REGIONAL COMMITTEE
Provisional Agenda item 5.6
Sixty-fourth Session Jaipur, Rajasthan, India 6–9 September 2011
SEA/RC64/10 20 July 2011
Regional Health Sector Strategy on HIV, 2011–2015 The attached Working Paper summarizes the progress made and lessons learnt within the HIV programme in the WHO South-East Asia (SEA) Region that includes prevention, treatment, care and support. This in turn guides the development of the new WHO SouthEast Asia Regional Health Sector Strategy on HIV (2011–2015). After sub-Saharan Africa, the WHO SEA Region has the second highest burden of HIV in the world with 3.6 million people affected with HIV though the overall adult prevalence is below 1%. Despite the burden and challenges, significant progress has been made and achieving universal access seems feasible even in resource-constrained settings. New directions and opportunities for achieving the Millennium Development Goal (MDG) include more efficient and effective HIV approaches and technologies, the crucial contribution of civil society to service delivery and decentralization, and integrated service delivery for maximizing synergies for a strengthened health sector response to HIV. The framework for the regional strategy has been developed in consultation with national HIV/AIDS programmes as well as with experts in the Region. The regional strategy follows the Global Health Sector Strategy for HIV: 2011–2015, which was presented and endorsed by the Sixty-fourth World Health Assembly. The Regional Health Sector Strategy covers a period of five years (2011–2015) and will guide the health sector response for achieving universal access to prevention, treatment and care for HIV. This working paper summarizes the proposed “Regional Health Sector Strategy on HIV, 2011–2015” that is being developed to address the regional differences and specificities of the epidemic areas between and within Member States. The targets and strategies mentioned in this document are consistent with those mentioned in the new global health sector strategy for HIV 2011–2015 with the clear focus on priorities most relevant to this Region. The document draws upon the achievements and lessons learnt during the past years.
The strategy:
contributes to a broader, multisectoral response to HIV. describes the future directions and focus of work related to the health sector response to the HIV epidemic in order to achieve universal access to prevention, diagnosis, treatment and care. provides a framework for priority interventions that shall eventually result in reducing the burden of HIV. Ultimately interventions promoted by the strategy will contribute to attaining the MDGs, in particular MDGs 4,5 and 6 (i.e. reducing child mortality; improving maternal and child health; and combating HIV, malaria and other diseases; and achieving universal access to prevention, treatment, care and support. is intended for policy-makers, members of technical advisory groups, inter-agency coordination committees or equivalent bodies at the national level and all partners supporting HIV prevention and control in the Region.
The High-Level Preparatory (HLP) Meeting held in the Regional Office in New Delhi from 27 to 30 June 2011 reviewed the working paper and made the following recommendations: Actions by Member States (1) The implementation of the WHO 2010 guidelines on prevention, treatment and care should be guided by national epidemiology, health sector preparedness and availability of resources, both human and financial. A phased approach with allocation of adequate financial resources for a sustained response in recommended. Ministries of health should take the lead for synergistic and harmonized national response to HIV involving multiple stakeholders.
(2)
Actions by WHO-SEARO (1) (2) Support Member States to adapt and implement the regional strategy. Support Member States to adapt and implement the recently-published men having sex with men (MSM) guidelines: “Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people: Recommendations for a public health approach”. Support Member States in resource mobilization efforts.
(3)
The working paper and the HLP meeting recommendations based on it are submitted to the Sixty-fourth Session of the Regional Committee for its consideration.
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Key facts 1. Following the World Health Assembly resolution WHA63.19, the Global Health Sector Strategy for HIV: 2011–2015 was developed through a broad consultative process, aligned with broader strategic frameworks and taking into consideration the changing international public health architecture. The strategy builds on the achievements and experiences of the “3 by 5” Initiative and the WHO HIV/AIDS Universal Access Plan for 2006–2010, based on existing good practices and available evidence on the effectiveness of interventions. The Global HIV Strategy was endorsed by the Sixty-fourth World Health Assembly in May 2011. 2. While there is considerable diversity in the HIV epidemic among countries of the Region, unsafe sex and injecting drug use are the main drivers. Sexual transmission accounts for the majority of cases in Bhutan, India, Myanmar, Sri Lanka, Thailand and Timor-Leste. The HIV epidemics among people who inject drugs are significant in Indonesia, Myanmar, Nepal, Thailand, some regions of India and the capital city of Dhaka, Bangladesh. Maldives has a growing threat of HIV epidemic due to injecting drug use. 3. An estimated 1.3 million (1.2–1.6 million) women (aged 15 years and above) are currently living with HIV in the South-East Asia (SEA) Region. Due to low coverage of the prevention of mother-to-child transmission (PMTCT) programme in the SEA Region, a large number of babies born of HIV-positive mothers acquire HIV infection perinatally. 4. Of the 448 million cases of sexually transmitted infections globally in 2005, 71 million were in the SEA Region. Sexually transmitted infections are disproportionately high among mostat-risk populations, particularly among female sex workers and their clients, and men who have sex with men (MSM) due to their high turnover partners. 5. A 31% reduction in the number of new infections was observed between 2001 and 2009 (320 000 to 220 000). About 230 000 deaths annually due to AIDS-related illnesses were reported in the Region. The estimated number of children living with HIV has increased by 46% from 2001 to 2009 (89 000 in 2001 to 130 000 in 2009). 6. Currently, 577 000 people with advanced HIV infection are receiving antiretroviral treatment, representing only 32% of those in need of treatment as per the latest WHO criteria. Access to antiretroviral therapy for children is higher in the Region (42%) compared with the global average (28%). India and Thailand have demonstrated successful scale-up of the antiretroviral therapy programme. Implementation and expansion of antiretroviral therapy programmes in the Region were accompanied by significant improvements in survival and a decrease in morbidity among persons accessing care. 7. Overall there has been good progress in HIV–TB collaborative activities. The HIV programmes are beginning to implement the intensified case-finding approach of TB programmes, exploring isoniazid preventive therapy (IPT) for those without active TB and recognizing that infection control in HIV-care settings is important. Similarly, TB programmes
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view interventions for HIV–TB as core activities and are linking known HIV-positive TB patients to HIV care and antiretroviral therapy. 8. Most countries in the SEA Region are due to develop new National Strategic Plans for HIV in 2011 in the next biennium, and the new Regional Strategy on HIV, 2011-2015 can provide evidence-based guidance on their development. 9. Based on regional specifications, the critical priorities including revitalization of primary health care, integrated service delivery, equitable access to health services; and strengthening links between HIV, TB, SRH and MNCH and other programmes and services, will need to be taken forward in order to ensure sustainability and to maximize efficiency and effectiveness.
Challenges and future priorities 10. Although there are encouraging signs of reduction in the burden of HIV in the Region, Member States face several challenges that must be addressed in order to sustain the current progress and to achieve universal access to HIV prevention, care and treatment services. The key concerns relate to:
Continuing stigma and discrimination faced by people living with HIV and most-at-risk populations; Limited capacity of health systems; Cost of antiretroviral drugs that still remains high; and Lack of sustained financing.
11. In the light of these challenges, the critical priorities for the future will be to reduce HIV transmission among most-at-risk population; minimize HIV-associated stigma and discrimination in community and health-care settings; reducing perinatal HIV transmission by increasing access to prevention of mother-to-child treatment services for pregnant women by integrating HIV services into related health services; decentralize HIV testing and counselling services further to enable more people to know about their status; ensure timely access to treatment and improve quality of antiretroviral treatment; provide treatment adherence support and close monitoring to “slow” the development of HIV drug resistance; continue advocacy for reducing prices of antiretroviral drugs; invest in building health systems and human resources to increase the implementation capacity for scaling up HIV interventions; strengthen epidemiological capacity at the country level, and conduct research on priority topics.
The new Regional Health Sector Strategy on HIV (2011–2015) 12. The Regional Strategy reaffirms and builds on global, regional and national commitments made towards achieving the MDGs. The goal of the strategy will be to achieve universal access to comprehensive HIV prevention, treatment and care and to contribute to the achievement of
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MDG 6 (Combat HIV/AIDS, malaria and other diseases) and other health-related goals (MDGs 3, 4, 5 and 8) and associated targets. 13. It addresses the regional differences in the epidemic within and across Member States and focuses on priorities relevant to the regional context and needs. The targets and strategies mentioned in this document are consistent with those noted in the new Global Health Sector Strategy for HIV 2011–2015. The strategy builds on the achievements and lessons learnt in the past years. Inputs received from Member States on the Global HIV Strategy (2011-2015) through national consultations have been considered in the development of the regional strategy. 14. The goals of the regional strategy are to: (1) (2) Achieve universal access to comprehensive HIV prevention, treatment and care; and Contribute to the achievement of MDG 6 (combat HIV/AIDS, malaria and other diseases) and other health-related goals (MDGs 3,4,5 and 8) and associated targets.
15. The following four strategic directions have been set to achieve the stated goals: (1) Optimizing HIV prevention, care and treatment outcome This calls for enhancing the quality, effectiveness and coverage of HIV interventions and approaches, and identifying new HIV interventions on: (i) prevention of sexual transmission of HIV; (ii) elimination of congenital syphilis (ECS); (iii) access to safe blood transfusion; (iv) elimination of HIV transmission in health-care settings; (v) eliminating HIV infection in children following the WHO-recommended comprehensive approach; (vi) increasing access to HIV testing and counselling; (vii) optimizing HIV treatment and care for children, adolescents and adults; and (viii) comprehensive and integrated services for key populations of sex workers, men who have sex with men, people who use drugs, important vulnerable populations of young people, displaced, mobile and migrant populations, and prisoners and people in other closed settings. (2) Strengthening strategic information systems for HIV and research Strategic information guides health policy, planning, resource allocation, programme management, service delivery and accountability. The four areas of importance that need to be strengthened are: (i) surveillance of HIV, sexually-transmitted infections and risk behaviours; (ii) drug resistance monitoring; (iii) programme monitoring and evaluation; and (iv) research. (3) Strengthening health systems for effective integration of health services To ensure that the expanded response to HIV will build effective, efficient and comprehensive health systems in which HIV and other essential services are available, accessible and affordable, health systems need to be strengthened to create broad synergies for better health outcomes through (i) adapted service delivery systems that deliver effective, safe, high-quality health interventions to the people who need them,
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when and where they need them and with minimum waste of resources; (ii) strengthened human resources for health; (iii) mobilizing resources and health financing; (iv) ensuring equity in access to essential medical products and technologies; and (v) supporting leadership and governance. (4) Fostering a supportive environment to ensure equitable access to HIV services The health sector plays an essential role in fostering a supportive environment, including reducing HIV-related stigmatization and discrimination, removing structural barriers to accessing HIV services, and providing evidence on the links between gender equity, human rights, the social determinants of health, and HIV. Some crucial steps include: (i) promoting gender equality, human rights and health equity to remove gender-based health inequities and protect the rights of people living with HIV and key populations; (ii) development of strategic national operational plans; (iii) building coalitions and partnerships with a range of stakeholders as a critical component for the health sector to scale up universal access; (iv) strengthening links between the HIV programme and other health areas to improve the efficiency and effectiveness of both HIV-specific and broader health investments; (v) mobilizing adequate financing from domestic or foreign donors as the key to continue scaling-up at HIV services and to keep pace with increased demand. The WHO SEA Region will optimize its HIV programme structure and operations on the basis of the six key principles: (i) WHO’s framework for results-based management; (ii) division of labour across the three levels of the WHO Secretariat; (iii) maximizing the synergies across other programme areas; (iv) collaboration with other partners; (v) WHO as a cosponsor of UNAIDS; and (vi) monitoring, evaluation and reporting. For monitoring of the health sector strategy, the joint reporting tool that has been agreed to by all partners will be used to generate a standard set of information to monitor and report on the progress in the health sector response to HIV/AIDS at national, regional and global levels. The indicators have been aligned with related efforts of partner agencies.
