REGIONAL COMMITTEE Sixty-first Session SEARO, New Delhi 8–11 September 2008
Provisional Agenda item 14 SEA/RC61/12 28 July 2008
PUBLIC HEALTH APPROACH TO COMBATING HIV/AIDS The HIV epidemic continues to take its toll in the South-East Asia (SEA) Region. Countries have, however, demonstrated that implementing an effective response is feasible, both to halt and reverse epidemics and to provide services to those in need. To date, efforts to scale up HIV/AIDS programmes have involved a variety of different service delivery models, guidelines and tools for multiple HIV/AIDS interventions. Countries seeking to scale up HIV/AIDS health services to achieve universal access will benefit by adopting a service delivery model that brings together the best of these approaches and helps to compensate for the significant health systems challenges that many of them face. The paper discusses a public health approach to combating HIV/AIDS. The approach consists of four steps: • • • • Define the problem and the risk factors; Find out what works to control the disease; Scale up effective interventions in a wide range of settings; and Monitor/evaluate the impact and cost-effectiveness of these interventions.
This paper was submitted to the Meeting of the Advisory Committee (ACM) held in the Regional Office, New Delhi from 30 June 2008 to 3 July 2008. The ACM made the following recommendations:
Action by Member States (1) Under the overall multisectoral approach to combating HIV/AIDS, the public health approach and role of health sector should be further strengthened in all Member States by: • • Reviewing and updating strategic information, including HIV/STI surveillance and research; Scaling up appropriate HIV prevention` in relevant population groups to have the desired impact on the epidemic and to meet the Millennium Development Goals (MDGs) by strengthening health systems using the available resources; Expanding antiretroviral treatment, giving priorities to prevention of mother-to-child transmission and TB/HIV interventions; and Conducting programme reviews to measure progress, identify challenges and use the opportunity for advocacy at country levels; and
• • (2)
Strengthen cross-border collaboration and develop effective coordinating mechanisms to combat HIV/AIDS.
Action by WHO/SEARO (1) (2) To facilitate and support cross-border coordination and collaboration to discuss innovative mechanisms for control of HIV/AIDS, TB and vector-borne diseases; and Continue the support that is required by Member States in the health sector response to HIV/AIDS.
The Sixty-first Session of the Regional Committee is invited to consider the public health approach to combating HIV/AIDS and provide guidance on strategies for its implementation.
Contents Background................................................................................................................................1 A public health approach to combating HIV/AIDS ......................................................................2 Defining the problem and the risk factors .............................................................................................. 2 Develop effective prevention and care strategies: What works? .............................................................. 4 Achieving broad coverage: scaling up interventions................................................................................ 6 Monitoring programme and evaluating the impact of scaled-up interventions ......................................... 7
Current challenges and opportunities .........................................................................................8 Roles of WHO ...........................................................................................................................9 Priorities for the SEA Region .......................................................................................................9 Points for discussion .................................................................................................................10
SEA/RC61/12 Page 1
Background 1. The human immunodeficiency virus (HIV) continues to be a major public health problem in the South-East Asia (SEA) Region. With an estimated 3.6 million people living with HIV/AIDS (PLHA), the Region is the second-most affected region in the world. Five countries – India, Indonesia, Myanmar, Nepal and Thailand – account for over 99% of the regional burden. The incidence of HIV is the highest among sex workers and their clients, men who have sex with men (MSM), and injecting drug users (IDUs). 2. An effective approach to such a massive public health problem must address HIV as both a preventable communicable disease and a manageable chronic infection. Global commitments to achieve the related Millenium Development Goals (MDGs) and Universal Access (UA) targets clearly mandate such a dual approach: to halt and reverse epidemics while extending the benefits of care, support and treatment to those affected. Efforts to achieve both these objectives must be informed by reliable epidemiologic data and based on sound public health principles. 3. While combating HIV requires a multisectoral approach, the health sector must spearhead the response, not only technically but also in implementing critical interventions that are unique to the health sector. The role encompasses surveillance, blood safety, STI management and control, counselling and testing, prevention of mother-to-child transmission, care and treatment. 4. Significant progress has been made in recent years in treating AIDS and opportunistic infections. As a result, HIV is increasingly seen as a manageable chronic disease where morbidity and mortality can be reduced and life expectancy and quality of life improved. The challenge is to extend HIV-related services – from HIV counselling and testing to prevention of mother-tochild transmission (PMTCT) and antiretroviral treatment (ART) – widely to those in need, working through existing health services and bolstering them in the process. 5. Yet, such efforts alone would do little to control or reverse HIV epidemics. Without controlling epidemics, treatment efforts will never keep pace with new infections. In some countries, up to eight new HIV infections occurred last year for every one person started on lifesaving ART, despite progress in scaling up treatment services. 6. A balanced response is clearly needed – to curb the growth of HIV epidemics while expanding access to needed HIV services for those affected. Where this has been done, countries have been better able to meet the needs and targets for PMTCT, ART and other HIV services. Real progress towards universal access can be made only when the incidence of new infections decreases. 7. As the directing and coordinating authority on international health, the World Health Organization (WHO) takes the lead within the UN system in the global health sector response to HIV/AIDS. WHO provides evidence-based, technical support to the Member States to help in scaling up treatment, care and prevention services with the public health approach and ensure a comprehensive and sustainable response to HIV/AIDS.
