ul><ul><ul><li>Challenges in collecting information as much of the data in facilities is paper based </li></ul></ul><ul><ul><li>Little or no feedback against plans or targets </li></ul></ul><ul><ul><li>No interpretation of the data collected in the previous stage for managerial implications </li></ul></ul>Strategy/ Policy Resource allocation (budgeting) Planning Implementation Monitoring & reporting Evaluation
  16. 16. Funding flows, technical support, and accountability lines flow through multiple stakeholders in the ARV programme Funding flows Reporting/account-ability mechanisms Technical support SOURCE: The Second Botswana National Strategic Framework for HIV and AIDS, 2010-2016; PEPFAR; UNGASS 2010 Botswana Country Progress Report; PEPFAR Partnership Framework; UNAIDS Country Harmonization and Alignment Tool (CHAT); interviews; team analysis District Health Facilities NGOs/CSOs International Partners Government of South Africa National DOH Mobile Clinics Provincial DoH SANAC NGOs/CSOs EU+ donors PEPFAR Global Fund PRELIMINARY
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