Actions for Member States and WHO’s contribution 16. Each of the above core elements contains a number of specific work areas. For each work area the recommended action by Member States and contributions by WHO are outlined.
Country actions are necessarily focused on developing, adapting, implementing and evaluating the national HIV response in order to meet the national goals and targets and to contribute to the multisectoral response to HIV.
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WHO’s contributions focus on providing normative guidance, policy advice and implementation guidance, and developing and disseminating a broad range of products and services to support country action. The main themes across all activities are: improving the efficiency and effectiveness of HIV responses; better integration of HIV programmes into other health programmes; supporting the strengthening of health and community systems; improving health access and equity; and ensuring that the health sector triggers a broader multisectoral response, such as the one that would lead to legal and policy reforms.
REGIONAL COMMITTEE Sixty-fourth Session Jaipur, Rajasthan, India 6–9 September 2011
Provisional Agenda item 5.6 SEA/RC64/10 Inf. Doc. 25 July 2011
Regional Health Sector Strategy on HIV, 2011–2015 The attached document provides detailed and supplementary information on Agenda item 5.6, the working paper for which was presented to the HLP meeting held in WHO-SEARO from 27-30 June 2011
Regional Health Sector Strategy on HIV 2011 – 2015
Contents Page 1. Introduction ........................................................................................................................1 1.1 Context and rationale .................................................................................................1 1.2 Global HIV epidemic ..................................................................................................2 1.3 HIV epidemic in the South-East Asia Region ...............................................................2 1.4 Health sector response to the HIV epidemic ...............................................................4 1.5 Challenges and future priorities...................................................................................5 1.6 Guiding principles.......................................................................................................6 2. Vision, goals and targets ......................................................................................................7 2.1 Vision .........................................................................................................................7 2.2 Goals ..........................................................................................................................7 2.3 Targets to achieve by 2015 .........................................................................................7 3. Strategic directions and key interventions ............................................................................8 3.1 Strategic direction 1: Optimizing HIV prevention, diagnosis, treatment and care outcome..............................................................................................................8 3.2 Strategic direction 2: Strengthening strategic information systems for HIV and research....................................................................................................................24 3.3 Strategic direction 3: Strengthening health systems for effective integration of health services ..........................................................................................................29 3.4 Strategic direction 4: Fostering supportive environment to ensure equitable access to HIV services ...............................................................................................35 4. Strategy implementation....................................................................................................39 4.1 WHO’s framework for results-based management ....................................................39 4.2 Division of labour across the three levels of the WHO Secretariat .............................39 4.3 Maximizing the synergies across other programme areas ...........................................39 4.4 Collaboration with other partners..............................................................................40 4.5 WHO as a cosponsor of UNAIDS..............................................................................40 4.6 Monitoring, evaluation and reporting ........................................................................40 5. Core indicators for monitoring of the health sector strategy ...............................................41
Key resources ............................................................................................................................41
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1. Introduction 1.1 Context and rationale The WHO South-East Asia (SEA) Region comprises 11 countries – Bangladesh, Bhutan, Democratic People’s Republic of Korea (DPR Korea), India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-Leste – and is home to a population of 1.8 billion. Since the first cases of acquired immunodeficiency syndrome (AIDS) were reported in 1981, infection with human immunodeficiency virus (HIV) has grown massively across the globe and has emerged as the most formidable challenge to public health and development. In the South-East Asia Region (SEAR), the first few cases were reported among homosexual men in Thailand in 1984. Today, the WHO SEAR has the second highest burden of HIV in the world after sub-Saharan Africa. Although the overall adult HIV prevalence in the Region is below 1%, the total burden in terms of absolute number of affected people is huge—approximately 3.5 million people are affected with HIV in SEAR. The past 20 years have seen unprecedented commitments to global, regional and national responses to HIV/AIDS. Despite the challenges, significant progress has been made and achieving universal access has proven to be feasible, even in resource-constrained settings. New directions and opportunities for reaching the goal continue to emerge. These include more efficient and effective HIV approaches and technologies, the crucial contribution of civil society to services delivery and decentralization, the integrating of services and synergizing of health systems. While the health sector has a leading contribution to make in the response to HIV, it has to collaborate with other sectors in order to tackle the social, economic, cultural As defined by WHO, the health sector is “… wide and environment issues that shape the ranging and encompasses organized public and private epidemic and access to health health services (including those for health promotion, services. disease prevention, diagnosis, treatment and care); health ministries, nongovernmental organizations; The Regional Health Sector community groups; and professional associations; as well Strategy on HIV 2011–2015 was as institutions that directly input into health-care system developed with the aim to guide the (e.g. pharmaceutical industry and teaching institutions). health sector response to human immunodeficiency virus (HIV) epidemics to achieve universal access to prevention, treatment and care. The strategy contributes to the broader, multisectoral response to HIV.
The Strategy describes the future directions and focus of work in the health sector response to HIV epidemic in order to achieve universal access to prevention, diagnosis, treatment and care. The targets and strategies detailed in this document are consistent with the new WHO global health sector strategy on HIV 2011–20151 but focus on priorities most relevant to this 1
Global Health Sector Strategy for HIV 2011 – 2015, World Health Organization 2011
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Region and build on what has been achieved during the past years. It provides a framework for priority interventions that shall eventually result in reducing the burden of HIV. Ultimately interventions promoted by the strategy will contribute to attaining the Millennium Development Goals (MDGs), in particular MDGs 4,5 and 6 (i.e. Reducing Child Mortality, Improving Maternal and Child Health and Combating HIV, Malaria and other Diseases) and achieving universal access to prevention, treatment, care and support.
1.2 Global HIV epidemic Globally, the HIV epidemic continues to remain a serious public health problem with an estimated 33.3 million (31.4–35.3 million) people currently living with HIV. While 0.8% of the adult population are infected with HIV, region-wise differentials exist. In recent times, globally a stable trend in HIV prevalence is being noted. In 2009, an estimated 2.6 million (2.3–2.8 million) people were newly infected with HIV. The majority of new infections occurred in low- and middle-income countries. The number of new HIV infections decreased by approximately 16% from 2001 to 2009. In 2009, an estimated 1.8 million (1.6 million–2.1 million) people died due to AIDS-related illnesses. Women account for 51% of people living with HIV (PLHIV), although this proportion varies among the various WHO regions. An estimated 2.5 million (1.6 million–3.4 million) children under 15 years are currently living with HIV in the world.
1.3 HIV epidemic in the South-East Asia Region2 The overall adult HIV prevalence is 0.3% with an estimated 3.5 million (3.2 – 4.0 million) PLHIV. The magnitude of HIV infection differs greatly between countries in the SEA Region. Five countries account for majority of the burden, namely India, Indonesia, Myanmar, Nepal and Thailand. No case has been reported from DPR Korea. The remaining five countries, Bangladesh, Bhutan, Maldives, Sri Lanka and Timor-Leste, together represent less than 1% of the total HIV burden in the Region. The estimated number of PLHIV ranges widely from <100 in Maldives to 2.4 million in India. The majority of countries in the Region have low level or concentrated epidemics; however, adult HIV prevalence above 1% is noted in Thailand, northeast India, and the Papua Province in Indonesia.
2
HIV/AIDS in the South-East Asia Region: progress report 2010, WHO SEARO 2010
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Estimated HIV Prevalence, South-East Asia Region, 2009 Five countries account for the majority of HIV/AIDS burden— India, Thailand, Myanmar, Indonesia and Nepal Nepal (64,000) Bhutan (<1000)
DPR Korea (No cases reported)
Myanmar (240,000)
India (2.4 million)
Bangladesh (7,000)
Thailand (610,000)
Sri Lanka (3,000) Maldives (<100)
Indonesia (190,000)
Numbers in parentheses indicate estimated number of people living with HIV/AIDS.
Source: Country reports of HIV estimates, national AIDS programmes Figures are rounded off
Timor-Leste (<1000)
z
During 2009, an estimated 220 000 (190 000–260 000) people were newly infected with HIV and 230 000 (200 000–270 000) died due to AIDS-related illnesses. The estimated number of new infections dropped by 31%, from 320 000 in 2001 to 220 000 in 2009, indicating that the HIV epidemic was declining in the SEA Region. Thailand was the first country to record a drop in HIV incidence in the early 1990s, followed by India, Myanmar and Nepal in the late 1990s to early 2000. HIV incidence is still on the rise in Indonesia. Estimated number of new HIV infections in the SEA Region, 1990-2009 450 400 Estimated number of new HIV infections (in thousands) 350 300 250 200 150 100 50 0 1990 1992 1994 Myanmar Nepal 1996 1998 2000 2002 2004 2006 2008 2009 Thailand SEAR India Indonesia
The number of new HIV infections in the Region fell by 31% in the past decade
Note: Number of new infections estimated by Spectrum model using surveillance data reported by national AIDS programmes, Member countries, South-East Asia Region
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Overall, the estimated number of PLHIV (both males and females) is decreasing in the Region. Within countries, the HIV prevalence is higher among urban than rural dwellers. Although the overall HIV prevalence in the Region is only 0.3%, certain population groups are highly affected. These include female sex workers, people who inject drugs, men who have sex with men and transgenders. Sexual transmission accounts for the majority of the cases in Bhutan, India, Myanmar, Sri Lanka, Thailand and Timor-Leste. In some areas, HIV prevalence has decreased among female sex workers; however, there is evidence of continuing high transmission among men who have sex with men and transgenders. HIV epidemics among people who inject drugs are significant in Indonesia, Myanmar, Nepal, Thailand, some regions of India and the capital of Bangladesh. Maldives has a growing threat of HIV epidemic due to injecting drug use. Globally, there were an estimated 1.2 million incident HIV-positive TB cases in 2009; the WHO SEA Region accounts for nearly 15% of the global burden [5]. Five countries in the Region with the highest HIV burden also have a high TB burden. HIV prevalence among new TB patients is 5.7%. An estimated 1.3 million (1.2–1.6 million) women (aged 15 years and above) are currently living with HIV in the SEA Region. The proportion of women with HIV in the Region (37%) is lower than the global average (51%). In all countries in the Region, except Bhutan and TimorLeste, female-to-male ratio for HIV infection is less than 1. Over time, the proportion of females among the reported HIV/AIDS cases gradually increased in all countries, although this proportion has stabilized in the past few years. Gender inequality, male dominance, stigma, low literacy and barriers to health care services are some of the key issues for higher vulnerability of women to HIV in the Region. The estimated number of children living with HIV increased from 89 000 in 2001 to 130 000 in 2009, a 46% increase. Due to low coverage of the prevention of mother-to-child transmission (PMTCT) programme in the SEA Region, a large number of babies born to HIVpositive mothers acquire HIV infection perinatally. Of the 448 million cases of sexually transmitted infections present globally in 2005, 71 million were in the SEA Region. Sexually transmitted infections are disproportionately high among most-at-risk populations, particularly among female sex workers and their clients, and men who have sex with men due to multiple partners.