SEA/RC61/12 Page 2
A public health approach to combating HIV/AIDS 8. To date, efforts to scale up HIV/AIDS programmes have involved a variety of different service delivery models, guidelines and tools for multiple interventions. Countries seeking to scale up HIV/AIDS health services to achieve universal access will benefit by adopting a service delivery model that brings together the best of these approaches and helps to compensate for the significant health systems challenges that many of them face. Such a model should ideally be standardized as much as possible so that it can meet the needs of large numbers of people and be implemented in a wide range of settings. 9. Accordingly, WHO promotes a public health approach to the delivery of health services for HIV/AIDS, drawing upon the successful experiences of other health programmes. A public health approach is one directed to addressing the health needs of a population, or the collective health status of the people, rather than merely individuals. A public health approach involves a collaborative effort by all parts of the health sector, working to ensure the well-being of society through comprehensive prevention, treatment, care and support. The approach consists of four steps: • Define the problem through the systematic collection of information about the magnitude, scope, characteristics and consequences of the disease and the causes and correlates of the disease; the factors that increase or decrease the risk for infection; and the factors that could be modified through interventions. Find out what works to control the disease by designing, implementing and evaluating interventions. Scale up effective interventions in a wide range of settings. Monitor/evaluate the impact and cost-effectiveness of these interventions as part of the programme.
• • •
Defining the problem and the risk factors 10. Defining the problem would involve surveillance and screening so that the magnitude and distribution of HIV/AIDS in different populations is known and can be monitored over time to measure the success or failure rates of interventions. 11. The HIV epidemiology shows clearly that transmission does not occur uniformly across populations. Rather, epidemics are driven by high incidence and rapid spread in networks of IDUs, sex workers and MSM, while incidence is much lower among the general population. 12. It is by secondary transmission – for example, from clients of sex workers to their regular partners – that epidemics extend into the general population. The challenge here is to effectively target disease control efforts “upstream” to prevent infection and interrupt the chain of transmission.
SEA/RC61/12 Page 3
13. The presence of other STIs augment the rapid transmission of HIV. An estimated 40% of the 340 million new STIs occurring globally in the SEA Region. The highest rates of incidence continue to be among sex workers. In the cities of Mumbai and Pune, India, genital ulcer disease was found to be common among sex workers and MSM. A high proportion of STIs associated with increased HIV prevalence was also reported from transgenders in Jakarta, Indonesia and India. In Nepal, prevalence of STIs was 19.4% among migrants and 11% in their wives. Early sexual debut and risky behaviours among the large youth population in the Region are contributing to increases in HIV and STI transmission. HIV prevalence in the SEA Region (2007) Five countries account for the majority of the HIV burden in the Region Nepal 70 000 Myanmar 242 000 242,000
India 2 500 000
Thailand 562,000 562 000
Indonesia 193 000
14. Strategic information including sentinel surveillance and research data can help in identifying risk factors, making estimations and projections, evaluating impact and creating advocacy. Data on prevalence, and if possible incidence, should be used to guide HIV/AIDS interventions. 15. In addition to individual behavioural risk factors, various social, cultural and economic factors increase vulnerability to HIV. Gender disparities remain common in the Region with women having few rights regarding marriage, inheritance or protection against violence. Unfavourable legal environment and policing attitudes are also fuelling the HIV epidemic in the SEA Region by driving sex workers, IDUs and MSM underground and thereby beyond the reach
SEA/RC61/12 Page 4
of prevention services. HIV discrimination is considered to be one of the major sociostructural determinants of the epidemic in South-East Asia. Across the Region, migration and mobility create favourable conditions for transmission of HIV and other STIs, and wide dissemination from migrant destination to source communities. Populations at greatest risk • • • HIV infection rates among female sex workers are very high in India, Myanmar and Indonesia, ranging from 11% to 50%. HIV among MSM is being increasingly reported from Thailand (28%), India (1% to 40%) and other countries of the Region. HIV epidemics among IDUs in the Region often appear early and spread rapidly. HIVprevalence among IDUs ranges from 5% to 77% in Bangladesh, Indonesia, Myanmar, Nepal and Thailand.