1.4 Health sector response to the HIV epidemic3 The health sector response to the HIV epidemic is spearheaded by the national AIDS programmes of health ministries of Member States in collaboration with national and international nongovernmental organizations (NGOs), the United Nations agencies and other developmental partners. The status and key indicators of progress in health sector response to HIV in the Region in the past years are summarized as follows: 3
HIV/AIDS in the South-East Asia Region: progress report 2010, WHO SEARO 2010
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Consistent condom use is reaching high levels among sex workers; however, men who have sex with men and transgenders have low rates of condom use. Coverage of a comprehensive package of HIV interventions for people who inject drugs continues to be low. The programme for the elimination of congenital syphilis is being scaled up in many of the Region’s Member States. The reported screening of pregnant women for syphilis is over 50% in India and Myanmar, and 80% in Sri Lanka. Resistance to ciprofloxacin (an antimicrobial to treat gonorrhoea) is very high, ranging from 75% in Thailand to 92% in Sri Lanka. Based on 2008 data, 10.5 million units of blood were collected against a total requirement of 17 million units. About 71% blood was collected from voluntary nonrenumerated donors. Overall, 0.32% of screened blood units were found to be positive for HIV antibody. A large number of facilities provide testing and counselling services resulting in approximately 15.1 million people being tested in 2009 across the Region. Access to testing and counselling services for most-at-risk populations is still far below optimal levels. Barely 18% of pregnant women have access to HIV testing and counselling. Of the estimated HIV-infected pregnant women, 34% received antiretroviral prophylaxis. Currently, 577 000 people with advanced HIV infection are receiving antiretroviral treatment. But these numbers represent only 32% of those in need of treatment as per latest WHO criteria. Of those started on treatment, 65–92% are alive and on treatment 12 months after start of therapy. Countries with HIV–TB dual epidemics have made substantial progress in implementing collaborative activities; however, detection of HIV–TB coinfected patients is still low. Substantial progress has been made in expanding surveillance systems in the Region leading to a better understanding of national epidemics. There is scope to improve routine programme monitoring systems to better track progress towards programme goals. HIV drug resistance surveys completed in three countries — India, Indonesia and Thailand — indicate a low level of transmitted drug resistance.
(For more details on the status and key indicators of progress in health sector response to HIV in the Region, please refer to the document “HIV/AIDS in South-East Asia Region: Progress Report, 2010”, weblink: (http://www.searo.who.int/LinkFiles/HIV-AIDS_HIV_report-201030Nov.pdf)
1.5 Challenges and future priorities The key challenges in achieving universal access to HIV prevention, care and treatment services include: continuing stigma and discrimination faced by people living with HIV and most-at-risk
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populations; limited capacity of health systems; still high prices of antiretroviral drugs; and lack of sustained finances. The critical priorities for the future in light of these challenges are listed below: (1) (2) Reducing HIV transmission among most-at-risk populations. Minimizing HIVassociated stigma and discrimination in community and health-care settings. Reducing perinatal HIV transmission by increasing access to prevention of mother-tochild treatment services for pregnant women by integrating HIV services into related health services. Decentralizing HIV testing and counselling services further to enable more people to know their status. Ensuring timely access to treatment and improving the quality of antiretroviral treatment. Providing treatment adherence support and close monitoring to “slow” the development of HIV drug resistance. Continuing advocacy for reducing prices of antiretroviral drugs and appropriate resource allocations for combating HIV. Investing in building health systems and human resources to increase the implementation capacity for scalingup HIV interventions. Strengthening epidemiologic capacity at the country level and undertaking research on priority topics. Mobilizing adequate financing to continuing the expansion of HIV services. Strengthening inter-sectoral collaboration.
(3) (4)
(5) (6) (7) (8) (9)
1.6 Guiding principles The Regional Health Sector Strategy on HIV 2011-2015 is developed keeping in mind the guiding principles set by high level forums and resolutions and commitments formally adopted by all Member States of the United Nations through the Millennium Declaration of 2000 and General Assembly resolutions of 2001 and 2005: to halt and reverse the spread of HIV as part of the broader MDGs; and, the health sector to collaborate with other sectors in order to tackle the social, economic, cultural and environmental issues that shape the epidemic and access to health services. The regional strategy takes note of the WHO global HIV strategy 2011-2015’s principles that HIV is embedded in the broader global health and development agenda, with programmatic linkages, improves overall health outcomes, and it is based on progress and evidence addressing current gaps using high impact evidence-based interventions tailored to national epidemics. It supports and reinforces the agreed division of labour among UNAIDS cosponsors, whereby, WHO is responsible for the health sector response to HIV, taking the lead on HIV treatment and care and on HIV/tuberculosis co-infection, shares responsibility with UNICEF for the prevention of mother-to child transmission of HIV, and collaborates with other cosponsors in
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supporting actions in all other priority areas. This regional strategy contributes to the broader, multisectoral response to HIV outlined in Getting to Zero: UNAIDS 2011-2015 Strategy. The primary guiding principles of the regional strategy will be:
Long-term, sustainable HIV response through strengthening health and community systems, tackling the social determinants of health that both drive the epidemic and hinder the response. Protecting and promoting human rights and promoting gender equity. Integration between HIV and other health services, improving both impact and efficiency.
2. Vision, goals and targets 2.1 Vision Zero new HIV infections, zero AIDS-related deaths and zero discrimination in a world where people living with HIV are able to live long, healthy lives.
2.2 Goals (1) (2) To achieve universal access to comprehensive HIV prevention, treatment and care; and To contribute to the achievement of MDG 6 (Combat HIV/AIDS, malaria and other diseases) and other health-related goals (MDGs 3, 4, 5 and 8) and associated targets.
2.3 Targets to achieve by 2015 (1) (2) (3) (4) Reduce incidence of HIV in young people (15-24 years) by 50% (compared with the 2009 baseline); Reduce new HIV infections in children by 90% (compared with the 2009 baseline); Reduce HIV-related deaths by 25% (compared with the 2009 baseline); and Reduce tuberculosis-related deaths among HIV-positives by 50% (compared with the 2009 baseline).
To reach the above goals and targets, four strategic directions are set out in this regional strategy: Strategic direction 1: Strategic direction 2: Strategic direction 3: Strategic direction 4: Optimizing HIV prevention, care and treatment outcome. Strengthening strategic information systems for HIV and research. Strengthening health systems for effective integration of health services. Fostering supportive environment to ensure equitable access to HIV services.
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3. Strategic directions and key interventions 3.1 Strategic direction 1: Optimizing HIV prevention, diagnosis, treatment and care outcome Strategic direction 1 ensures that combined HIV-specific interventions are strengthened and expanded. These core programmes aim to enhance the quality, effectiveness and coverage of HIV interventions and approaches, as well as to identify new HIV interventions on prevention, diagnosis, treatment and care. Prevention of sexual transmission of HIV Essential HIV prevention interventions include providing free condoms to those most in need and ensuring that condoms are available to all sexually active people. Combination prevention package includes a range of proven interventions including male and female condom programming, early initiation of treatment, behavioural interventions to reduce sexual risk and post exposure prophylaxis where applicable. Proposed country actions:
Identify the target populations, networks and settings where HIV risk behaviours are prevalent and transmission occurs. Implement comprehensive essential service package for most- at- risk populations. Scale up condom use programme as part of comprehensive HIV prevention programmes. Ensure that quality condoms are accessible to those who need them when they need them and that people have the knowledge and skills to use them correctly and consistently. Condoms should be promoted in ways that help overcome social and personal obstacles to their use. Promote behaviour change interventions designed to increase demand and improve use of condoms by young people and risk groups. Promote testing and counselling, and implement measures to prevent HIV transmission among discordant couples. Health sector should provide guidance on sex education, school-based HIV education, mass media information and communications. Expanding services for screening and testing for STIs.
WHO contribution:
Advocate for high-level commitment and allocation of adequate resources for prevention interventions. Develop evidence-based HIV prevention package for the health sector and support its implementation at national level. Provide guidance, tools and approaches on delivering HIV prevention for key populations, women and young people.
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Develop comprehensive package for addressing socio-cultural barriers including behaviour change. Develop and assist implementation of monitoring and evaluation frameworks for data collection, analysis and use for local decision-making. Advocacy for increased focus on key drivers of the epidemic within national strategies.
Detecting and managing sexually-transmitted infections Services for STI prevention, case management and partner treatment contribute to HIV prevention. A range of models for delivering STI services are required to ensure most-at-risk and vulnerable populations have access to these services. Proposed country actions:
Expand the provision of good quality STI management into primary health care, sexual and reproductive health services and HIV services. Comprehensive STI services include: – – – – – – – – – –
correct diagnosis by syndrome or laboratory test; provision of effective treatment at first encounter; reduction in further risk-taking behaviour through age-appropriate education and counseling; promotion and provision of condoms, with clear guidance on correct and consistent use; notification and treatment of STIs in sexual partners, when applicable; promotion of screening for asymptomatic STIs among key populations; screening and treatment for syphilis in pregnant women; Promotion of hepatitis B vaccines to prevent infection among key populations; Considering application of HPV vaccination according to national policy; and HIV testing and counselling in all settings providing care for STIs.
For primary care settings in low- and middle-income countries, apply syndromic management of STIs in patients presenting with consistently recognized signs and symptoms. Develop national guidelines based on regional guidelines and identified patterns of infection and disease, and disseminate to all providers of STI care.
WHO contribution:
Update guidelines on STI case management. Advocacy for high-level commitment and allocation of resources for STI control. Build capacity of countries on STI surveillance. Support countries to set control targets according to their epidemiological situation.
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Elimination of congenital syphilis To ensure that congenital syphilis is no longer a public health problem, the Elimination of Congenital Syphilis initiative (ECS) has been launched. The specific goal of the ECS initiative is to prevent transmission of syphilis from mother to child and thereby reduce the incidence of congenital syphilis. This can be achieved by the following:
Early antenatal care (ANC) registration for universal screening of all pregnant women, and prompt treatment of all seropositive women; Treatment of partners of seropositive women, promotion of condom use, and education and counselling to prevent infection/reinfection; Prophylactic treatment of all infants born to seropositive women; and Treatment of infants with congenital syphilis.
Screening is more effective if it is performed on-site early in pregnancy and treatment provided immediately to seropositive women. There is also the need to prevent reinfection by treating sexual partners and re-screening in late pregnancy. Proposed country actions:
Formulate a policy on a priority basis for ECS and secure sustained commitment at all levels to ensure that the required resources are allocated for ECS. Integrate interventions for ECS into the MCH services, PMTCT of HIV infection, and STI prevention and control programmes. Raise awareness in the community about congenital syphilis and encourage all pregnant women to seek early ANC. Develop surveillance and monitoring and evaluation systems for ECS. National response for ECS should include assessment of the situation, training of staff, provision of guidelines and supervision and management, advocacy at all levels, human resource plan, an efficient logistics system and adequate financial allocation to ensure sustainability.
WHO contribution:
Advocacy for high-level commitment and allocation of adequate resources for ECS. Develop guidelines, protocols and tools for implementing, monitoring and evaluating the programme. Provide support to countries to implement the ECS programme. Provide tools and guidelines for supporting integration of the ECS interventions into PMTCT of HIV, and STI prevention and control programmes. Collaboration and partnerships with key stakeholders to achieve the goal of elimination of congenital syphilis.
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Blood safety Access to safe blood transfusion is an essential part of modern health care. Every national AIDS programme needs to advocate for the establishment/strengthening of nationally coordinated blood transfusion service to ensure the availability of safe blood and blood products. A wellorganized blood transfusion service based on voluntary non-remunerated donations, with quality systems in all areas, is a prerequisite for the safe and effective use of blood and blood products. WHO has developed an integrated strategy to promote the provision of safe and adequate supplies of blood and to reduce the risks associated with transfusion. Proposed country actions:
Ensure political commitment towards national blood safety programmes, supported by effective legislation. Promote recruitment of carefully screened, voluntary non-remunerated blood donors selected from low-risk populations. Support efficient screening of donated blood to prevent transfusion of transmissible infections (HIV, hepatitis viruses, syphilis and other infectious agents). Promote appropriate and rational use of blood in clinical settings. Ensure quality in all steps from blood collection to blood transfusion (vein-to-vein).
WHO contribution:
Advocate establishment of efficient nationally coordinated blood transfusion programmes. Advocate for voluntary non-remunerated blood donations. Building capacity for processing of blood and its rational use. Support strengthening of monitoring and evaluation activities including quality assurance.
Elimination of HIV transmission in health-care settings In health-care settings, transmission of HIV can be prevented through primary prevention measures such as standard precautions, injection safety and safe waste disposal, as well as secondary prevention measures such as post-exposure prophylaxis for occupational exposure. Comprehensive infection control strategies and procedures can dramatically reduce the risk of transmission associated with health care. However, implementing infection control guidelines does require a permanent HIV prevention and control structure, specific equipment and trained and motivated staff.
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Proposed country actions:
All health facilities should have: (a) a zero tolerance policy for HIV transmission; (b) an infection control plan; (c) a person or team responsible for infection control, and (d) available supplies to ensure the implementation of preventive measures including standard precautions. All countries should have a recording and reporting system for accidental exposures. Develop strategies, tools and guidelines for infection control, standard precautions, the rational and safe use of injections and infectious waste management. Implement secondary prevention measures such as post-exposure prophylaxis for occupational exposure to HIV.
WHO contribution:
Advocate for high-level commitment and allocation of adequate resources to ensure infection control in health-care settings. Promote and provide tools and guidelines for safe waste management and injection safety. Support capacity building and training for health staff. Monitoring and evaluation of safe waste management and issues of quality of care.
Eliminating new HIV infections in children A comprehensive approach to preventing HIV in infants and young children consists of four elements:
primary prevention of HIV transmission; prevention of unintended pregnancies among women living with HIV; prevention of HIV transmission from women living with HIV to their children; and provision of treatment, care and support for women living with HIV and their children and families.
WHO recommends implementing all four components of the comprehensive approach. It also promotes integrating/linking prevention of mother-to-child transmission (PMTCT) of HIV with maternal, newborn and child health care; antiretroviral therapy, family planning, reproductive health, and sexually transmitted infection (STI) services to ensure the delivery of a package of essential interventions for quality maternal, newborn and child care. HIV testing and counselling is recommended for all pregnant women. Proposed country actions:
Setting national targets for elimination of new paediatric HIV infections and scaling up comprehensive approaches to prevent mother-to-child transmission using evidencebased national prevention and treatment protocols.
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Ensure that health services provide effective interventions to reduce sexual transmission of HIV, with particular focus on preventing new HIV infections in women during pregnancy or the breastfeeding period. Provide support and enable women to make informed choice for their reproductive life. Health services should ensure that women with HIV are (1) provided with the skills, knowledge and commodities necessary to avoid unintended pregnancy or (2) are given support for planning a pregnancy. All pregnant women should have access to standardized ANC care and HIV and syphilis testing as part of the essential package of services. All pregnant women with HIV should receive antiretroviral (ARV) medicines: either ARV treatment for life, if eligible for therapy, or combined ARVs for prophylaxis to reduce HIV transmission. All infants born to women living with HIV should receive ARV prophylaxis and followup care and support including early infant diagnosis. Health services should ensure that women with HIV have access to the skills, knowledge and support needed to make infant feeding safe, so as to reduce HIV transmission and promote child survival.
WHO contribution:
Provide and support adaptation of normative guidelines and recommendations for best practices and programme standards for PMTCT delivery and for broader MCH programmes. Provide technical assistance to countries to optimize HIV/STI prevention, care and treatment services of women and children. Support the availability of key health technologies and laboratory testing, health system strengthening, and monitoring and evaluation across both HIV and MCH programmes. Support operational research to guide effective PMTCT programmes. Provide support to expand and strengthen health information systems to provide effective geographical and population-based monitoring of coverage.
Increase access to HIV testing and counselling as entry point to HIV prevention, treatment and care Increasing the numbers of people who know their HIV status – especially among most-at-risk populations – through HIV testing and counselling is key to expanding access to HIV prevention, treatment and care. The WHO guidance on HIV testing and counselling aims to achieve synergies between medical ethics, human rights and clinical and public health objectives. The fundamental principle of HIV testing is that it must be accompanied by basic pre-test information to enable the client to make an informed and voluntary decision to be tested. The “Three Cs” – informed Consent, Counselling and Confidentiality—should always be maintained.
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The UNAIDS/WHO policy on HIV testing and counselling defines two main categories: (1) (2) client-initiated HIV testing and counselling (CITC); and provider-initiated HIV testing and counselling (PITC).
Proposed country actions:
Optimize convenience for clients, decentralize services and provide testing and counselling in a wide variety of settings including health facilities, community-based locations and work places and through outreach services that may be stationary or mobile. CITC should focus on increasing access and uptake among most-at-risk populations. In all HIV epidemics, PITC is recommended for all patients whose clinical presentation might result from underlying HIV infection. Testing and counselling is also recommended for all HIV-exposed children and prior to HIV post-exposure prophylaxis. It should also be considered in a range of specific situations (where patients have come for STI services; where services are provided to most-at-risk populations; where patients have come for antenatal, childbirth and postpartum services, or tuberculosis (TB) and hepatitis-related services). To ensure that all identified HIV infected persons are linked to appropriate treatment, care and support services.
WHO contribution:
Provide guidelines and tools, and support capacity building within the country to expand the delivery of HIV testing and counselling services, with the focus to improve and strengthen linkages with other HIV services. Advocate for high-level commitment to increase CITC for most-at-risk population groups. Provide guidelines for monitoring progress in expansion of testing and counseling services including equity and access for most-at-risk and vulnerable groups.
Optimize HIV treatment and care for children, adolescents and adults 1. Antiretroviral treatment (ART) A public health approach to antiretroviral therapy (ART) facilitates quality HIV treatment for all who need it, an essential component of the universal access goal. Early referral to ART services and measures to retain patients in care are essential to the achievement of good patient and programme outcomes. To maintain the effectiveness of first- and second-line antiretroviral regimens, WHO recommends that countries develop a national strategy for HIV drug resistance prevention and assessment. Treatment access and adherence can be improved by involving the community in planning and managing the treatment programme. Greater involvement of community-based organizations in treatment maintenance, adherence support and monitoring will reduce the burden on health systems and improve access and adherence.
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Proposed country actions:
Develop or update national treatment protocols for adults, children and infants, ensuring everyone in need has access to treatment, according to the current WHO treatment guidelines. Develop implementation plan to ensure continuity of quality treatment; outline an expanded role for laboratory monitoring, including CD4 and viral load testing. Strengthen adherence support for those receiving ART. Develop and maintain recording and reporting system for antiretroviral treatment programme including information on drug resistance. Treatment failure should be recognized by using clinical, immunological and, where feasible, virological parameters. Second-line therapy should be made available for patients who develop failure of their first-line therapy. Incorporate pharmacovigilance in antiretroviral therapy programmes as a standard of care. Ensure community participation in the design and implementation of treatment and care programmes. Ensure that ARV drugs are available and affordable to all those who need them. Promote decentralization of comprehensive package of HIV services as a way to scale up coverage.
WHO contribution:
Advocate for higher commitment to optimize HIV treatment for all those in need. Regularly update the guidelines on ART for HIV infection for children, adolescents and adults. Develop guidelines for monitoring and evaluation of HIV care and ART. Provide updated information on affordable medicines and diagnostics for HIV. Provide guidance on pharmacovigilance as part of antiretroviral therapy programmes along with standardized tools for monitoring and preventing drug resistance. Collaboration and partnerships with key stakeholders for ensuring access to key drugs and diagnostics. Design operations research for innovative approaches for improving access to HIV care and treatment.
2.
Reduce co-infections and co-morbidities among people living with HIV
Treatment and care programmes should include prophylaxis, diagnosis and treatment for common opportunistic infections and co-morbidities. Particularly important is diagnosis and treatment for pneumonia, diarrhoea, malaria, viral hepatitis, malnutrition and other clinical conditions that are more serious for people living with HIV.
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Proposed country actions:
Ensure that co-morbidities and co-infections are part of national HIV response. Strengthen health service capacity for screening, diagnosis and management of coinfections. Preventive measures like hep. B vaccinations should be available to all persons at risk including health-care workers.
WHO contribution:
Advocate for high level commitment and allocation of adequate resources towards the adverse health consequences of co-infections (HIV and hepatitis). Support countries to collect and analyse data on burden of HIV and hepatitis coinfection. Provide guidelines when available on prevention, screening, vaccination and management of viral hepatitis and HIV. Provide support to build capacity to raise the profile and improve response towards coinfections. Provide clinical guidelines to diagnose, prevent and manage the most serious HIVrelated co-infections and co-morbidities in adults and children.