Develop effective prevention and care strategies: What works? 16. There are a number of examples of successful HIV programmes in the Region. Many are described in WHO strategies1 and build on established scientific evidence – for example, that effective STI case management lowers HIV viral load; that antenatal HIV testing and ART reduces rates of mother-to-child transmission; that provision of ART can reduce morbidity, mortality and hospital admissions and prolong and improve the quality of life. 17. Based on this experience and evidence, strategies, guidelines and tools have been developed and adapted for use in the Region. Essential packages of interventions have been described for sex workers, IDUs and MSM, and for populations with mixed risk profiles such as migrant and mobile men. In addition, guidelines and tools exist for a range of HIV-related clinical services from STI case management to ART. 18. Once strategies are adapted, planning should focus on piloting of interventions and services in a limited number of priority areas as the basis for wider scale-up. Sufficient technical assistance and resources should be provided to ensure the successful implementation of adapted strategies under field conditions. This was a key step in the successful implementation of the initiative for 100% condom promotion in Thailand, HIV/STI control through community mobilization in Sonagachi, West Bengal, India, and for ART and PMTCT scale-up in several countries. 19. It is also important to learn from experience in order to make informed decisions subsequently about how to scale up. Simple monitoring and operations research can be
1
Regional Strategy for the Prevention and Control of Sexually Transmitted Infections (STIs) 2007–2015; Biregional Strategy for Harm Reduction 2005-2009; Expanding Access to HIV/AIDS Treatment: A Strategic Framework for Action at Country Level.
SEA/RC61/12 Page 5
conducted to evaluate the experience and identify lessons learnt for subsequent programme expansion. 20. Introducing HIV-related services within the health system involves different challenges. Compared to targeted interventions that focus on relatively small populations, many more people in the general population are potentially affected and may need access to services. Perhaps the overriding challenge is how to decentralize and integrate services sufficiently to meet the needs of widely dispersed populations affected by HIV and STIs. Another common constraint is the lack of sufficient human resources to support the scale-up of new services. Physicians, nurses and other health staff frequently complain about taking on new tasks when they are already overstretched. 21. Solutions to these and other potential implementation problems should be worked out in a limited number of sites before attempting to roll out activities/services on a national scale. Experience from the Region suggests that this approach leads to better outcomes. Successful Regional Interventions (1) Targeted interventions guided by reliable surveillance can reverse epidemics • The successful 100% condom programme in Thailand led to a sharp reduction in HIV cases (ascertained among sex workers, military recruits and pregnant women) as a result of increased condom use in sex-work settings, implemented through a nationwide network of STI clinics. By 2002, an estimated 5.7 million HIV infections had been averted.
(2) HIV and other STIs can be controlled by scaling up STI services, promoting 100% condom use in sex work and involving target populations in programme implementation • In West Bengal, India, peer involvement decreased HIV vulnerability, increased sex worker empowerment, and stalled HIV take-off. Condom use in Sonagachi, West Bengal, increased from 3% in 1992 to 87% in 2007 while syphilis among sex workers there declined from 25% to 4%. India and Myanmar, like Thailand, have begun to report a decrease in STIs and HIV since they scaled up targeted interventions with sex workers and migrants. Sri Lanka has been successful in averting an HIV epidemic to date despite a longstanding civil war and absence of male circumcision; data from sentinel STI clinics document sustained reductions in curable STIs. HIV cases are rare even among highrisk populations. In India, every district in the six high-HIV burden states and more than 90% districts in the low-HIV burden states have at least one PMTCT centre. In Myanmar, the PMTCT programme currently covers 89 of 325 townships. Thailand has reached universal access targets for PMTCT and reports a decrease in the number of paediatric AIDS cases.
•
(3) Prevention of mother-to-child transmission is a crucial area •
SEA/RC61/12 Page 6
(4) Scaling up ART and improving survival is possible • Remarkable progress has been made in the Region on scaling up HIV antiretroviral treatment since November 2003, when the WHO “3 by 5” initiative was launched. Over four years, the number of people started on treatment has increased eighteenfold to 320 000. However, there are wide variations in coverage rates among countries. Less than 25% of those who need treatment have access to it. ART has been successfully scaled up in Thailand. In India, scale-up of the ART programme has been exemplary. Survival on first-line drugs was high and compared favourably with other countries, and opportunistic infections declined over time.