Reduce burden of tuberculosis Tuberculosis remains the main cause of mortality in people living with HIV including those who are on ART. Collaborative HIV–TB activities are essential to ensure that HIV-positive TB patients are identified and treated appropriately, and to prevent TB in HIV-positive patients. The recommended activities include: establishing mechanisms to collaborate between HIV and TB programmes; TB infection control in health care and congregate settings; HIV testing of TB patients; antiretroviral therapy and cotrimoxazole preventive therapy (CPT) for TB patients infected with HIV; and intensified TB case finding among PLHIV followed by isoniazid preventive therapy (IPT) for those without active TB. Proposed country actions:
Strengthen mechanisms for collaboration between HIV and TB programmes and establish national coordinating body to guide the development of national policies and strategies, and oversee the implementation of joint TB and HIV collaborative activities. Strengthen capacity of both programmes for enhanced surveillance, diagnosis and management of TB-associated HIV. Regularly monitor and evaluate TB/HIV interventions and their impact. Strengthen infection control measures in TB/HIV settings. Implement the WHO TB/HIV 12-point policy package including 3 “I”s (intensified case finding, infection control and isoniazid preventive therapy).
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WHO contribution:
Advocate for high-level commitment and allocation of adequate resources to reduce the burden of tuberculosis by supporting countries to implement the TB/HIV 12-point package including 3“I”s. Provide technical assistance to countries in developing national policy, guidelines and implementation plans for TB/HIV activities. Assist in capacity building to scale up TB/HIV collaborative activities for intensified surveillance, effective diagnosis and management of TB-associated HIV. Provide forum to strengthen mechanisms for collaboration between HIV and TB programmes. Regularly monitor and evaluate TB/HIV interventions and their impact.
Community-based care Community based care for HIV/AIDS implies care that a group of people provide at the primary care level for prevention, care and support. Health-care providers at community level should be the key players; however, family members including spouses, parents and children are also the main caretakers for PLWHIV. Community leaders, community health workers, religious groups, community club/groups, NGOs, friends and neighbours can make significantly impact on prevention, care and support. Mechanisms in the community should be in place to ensure the continuing of care between hospital and home. The community may have to invest in setting up a system for monitoring and support of HIV/AIDS. Proposed country actions:
Support involvement of civil society including NGOs, faith-based organizations, people living with HIV and AIDS and community health workers in the planning, implementation and monitoring of HIV/AIDS-related continuum of care. Strengthen linkages between prevention, treatment and care centres and community for continuum of care and promote sharing of information. Support/strengthen community-based care systems and activities, including guidelines development, training of staff, implementation of activities, sharing of information, recording and reporting, monitoring and evaluation.
WHO contribution:
Provide guidelines and tools related to community-based care e.g., IMAI, IMCI, community-based prevention and care, self-care and palliative care, etc. Document good models or lessons learned from the region on community-based care for HIV/AIDS patients.
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Comprehensive and integrated services for key populations The health sector is responsible for configuring and supporting comprehensive programmes and service delivery models that address the needs of populations most-at-risk for HIV and for ensuring that these services are accessible, acceptable and equitable. Where there are barriers to implementation of priority interventions, there is a need to actively create a supportive policy, legal and social environment that facilitates equitable access to prevention, treatment and care. 1. Sex workers, men who have sex with men and transgender populations Sex workers, male and female, are among the groups most vulnerable to and affected by HIV. Specific behaviours can place sex workers, their clients and regular partners at risk, and contextual factors can further exacerbate their vulnerability to HIV. The evidence base is firmly established to support a range of interventions to prevent transmission of HIV and other sexually-transmitted infections (STIs) in sex-work settings, to provide care and support services, and to empower sex workers to improve their own health and well-being. Interventions can be tailored for brothel or other entertainment establishments, or for more informal street-based and home-based settings. The health sector has an important role to play by including services for MSM and transgender people in its programme priorities and by advocating for decriminalization of same-sex acts and for legislation against discrimination based on sexual orientation. A comprehensive set of interventions is recommended to increase condom use and safe sex, reduce the STI burden and maximize sex worker involvement in and control over their working and social conditions. Proposed country actions:
Systematic collection of strategic information on HIV and other STIs among sex workers and their clients, men who have sex with men and transgender populations is required to guide comprehensive programme implementation. Programme planning to include formative assessments to determine the needs and vulnerabilities of sex workers and their clients, men who have sex with men and transgender populations and these populations should be proactively involved in the design and delivery of programmes. The health sector should promote and support legal and social frameworks that are rights-based and consistent with public health and HIV prevention goals. Provide priority interventions for sex workers and their clients, men who have sex with men and transgender populations to prevent sexual transmission of HIV and other STIs including: – –
promoting and supporting condom use (male and female condoms), including water-based lubricants; detecting and managing STIs;
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– – –
information, education and communication through peer outreach; enabling people to know their HIV status; and Social support, including income generation and legal services.
WHO contribution:
Advocate for high commitment to promote availability and accessibility of appropriate health services for most-at-risk population groups. Provision of tools and guidelines to implement health sector interventions for the prevention, treatment and care of HIV and STIs among sex workers, MSM and transgender populations. Promote and provide toolkits for monitoring and evaluation of interventions for sex workers.
2.
People who inject drugs A comprehensive set of interventions for HIV prevention, treatment and care for people who inject drugs (PWID) should be implemented. These interventions are also known as harm reduction programmes. Despite overwhelming public health evidence demonstrating the effectiveness of harm reduction interventions, many decision-makers remain reluctant to implement or scale up these interventions because of their controversial nature. Intense advocacy, citing public health evidence, is often required to initiate and sustain harm reduction programmes. Where there are barriers to implementing harm reduction interventions, there is a need to create a supportive policy, legal and social environment that facilitates equitable access to prevention and treatment for all, including PWID. There is also the need for appropriate models of service delivery, health systems strengthening and strategic information to guide harm reduction programmes.
3.
Comprehensive harm reduction programming—a comprehensive package of HIV prevention, treatment and care for PWID includes the following nine interventions: (a) (b) (c) (d) (e) (f) (g) (h) (i) needle and syringe programmes (NSPs); drug dependence treatment, in particular opioid substitution therapy; targeted information, education and communication for IDUs; enabling people to know their HIV status; HIV treatment and care; promoting and supporting condom use; detection and management of sexually transmitted infections; prevention and treatment of viral hepatitis; and tuberculosis prevention, diagnosis and treatment.
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Community-based outreach is the most effective way of delivering HIV prevention, treatment and care to PWID. The outreach approach can assist with the referral process for PWID to be directed towards specific health services. Proposed country actions:
Ministry of Health should strengthen collaboration and coordination with relevant ministries, civil societies and people who use drugs in the provision of health services. Design and implement a comprehensive package of interventions, tailored to the country’s known drug-use patterns and to other unique elements of the national context. Advocate for increased political commitments necessary to initiate and sustain harm reduction programmes for PWID. All key interventions should be scaled up at the necessary intensity to cover all drug users in the community and in closed settings (prisons and compulsory drug treatment centres). Continuously monitor and document the changing patterns of drug use and HIV related risk behavior.
WHO contribution:
Advocate for high level commitment and sustained support for harm reduction interventions using the multi-agency strategy to halt and reverse the HIV epidemic among PWID in Asia and the Pacific (2010-2015). Provide technical assistance and guidance on harm reduction interventions and to develop where necessary a harm reduction strategy and guidelines to suit country context. Provide and promote monitoring and evaluation guidance for PWID. Promote and provide guidance on prevention, screening, vaccination and treatment of viral hepatitis and HIV in PWID.
4.
Vulnerable populations: young people, displaced, mobile and migrant populations, prisoners and people in other closed settings (1) Young people In order for young people to benefit from HIV prevention, health services must take their unique concerns and needs into consideration. In terms of content, the basic package of interventions to prevent HIV is much the same for young people as it is for adults. Prevention services for adults can be modified so that they are also appropriate for young people, but there should also be youth-specific prevention in settings where young people are more likely to access them. These may include schools, universities, youth clubs, popular youth hang-outs, workplaces and pharmacies.
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The health sector should support community outreach to young people by providing guidance and linkages between services in the health sector and other sectors. Some adolescents and young people belonging to most-at-risk groups and may not access the services due to legal constraints related to their age. Therefore, policy issues related to age constraints should be addressed. Services targeting adolescents and young people should also be designed or modified to be youth-friendly. Proposed country actions:
Address legal and social barriers that hinder access and utilization by young people of HIV and reproductive health services. Ensure that the comprehensive package of interventions for young people is integrated into existing adolescent-friendly health services provided by the health sector that include: –
information and counselling to help young people acquire the knowledge and skills to delay sexual initiation, limit the numbers of sexual partners, use condoms correctly and consistently, and avoid substance use or, if injecting drugs, use sterile equipment; condoms for sexually active young people; harm reduction for young people who are injecting drug users; diagnosis and treatment of sexually-transmitted infections; HIV testing and counselling; access to HIV treatment and care services; human papillomavirus (HPV) vaccination for young females, wherever feasible and as per standard guidelines; and Develop/strengthen and Implement policies and guidelines for removing barriers for accessing services including those for unaccompanied minors.
– – – – – – –
Collect and analyse data on young people accessing and utilizing HIV and reproductive health services, disaggregated by age and sex.
WHO contribution:
Advocate for high-level commitment and support towards population groups considered vulnerable in the community. Provide and promote manuals for the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the ASSIST-linked brief interventions for hazardous and harmful substance use (including among young people): a manual for use in primary care. Provide and promote toolkits and guides specific to adolescents and youth: (i.e. preventing HIV among young people. Promote the use of Standards for Adolescent Friendly Health services in the context of HIV to strengthen linkages between the two services.
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(2)
Displaced, mobile and migrant populations
Increased vulnerability to HIV associated with displacement, sexual violence, and disruption of families and social and community structures, has been evident in some complex emergencies. However, in some instances, refugees or populations in conflict situations may be less at risk of HIV transmission than surrounding populations when protected in camps and supported by international organizations, or when living in isolation. Millions of people each year migrate within countries or across countries and along borders. Increased vulnerability to HIV associated with displacement and the disruption of families and social and community structures has been evident in many settings with migrant and mobile populations. All migrant and mobile populations are difficult to reach with behaviour change communications and other prevention interventions. This is due, in part, to the fact that their movement places them in situations where they are ethnic minorities and face cultural and language barriers. Proposed country actions:
Assess the situation of migrants and needs for HIV health services and based on the local situation, ensure equitable access to health services including access to antiretroviral treatment according to need without discrimination to displaced, migrant or mobile populations. Availability of Interventions to provide information and education about prevention of HIV and other sexually-transmitted infections (STIs) at source, transit and destination of migrant and mobile populations, including ethnic minorities, who may require information and education in their own languages. Promote and strengthen network of health-care providers providing services to migrant populations.
WHO contribution:
Support the mapping of displaced, migrant and mobile populations and their access to health service. Support the use of evidence-based information in planning health services for this group of populations. Within the framework of bilateral cooperation between the countries, WHO and other partners to promote access to health services including on HIV for migrant populations. Prisoners and people in other closed settings
(3)
Prisons and other closed settings are key points of contact; millions of people in such settings are living with or at high risk of HIV infection. It is in the interest of public health that all people in these settings have access to HIV prevention, treatment and care. They are entitled to the same standard of health as all other members of society.
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A wide range of services is required for people in prisons and similar settings, including condom and water-based lubricant distribution, clean needle and syringe provision, opioid substitution therapy, HIV testing and counselling, provision of antiretroviral therapy and treatment for sexually-transmitted infections. Prison authorities should work with people in other branches of the criminal justice system and with health authorities and nongovernmental organizations to ensure continuity of care, including antiretroviral therapy (ART), from community to prison and back to community, and also between prisons. Proposed country actions:
Ministry of Health should strengthen collaboration and coordination with relevant ministries and stakeholders in the provision of health services. Develop prevention, care and treatment programmes that address the needs within prisons and other closed settings and offer a full range of HIV prevention, treatment and care services and commodities, including HIV testing and counselling and ART. Ensure confidentiality and client safety while providing HIV services. Ensure continuum of care including ART, from community to prison and back to community, and between prisons.
WHO contribution:
Provide and promote toolkits and guides that address the health needs of those in prisons or other closed settings including HIV testing and counseling. Advocate for high-level commitment to support provision of OST. Promote clinical guidelines for withdrawal management and treatment in closed settings.
Core indicators Strategic direction 1. Optimizing HIV prevention, care and treatment outcome Core indicators 1.1 Percentage of young people aged 15-24 years who are HIV infected (MDG). 1.2 Percentage of women accessing antenatal care services who were tested for syphilis at first ANC visit (UA). 1.3 Percentage of antenatal care attendees positive for syphilis who received treatment. 1.4 Number of new HIV infections among children aged 0-4 years old. 1.5 Percentage of men and women aged 15-49 years old who received an HIV test in the previous 12 months and know their results (UNGASS #7).
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Strategic direction
Core indicators 1.6 Percentage of most at risk populations (MARPs) who received an HIV test in the last 12 months and who know their results (UNGASS #8). 1.7 Percentage of, sex workers, men who have sex with men and injecting drug users who are HIV-Infected (UNGASS #23). 1.8 Percentage of eligible adults and children with HIV infection who receive antiretroviral therapy (UNGASS #4). 1.9 Percentage of adults and children with HIV still alive and known to be on treatment 12 months after initiation of antiretroviral therapy (UNGASS #24). 1.10 Percentage of HIV-infected pregnant women who received antiretroviral medicines to reduce the risk of mother-to-child transmission of HIV (UNGASS #5). 1.11 Percentage of estimated number of HIV-positive patients with incident tuberculosis who received treatment for HIV and tuberculosis (UNGASS #6).
3.2 Strategic direction 2: Strengthening strategic information systems for HIV and research Strategic information guides health policy, planning, resource allocation, programme management, service delivery and accountability. It is essential for action at all levels of the health system. As countries scale up their HIV response towards universal access, there is an increasing recognition of the need to invest in strategic information to guide programme planning and sustain national and international commitment and accountability. Surveillance of HIV, sexually transmitted infections and risk behaviours HIV surveillance provides essential data to understand the magnitude and determinants of the epidemic in a country, assess the burden of disease, monitor trends over time, develop interventions and evaluate their impact. In addition, second-generation HIV and STI surveillance systems measure trends in risk behaviours. HIV surveillance systems should be capable of being adapted and modified to meet the specific needs of each epidemic. For example, surveillance methods and activities in a country with a predominantly generalized heterosexual epidemic should differ greatly from those in countries where HIV infection is mostly concentrated among populations at high risk of infection, such as sex workers, men who have sex with men and PWID, as well as the sexual partners of these groups. In addition to collecting data from HIV surveillance, countries also use statistical modelling to better understand their specific HIV epidemics, including trends in HIV prevalence in the general population and most-at-risk populations, and estimates of the numbers of people who
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need particular interventions, such as antiretroviral therapy and antiretrovirals for preventing mother-to-child transmission. It is also important to have age and sex disaggregated data to better understand the epidemic and design an appropriate response. Proposed country actions:
The health sector plays the lead role in comprehensive HIV surveillance. National HIV/AIDS programmes should build surveillance systems that provide data in a routine, standard manner with consistency of methods, tools and populations surveyed. Vital elements of a comprehensive HIV surveillance system include: – – –
HIV infection and advanced HIV infection cases reporting and HIV related mortality, disaggregated by age, sex and geographical location; Probable mode of HIV transmission of reported HIV cases; Integrated biological and behavioural data among most-at-risk populations may be relevant for all endemic levels and are a priority for concentrated and low-level epidemic; HIV data from antenatal women either through sentinel surveillance or PMTCT programmes where appropriate; Periodic national population-based surveys (e.g. demographic and health surveys) with HIV testing in countries with HIV prevalence above 1 %; and Data from HIV surveillance among TB patients.
– – –
Mapping and developing reliable estimates of the size of populations at high risk for HIV is another important aspect of surveillance, to inform assessment of needs and development of appropriate policies and programmes. Data triangulation should be conducted between the results of estimates of the population size of most at-risk-population groups with data from integrated biological and behavioural surveillance and programme data. STI surveillance is strongly recommended both in its own right and as a useful early warning system for expansion of an HIV epidemic.
WHO contribution:
Provide guidance and support for improved surveillance, data collection, analysis and use in the health sector for advocacy, planning, resource mobilization and resource allocation. Based on the recommendations of the UNAIDS Reference Group on Estimates, Modelling and Projections, WHO and UNAIDS provide technical assistance and training to country teams to generate country estimates. Provide technical support to countries to conduct periodic incidence surveys.
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Drug-resistance monitoring Given the high replication and mutation rates of HIV and the necessity of lifelong antiretroviral treatment, the emergence of some level of HIV drug resistance (HIVDR) is inevitable. However, the risk of HIVDR can be reduced with appropriate action. The key interventions for preventing and managing HIV drug resistance include:
promoting the use of standard ART regimens. supporting the use of standardized individual treatment records. supporting adherence and active monitoring of adherence. removing barriers to continuous adherence. quality assurance/control for ARV drugs, and ensuring adequate and continuous drug supply. monitoring of “early warning” indicators of HIVDR. conducting surveillance for HIVDR transmission, and monitoring HIVDR emergence in treated populations where relevant. taking appropriate actions based on the results of monitoring and surveillance.
Proposed country actions:
Establish an HIV DR working group. Develop a national strategy for HIVDR prevention and assessment. Monitor adherence of ARVs drugs. Conduct and expand monitoring of early-warning indicators. Where relevant, conduct HIVDR surveys regularly.
WHO contribution:
Assist in development of national strategy for preventing and assessing HIV drug resistance. Assist countries in developing and conducting early-warning indicators for HIV drug resistance. Facilitate and support establishment and assessment of regional and national reference laboratories for HIV drug resistance, where capacity and demand exist. Assist countries in building capacity to undertake regular drug resistance surveillance in high-burden countries. Sharing information on drug resistance within the Region.
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Programme monitoring and evaluation An efficient monitoring and evaluation system is the cornerstone for measuring a country’s progress in providing universal access to prevention, care and treatment services and achieving the Millennium Development Goals (i.e. to “halt and reverse the spread of HIV” by 2015). Monitoring and evaluation are often cited as weak elements of the health sector that need strengthening. The recommended ingredients of the monitoring and evaluation package should include: a national monitoring and evaluation plan, a monitoring and evaluation unit, key performance indicators, establishment of a technical working group, adequate budget, dedicated staff, adequate infrastructure, standard data collection forms, channels for data flow, data analyses, use and dissemination, and quality assurance. It is important that indicators are defined and measured in a consistent and standard way in order to assess trends and measure progress towards programme goals. It is also important that monitoring and evaluation (monitoring and evaluation) systems are able to capture data disaggregated by age, sex, population groups (including most-at-risk population groups, such as sex workers, men who have sex with men and injecting drug users; patients with TB and hepatitis B and C coinfection) and by geographical regions or socioeconomic groups as appropriate. Data for monitoring the health sector response to HIV come from several sources. These include routine medical and other records that are part of the broader health information management system; mapping available services in health facilities and other health settings; health facility surveys; population-based surveys; cohort studies of people living with HIV; monitoring procurement and supply of HIV medicines and diagnostics; and impact assessment. Other sources include surveillance data (e.g. behavioural and biological surveys) and mortality records and reports. Special studies should be considered when routine data collection and analysis is inappropriate or not feasible. Getting data from organizations providing communitybased HIV services is also essential. Strengthening evaluation is essential for programme managers and decision-makers since it enables them to assess how successfully programmes are meeting their goals. Evaluation is also critical for countries and their development partners since it demonstrates the effectiveness of aid and argues for sustaining or increasing it. The effective use of evaluation data will ensure that the HIV response is based on the best available evidence and will guide continued programme improvement. Proposed country actions:
Establish a technical advisory group with representation from National HIV/AIDS programme, ministries of health and other stakeholders to strengthen the national monitoring and evaluation system. Develop a costed monitoring and evaluation plan. Develop country’s monitoring tool to include input, process, output, outcome and impact indicators for HIV, AIDS and STI in a standardized and harmonized way.
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Strengthen ongoing data collection systems and optimize use of resources by integrating HIV reporting into other health programmes such as HMIS, MCH, TB, drug treatment centres. Minimize the burden of data collection by leveraging the use of other data sources such as DHS and census, etc. Conduct period programme reviews in collaboration with policy-makers, project managers, international stakeholders and evaluation experts. Regularly analyse and disseminate the data generated to all appropriate stakeholders for action.
WHO contribution:
Support countries with monitoring and evaluation tools and guidelines for national HIV/AIDS programme. Provide support to countries for developing harmonized and standardized monitoring and evaluation tools for stakeholders. Collect, collate and analyse HIV/AIDS/STI country data and publish regional reports. Support external and internal reviews of the programme involving key stakeholders.
Research An effective response to HIV/AIDS requires that interventions and approaches be continually improved over time. The HIV response can be strengthened through different types of research—clinical/epidemiologic, socio-behavioural and health systems. In each of these areas, new evidence should be collected, assessed and then brought to bear on policies, strategies and programmes. Operational research builds on the different disciplines that are used for basic research to address questions related to programmes. Performing research alone is not enough; there must also be processes for bringing it quickly to bear on decisions so that they are based on the most up-to-date evidence. Proposed country actions:
Build up strengthen the research capacity in terms of capacity building of human resources, developing research infrastructure, including laboratories and strengthening health management information system. Ensure that there is greater collaboration between researchers and policy-makers in HIV and STI research work and that the findings are translated into practice. Collaborate with national partners, donors organizations and academic networks to design and conduct research. Utilize research findings to strengthen HMIS. Identify and prioritize research areas in the country to address programme needs. Establish guidance and mechanisms for ethical conduct of HIV-related research.