•
Achieving broad coverage: scaling up interventions 22. A high coverage – 80% condom use in commercial sex, 60% for harm reduction – is probably required to have an impact on halting or reversing HIV epidemics. Coverage is also key to controlling STIs, reducing mother-to-child transmission and improving survival in ART programmes. 23. Achieving high coverage presents a different set of challenges. Systems need to be built to support the scale-up from a limited number of sites towards coverage targets. The contributions of a range of donors and implementing partners require direction and coordination. An important element of success is effective programme management. 24. In addition, a functional capacity-building mechanism is essential to support the scale-up of both targeted interventions and clinic-based services. This may take the form of a technical support unit in or allied to the National AIDS Programme with sufficient technical expertise to standardize approaches (guidelines, tools, etc.), organize training and conduct regular monitoring and supervision. • The National AIDS Programme (NAP) should be in a controlling position. It should set standards for interventions and services, coordinate activities of implementing partners and monitor key outcomes. Training for NAP managers has been conducted in the Region. In addition, the SEA Region organizes annual meetings of NAP managers to share experiences and set regional priorities (see 2008 recommendations below).
•
25. Coordination is also needed at the district level. District medical offices or AIDS control committees should be supported to map epidemic “hotspots”, targeted interventions and clinical services. They should use this information to facilitate district-level planning and coordination involving local health-care facilities and other implementing partners. 26. At the local level, support is needed for decentralization of HIV-related services to health facilities and at the community level, and their integration into other priority health interventions. WHO has developed a model essential package of integrated health-sector
SEA/RC61/12 Page 7
interventions for HIV/AIDS to guide countries. It provides a wide range of tools and technical support to assist countries with its implementation. Implementation support should include plans to relieve human resource constraints – including task-sharing, co-management and integration of services at different levels of health facilities. 27. As countries scale up their national HIV/AIDS programmes towards the goal of universal access to prevention, treatment, care and support by 2010 and achieving the related Millennium Development Goal (i.e. to “halt and reverse the spread of HIV”) by 2015, it is increasingly important to strengthen monitoring and evaluation systems to inform policies and programmes, improve the effectiveness of interventions and promote accountability.
Monitoring programme and evaluating the impact of scaled-up interventions 28. The monitoring and evaluation (M and E) system should be customized to suit the type and level of the epidemic. The essential ingredients of the M and E package should include: a national M and E plan in line with the national strategic plan, a central M and E unit, key indicators and standard data collection forms, and regular data analyses and dissemination. A standard set of indicators should be identified at the national level to measure the availability, coverage and impact of interventions in the health sector, namely prevention of sexual HIV transmission and transmission through injecting drug use; prevention in the health-care setting; HIV testing and counselling; PMTCT; and treatment and care. It is also important to measure progress in strengthening key components of the health system to support the scale-up of priority interventions, e.g. procurement and supply management, human resources, financing and information systems. Trained human resources with the required skills and expertise are needed to ensure timely collection, analysis and use of information. Adequate funds (7-10% of total national HIV programme budget) should be allotted for strategic information, which includes monitoring and evaluation and surveillance activities. Annual new HIV infections decreased with increased coverage of the 100% condom programme in Thailand 120,000 100,000 80,000 60,000 40,000 20,000 0 1985 1990 1995 200 0 Male 2005 Female 2010 Child 2015 2020 S ca ling up H IV testing a nd c o unse lling in Asia a nd the Pa cific, 4-6 June 2 007 T ow ard s U nive rsa l Ac cess
D ecrease in p aediatric H IV infections after im plem entation of prevention of m other-to-child transm ission p rogram m e in Thailand, 1 994-2004 1400 P o licy to provid e HIV cou n se ling a n d te stin g to a ll p re g n a n t w o m e n O pe ra tio na l re se a rch o n ARV p ro ph yla x is Na tion a l P o licy a n d p rgra m m e o n P M T CT la un ch e d
100% condom program me begins Number of paediatric HIV cases
1200
1000
800
600
400
200
0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
29. To assess the achievements of national AIDS programmes, its relevancy and adequacy in the national response, especially in health sector, and to provide recommendations for improving strategies and interventions, the Regional Office carried out National AIDS Programme evaluation/review in five countries during the period 2005-2008: Indonesia,
SEA/RC61/12 Page 8
Myanmar, Nepal, Sri Lanka and Thailand. Three more countires, Bhutan, DPR Korea and TimorLeste, have planned this review in 2009-2010.