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WHO contribution:
Identify research priorities in the Region and assist countries in developing research agendas channelled to address programme needs. Assist in building capacity for operational research and promote linkages between HIV programmes and research institutes. Provide technical support for operational research aimed at increasing quality and equity of HIV services through development of innovative approaches. Facilitate networking between research institutes within and outside the Region and disseminate information on published and ongoing research. Assist countries in disseminating research data to mobilize resources and to advocate with policy and decision-makers.
Core indicators Strategic direction 2: Strengthening strategic information systems for HIV and research Core Indicators 2.1 Number of countries that have a costed national monitoring and evaluation plan covering HIV response in the health sector response? 2.2 Number of countries conducting systematic surveillance among MARPs. 2.3 Number of countries conducting periodic IBBS. 2.4 Number of countries having HIV drug resistance prevention and assessment strategy in place? (UA) Does it include: 2.4.1 Regular evaluation of HIVDR early warning indicators from ART sites. 2.4.2 HIVDR transmission threshold surveys, wherever applicable in areas of widespread ART use for past three years. 2.5 Number of countries with routine reporting of STI disaggregated by age and sex. 2.6 Number of countries conducting STI surveillance. 2.7 Number of countries conducting research on HIV.
3.3 Strategic direction 3: Strengthening health systems for effective integration of health services Strategic direction 3 ensures that the expanded response to HIV will build effective, efficient and comprehensive health systems in which HIV and other essential services are available, accessible and affordable. Systems need to be improved so as to create broad synergies and better health outcomes. Adapt service delivery systems that work Good health services are those that deliver effective, high-quality health interventions to people who need them, when and where they need them and with minimum waste of resources.
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Appropriate cost-effective service delivery models that deliver good health outcomes need to be selected to meet the needs of populations at risk of HIV infection and those living with HIV. Community-based systems have a vital role to play in planning and implementing health services, particularly for key populations that do not access the traditional health care system. In many contexts, community-based organizations are the only agencies that are able to reach the most-at-risk populations with services as well as create the social, political, legal and financial environments needed to effectively respond to the HIV/AIDS epidemic. Laboratory support is the most basic and fundamental tool. Monitoring of antiretroviral therapy, diagnosis of HIV and associated infections and evaluation of response to therapy in the individual and various public health interventions cannot be accomplished until reliable laboratory support is available both at clinical and public health areas. Proposed country actions:
Update national normative guidelines and tools to reflect the best international practices and the latest recommendations. Strengthen management capacity in the health sector to ensure an adequate number of managers at all levels of the health system, ensure that managers have appropriate competencies, create better management support systems and enabling working environments. Establish quality management systems to address clinical care, laboratory testing and workplace improvement. All facilities and providers, whether run by government, NGOs or private actors should be covered. Involve people living with HIV and those vulnerable or most-at-risk in the design, management, delivery and monitoring of services to ensure that services meet their needs and concerns.
WHO contribution:
Provide guidance on models of integrated decentralized HIV service delivery for different epidemic types. Promote the use of streamlined tools for Integrated Management of Adolescent and Adult Illness (IMAI), Integrated Management of Childhood Illness (IMCI) and Integrated Management of Pregnancy and Childbirth (IMPC) in order to provide a simplified, efficient approach to service delivery. Provide guidelines to ensure optimal utilization of laboratory support in providing quality care and reliable diagnostic support to various interventions against HIV/AIDS. Support community systems strengthening as a key element to improving the quality, efficiency and coverage of HIV services. Promote the involvement of civil society in WHO’s policy development and implementation.
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Strengthen human resources for health Effective service provision requires trained service providers in the right number, at the right place, at the right time, working with the right attitude, knowledge and skills, commodities (medicines, disposables, reagents) and equipment, and with adequate financing. It also requires an organizational environment that provides the right incentives to providers and users. Groups of people living with HIV, community- and faith-based organizations, and many others have learned to play a wide range of roles in the response to HIV, serving as outreach workers, home carers, adherence supporters, providers of psychosocial support, counsellors and managers. This has led to the creation of entirely new health professions in some countries. It has led to strong momentum in the direction of task shifting and to persuasive calls for recognition and payment for some of the essential services they provide. Their roles are increasingly recognized and institutionalized and are beginning to transform the debate on universal primary health care from a distant dream to an achievable goal. Proposed country actions:
In countries with health worker shortages, efforts should be made to increase, retain and motivate competent health-care workers. WHO recommends: – – – –
recruiting and training health workers as needed; considering task-shifting/task-sharing as a knowledgeable HIV-related service providers; way to increase the pool of
sensitizing health workers to the needs of people living with HIV; ensuring relevant HIV content in pre-service curricula and in-service training and support continued learning (including mentoring and continuing medical education); ensuring that health workers have access to prevention and other HIV- and TBrelated services; and ensuring that health workers have access to immunization against vaccinepreventable diseases, especially hepatitis B immunization. reducing the draw of private and NGO-run programmes on workers in public health programmes and agreeing on nationwide standard incentive practices; improving the quality of the workplace, including: establishing occupational health and safety procedures to reduce the risk of contracting HIV and other blood-borne diseases; addressing stress and burnout; advocate against HIV-related and other forms of discrimination; providing social benefits, financial incentives and non-financial incentives such as career and training opportunities; and adjusting work demands.
– –
To retain existing health workers, the following policy changes should be considered: – –
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A full package of HIV prevention, treatment and care services should be made available to health workers and their families on a priority basis and should be tailored specifically to their needs according to national policy; and Recognize and support the vital roles played by people living with HIV, community organizations and lay workers. Actions should be integrated into national plans for developing human resources for health and HIV.
WHO contribution:
Provide conceptual approaches and tools for health workforce development. Advocate for integrating the human resource plan into the national health plan and HIV/AIDS plan. Support capacity building - targeting providers and managers in Member States - and promote exchange with other human resources and health stakeholders and partners at all levels, within and beyond WHO.
Health financing Health systems should raise and secure adequate funds for health in order to ensure that people can use the services they need and are protected from financial catastrophe or impoverishment because they have to pay for services. Proposed country actions:
Plan the transition to universal coverage in ways that contribute to: meeting the needs of the population for quality health care; reducing poverty; attaining internationally agreed development goals, including those contained in the United Nations Millennium Declaration; and achieving health for all. Ensure adequate and equitable distribution of good-quality, health-care infrastructures and human resources for health so that those insured receive equitable and goodquality health services according to their benefits package. Ensure that external funds for specific health programmes or activities are managed and organized in a way that contributes to the development of sustainable financing mechanisms for the health system as a whole. Promote health financing systems that include a government managed social security system that reduces out-of-pocket expenditures by patient.
WHO contribution:
Provide Member States with the tools to cost national health sector plans and services. Provide support for development of national health-care financing plans that incorporate HIV programmes. Advocate for additional health sector investments required to achieve MDG targets and the goal of universal access.
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Support operational research on innovative, sustainable health financing mechanisms Provide support to Member States in mobilizing and implementing external funding, including from the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Ensuring equity in access to essential medical products and technologies A well-functioning health system should ensure equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, as well as access to their scientifically sound and cost-effective use. Proposed country actions:
Establishing national policies, standards, guidelines and regulations for procurement of drugs and other commodities. Providing health authorities with information on prices, international trade agreements and capacity to set and negotiate prices. Ensuring reliable manufacturing practices and quality control for priority products. Establishing procurement, supply, storage and distribution systems that minimize leakage and other waste. Providing support for rational use of essential medicines, commodities and equipment through guidelines, strategies and training to ensure enforcement, reduce resistance and maximize patient safety. Delivering on countries’ obligations under UN Conventions to provide access to appropriate analgesics and opioid substitution therapy.
WHO contribution:
Disseminate information on medicines and diagnostics through the AIDS Medicines and Diagnostics Service. Providing health authorities with information on prices, international trade agreements and capacity to set and negotiate prices. Provide support to countries to deliver uninterrupted supply of HIV-related commodities through technical assistance, capacity building and training in the effective use of tools for procurement and supply management. Promote sharing of knowledge and expertise among countries in the Region in issues related to TRIPS and GMP for prequalified medicines.
Supporting leadership and governance Effective and motivated leadership in HIV creates momentum for and provides oversight of the HIV response. It is defined both by its actions and by its outcomes including national financial commitments. Leadership should create an environment that accelerates scale-up of the HIV response, defines the values and principles that should shape the process, holds the different stakeholders accountable and supports innovation to maximize the impact of interventions.
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Among the outputs that should be expected of leadership are development, implementation and adaptation of strategic policy frameworks, policies, legislation and regulations that create a favourable environment for an effective response to HIV, coalitions and partnerships that contribute to a better response, and new and more effective interventions. Proposed country actions:
To promote and support effective coordination; health sector stakeholders should participate in and liaise regularly with key country mechanisms that have a coordination function, such as national AIDS councils/commissions, CCMs, UN Theme Groups and donor forums. Establish and strengthen coalitions and partnerships with a range of stakeholders (e.g. nongovernmental, community-based and faith-based organizations, people living with HIV, marginalized groups, academic institutions and the private sector) as these are critical to scaling-up of universal access. Leadership should also support innovation and foster an environment that promotes human rights, including gender equality, women’s empowerment and the reduction of stigma and discrimination.
WHO contribution:
Support capacity building in HIV/AIDS programme management including leadership and governance through provision of tools and training. Support advocacy with high-level groups and organizations, including government authorities, UN systems, and forums such as Regional Committee, ASEAN and SAARC, etc.
Core Indicators Strategic direction 3: Strengthening health systems for effective integration of health services Core Indicators 3.1 Percentage of health facilities dispensing antiretrovirals (ARV) that have experienced a stock-out of at least one required ARV in the last 12 months. 3.2 Number of countries with human resource development plan for HIV.
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3.4 Strategic direction 4: Fostering supportive environment to ensure equitable access to HIV services The health sector plays an essential role in fostering a supportive environment in the form of reducing HIV-related stigmatization and discrimination, and removing structural barriers4 to accessing HIV services. Linking of HIV and other key health areas is crucial for leveraging broader health outcomes. Such links are also important to ensure that HIV response benefits from investments in other related health areas. Promote gender equality, human rights and health equity Removing gender-based health inequities and protecting the rights of people living with HIV and key populations are crucial steps to achieving universal access goals and health-related MDG targets. The health sector also has an important role to play in providing evidence on the links between gender equity, human rights, the social determinants of health, and HIV. Specific interventions should be implemented in the health sector by revising policies and programmes to reduce gender-based inequities, and ensuring human rights protection for key populations. Proposed country actions:
Collect gender-based health information. Information systems for HIV and broader health aspects should collect and analyse sex, and age aggregated data in order to identify HIV transmission patterns, health-service inequities and programme impact among girls and boys, men and women.