Current challenges and opportunities 30. In order to make real progress towards MDGs and UA targets, a stronger response is needed to prevent new infections and care for those already affected. A measure of this progress is the percentage of people with HIV in the Region who have access to key prevention, treatment, care and support services. 31. While access to services has increased since 2001, it is low for VCT, PMTCT and for IDUs, MSM, sex workers and prisoners. Coverage levels are still low for care and treatment services. Less than half (47%) of the SEA Region’s population receives the “essential package” of care and treatment stipulated by WHO and UNAIDS. There is an obvious gap in implementation, which is related to low coverage of services, low percentage of health spending, poor allocation and utilization of existing funds and inadequate coordination of donors. Also, unfavourable policies – prohibiting methadone, needle exchange programmes, condoms and clean needles in prisons – despite available evidence of benefits, are amplifying the epidemic. The challenge of coverage • • • • The coverage of prevention programmes for IDUs and MSM in the Region is only 3% and 2% respectively. Prevention programmes reach only 20% of 1.6 million sex workers in the Region. HIV testing and counselling is offered only to 5% of pregnant women in the Region. Despite the rapid scale-up of ART in the past few years, it is available only to 23% of the 1.2 million who need it.
32. There are available opportunities to bolster the public health approach to HIV in the Region. National AIDS Programme Managers had set priorities for 2008 at their annual meeting in Bali, Indonesia, in November 2007. Commitments were made to achieve progress in the following areas: • Addressing barriers to scaling up (i) targeted condom and STI interventions to slow sexual transmission; and (ii) proven harm reduction interventions to prevent injectionrelated transmission. Specific attention paid to achieving high coverage, ensuring sufficient quality and intensity to have tangible impact, and creating an enabling environment. Rational ART provision reduces morbidity and mortality, slows the development of HIV drug resistance and reduces cost. It involves effective first-line treatment, adherence support, and close monitoring with early warning indicators. Increase implementation capacity, with focus on human resources. Scaling up interventions and services requires investment in primary health care and human
•
•
SEA/RC61/12 Page 9
resources for health. Improved health systems, sustained finances and increased capacities of human resources are critical for a successful response. • Strengthening of strategic information (surveillance and M and E) is a crucial component of national response. All countries agreed to implement the Working Group’s recommendations with technical assistance from WHO, UNAIDS and other partners.
Roles of WHO 33. WHO takes the lead role within the UN system in health sector response to HIV/AIDS. WHO collaborates with other UN agencies, ministries of health, development agencies, nongovernmental organizations (NGOs), health services providers, health-care institutions, people living with HIV and other partners. The aim is to strengthen all aspects of the health sector in order to deliver the much-needed HIV services. WHO provides technical support and develops evidence-based norms and standards that will help transform the goal of universal access into reality.
Priorities for the SEA Region • Successful interventions to combat HIV/AIDS should be adapted quickly and scaled up for impact. Targeted interventions such as the “100% condom use” and harm reduction interventions for injecting drug users need to be re-emphasized and expanded. Prevention of mother-to-child transmission should be prioritized in countries with high rates of vertical transmission. Factors hindering the scale-up of interventions include, for example, costs of drugs, poor infrastructure and drug resistance. Careful analysis of gaps and barriers will enable the barriers to be overcome. Unprecedented levels of funding are now available for the scale-up of interventions through the Global Fund to Fight AIDS, TB and Malaria (GFATM). Countries should strengthen their capacity to absorb those funds by reducing spending bottlenecks, and increase human resource and technical capacity to enhance implementation performance. HIV resources should be utilized to build the necessary health systems. This includes investing in primary health care to improve access to HIV services at the community level. Decentralization of HIV/AIDS services at the district level should also be supported. National AIDS programmes are responsible for leading the response to HIV and coordinating efforts by other sectors and partners. Managerial capacity of the national AIDS programmes should thus be bolstered with adequate human resources, technical capacity and supportive systems. Regional efforts to facilitate cross-border collaboration for HIV/AIDS prevention and care should be supported. Sharing of information and experiences on cross-border interventions should be promoted, including informal meetings at the local level. Involvement of regional organizations such as ASEAN and SAARC may be continued.
•
•
•
•
•
SEA/RC61/12 Page 10
•
Though the health sector has the major role to play and therefore has to spearhead the public health approach, other sectors also have to contribute. Multisectoral involvement should be promoted and advocated at the highest political level.
Points for discussion 34. The Sixty-first Session of the Regional Committee is invited to endorse and provide guidance, as per the recommendations of the Advisory Committee, for the adoption of the public health approach to combating HIV/AIDS.