Include gender issues in the design, delivery and monitoring of health services: – – –
Promote equity between the sexes in sexual decision-making, including negotiation of safer sex and use of male and female condoms. Financial and human resources should be allocated to programmes aimed at overcoming gender-related barriers to accessing health services. Specific attention should be given to female carers so as to ensure that they have good, equitable working conditions, and are empowered to participate in leadership roles in health and community systems. Services relating to gender-based violence, including comprehensive services for survivors of rape and other sexual violence, should be introduced.
–
4
Structural barriers are systematic barriers (social, cultural and legal) faced by key populations that deter them from accessing HIV services and reduce the effectiveness of services.
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Involve people living with HIV and key populations in the design, implementation and evaluation of national HIV response with an aim to eliminate stigmatization, discrimination and other human rights abuses in health service delivery. Laws and regulations should be reviewed and if necessary reformed in order to decrease HIV vulnerability, improve access to health services and protect human rights. Legislation should be enacted to uphold non-discrimination in all areas. Specific attention should be paid to: travel restrictions, employment, homophobia, sex work, drug control laws and criminalization of HIV transmission.
WHO contribution:
Support improved gender equity and the generation of evidence related to genderbased health equities. This includes identification and overcoming gender-based barriers to access services and related social inequalities. Provide support for advocacy and research on the relationship between HIV risk, gender-based violence and other human rights violations, and provide guidance on the implementation of programmes addressing violence against women. Include women (including women living with HIV) and community care providers in developing policies and normative guidance aimed at ensuring that HIV services meet the needs of women. Advocate and support countries in reviewing and developing health-related policies and legislation to ensure that the health needs of key populations are adequately addressed.
Leverage broad participation and collaboration of stakeholders Building coalitions and partnerships with a range of stakeholders is critical for the health sector in scaling up efforts towards universal access. People living with HIV (PLHIV) are a vital resource in the response to the epidemic. The involvement of PLHIV in advocacy efforts, in policy dialogue, in service delivery and in the effort to reduce stigma and discrimination has already been documented extensively. An effective and comprehensive response that ensures equitable access to HIV services demands the active involvement of the private sector and civil society, as well as nongovernmental, faith-based and academic organizations. Community mobilization is key to promoting HIV prevention, treatment, care and support. Civil society organizations including faith-based organizations and private agencies also complement and supplement formal health services. These roles need to be reinforced as much as possible by providing adequate resources for community-health activities and building strong links between health services and community organizations. Academic institutions have an important role in capacity building, adapting guidelines and tools for local use, supporting operational research and providing technical assistance.
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Proposed country actions:
National health sector strategies and plans should call for the active and meaningful engagement of civil society, NGOs, faith-based organizations, private businesses and academic institutions in strategic planning, programme development, implementation, and monitoring and evaluation. These non-governmental players often constitute a significant portion of all health-care providers and can play critical roles in expanding access to services, particularly for most-at-risk, vulnerable and marginalized populations. People living with HIV should be engaged in all aspects of planning, implementing, monitoring and evaluating health sector response to HIV at global, regional, national and local levels; this includes the development and adaptation of normative policies, tools and guidelines, and delivery of services.
WHO contribution:
Promote exchange of information among partners at global, regional and national levels through forums such as meetings of programme managers, experts and technical groups; Involve various stakeholders in the activities implemented or supported by WHO, e.g. in planning and training, developing guidelines, and in conducting research, monitoring and evaluation.
Strengthening links between HIV programme and other health areas Links between programmes and integration of HIV into other key health services have the potential to improve the efficiency and effectiveness of both HIV-specific and broader health investments. Collaboration between HIV and other health programmes will facilitate programme coordination and align programme targets, guidelines, services and resources. Proposed country actions:
Strengthen HIV/TB collaborative activities. Strengthen linkages between HIV and maternal, new born and child health services for improved access, coverage and quality of HIV prevention, care and treatment services including STIs in the context of strengthened MNCH services. Address sexual and reproductive health and rights to improve access and coverage for most-at-risk and vulnerable populations. Integrate HIV interventions into drug prevention, treatment and control programme. Leverage broader disease and health outcomes through health systems strengthening. Strengthen strategic health information systems for data collection, and their analysis and use.
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WHO contribution:
Guidance for designing and developing national strategies for integrated health service delivery including role of families and communities. Develop package of essential interventions for integrated service delivery/linked response for improved HIV outcomes in the context of MNCH services. Develop/update tools and guidelines for effective implementation of integrated service delivery packages. Design and test innovative models of service delivery for integrated services/linked response. Monitor progress towards key outcomes in MNCH and HIV programmes towards achievement of health MDGs. Collaboration and partnerships with key stakeholders for systems strengthening e.g., GAVI HSS and The Global Fund. Technical support for assessment of integrated services in the context of national programmes.
Mobilizing resources Mobilizing adequate financing from domestic or foreign donors will be the key to continue scaling-up of HIV services, and to keep pace with increasing demand.
Advocate with local governments to ensure adequate funding for HIV programme at intermediate (regional or provincial) and peripheral levels (district and sub district) under decentralized health systems. Develop long-term resource mobilization plans supported by a good advocacy and communication strategies and plans to mobilize and sustain both external and domestic funding. Coordinate external financial assistance for HIV with relevant national and international health partners. Develop proposals to be submitted to donors. Efficiently implement and monitor the programmes supported by internal and external funding sources for the maximum use of resources.
WHO contribution:
Provide technical support to Member States in mobilizing resources from various sources of funds, e.g. GFATM. Resource tracking for tends in investment for HIV/AIDS prevention, care and treatment services. Assist in monitoring and evaluation of programmes.
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4. Strategy implementation The HIV Programme of WHO embraces action taken at all three levels of the Organization and across a wide range of departments and units. While the Department of HIV at headquarters is responsible for coordinating the overall programme, at the WHO Regional Office for South-East Asia, the HIV unit under the Department of Communicable Diseases focuses its efforts on coordination and facilitation of technical support to Member States. WHO country offices in all of the Member States in the Region have staff working full time or part-time on HIV. WHO will optimize its HIV programme structure and operations through the following activities.
4.1 WHO’s framework for results-based management WHO’s Medium-term strategic plan 2008-2013 that sets the Organization’s strategic direction for that period has much of HIV related work under Strategic objective 2 as well as HIV-related activities under other strategic objectives. Each strategic objective has a set of Organization-wide expected results with indicators, targets and resource requirements. This Regional Health Sector Strategy on HIV will guide the development of outputs and main activities to be carried out by WHO offices at regional and country levels. Workplan implementation is monitored through a medium-term review at the end of the first year of each biennial workplan and progress towards achievement of the Organization-wide expected results is reported at the end of each biennium.
4.2 Division of labour across the three levels of the WHO Secretariat
WHO headquarters will focus on global policy and normative work and be responsible for global monitoring and reporting on HIV pandemic and response. Global guidance will be streamlined so as to ensure timely communication of new recommendations and greater coherence. Regional offices will focus their efforts on coordination and facilitation of technical support to countries, including adaptation of global guidance at country level. Country offices will focus their efforts on providing strategic policy advice to national stakeholders and assist in planning, implementation, monitoring and evaluation of the national programme in coordination with partners.
WHO will invest in developing core competencies of its programme staff, focusing on the technical and policy areas required to deliver on the four strategic directions of the strategy. Management skills will be strengthened to ensure efficiency, effectiveness and the ability of the Organization to adapt to a changing environment.
4.3 Maximizing the synergies across other programme areas WHO’s work on HIV links with a range of other high-priority areas within the Organization, including: health system strengthening; health-information systems; maternal, newborn and child health; sexual and reproductive health; tuberculosis and other infectious diseases; blood and injection safety; emergency and surgical care; nutrition; noncommunicable diseases and mental health; gender and women’s health; vaccine development; access to essential
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medicines; innovation and intellectual property; social determinants of health; health law, human rights and ethics; and health in humanitarian crises. The strategy promotes strong linkages across these health programmes. Priority will be given to strengthening integration of HIV into the core work of these other programme areas. Mechanisms for joint planning and coordination across programmes will be enhanced. For example, WHO’s support to the Elimination of New HIV Infections in Children initiative will be coordinated across units responsible for HIV, maternal and child health, sexual and reproductive health, and nutrition. WHO’s contribution to Treatment 2.0 will be coordinated across units responsible for HIV, tuberculosis, essential medicines and diagnostics, child and adolescent health, and nutrition.
4.4 Collaboration with other partners WHO works with partners at all levels particularly with major donor and development agencies, including GFATM, bilateral and multilateral programmes, private foundations and implementing partners. WHO will aim to strengthen national institutions, structures and systems for a sustainable response, working through knowledge hubs, WHO collaborating centres and technical networks. WHO plays an important convening role in promoting collaboration between civil society, the government and the private sector. Civil society partners provide technical and programming support for WHO’s work, including advocacy and development and implementation of policies, tools and guidelines. WHO’s collaboration with civil society is particularly important in ensuring that essential services are delivered to populations not reached by state services and advocating for evidence-based policies, adequate resources, greater accountability and human rights protections for key populations.
4.5 WHO as a cosponsor of UNAIDS WHO’s collaboration within the United Nations system in the area of HIV is primarily managed through the mechanisms and structures of UNAIDS, including the Committee of Cosponsoring. Organizations and the Programme Coordinating Board at the global level, meetings of the Regional Directors Group of UNAIDS Cosponsors at the regional level and United Nations Theme Groups on HIV/AIDS and Joint United Nations Teams on AIDS at country level. The UNAIDS Division of Labour aims to coordinate roles, responsibilities and actions across its cosponsors and its own secretariat. Among the UNAIDS cosponsors, WHO leads the health-sector response to HIV, acts as the convening agency on the priority areas of HIV treatment and care and HIV/tuberculosis, and jointly coordinates with UNICEF work on prevention of mother-to-child transmission of HIV.
4.6 Monitoring, evaluation and reporting Regular reviews are planned to assess progress made at country and regional levels. The UNGASS, UA and MDG reports will be used as key progress reports on the commitments and targets made at global level. Progress at regional level in moving towards the targets set out in
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this strategy will be regularly assessed. WHO will continue to work with UNAIDS and other agencies to provide support to countries for harmonized and standardized collection of core indicators, and in preparation of regional and country reports. An annual report on HIV/AIDS in the South-East Asia will be made by WHO-SEARO to presents key achievements in prevention and control of HIV in the Region and highlight areas where further work is needed. WHO-SEARO and country offices will support and assist in the assessment or review of the programme when needed to provide feedback for the development and revision of national strategic plans. Core Indicators Strategic direction 4. Fostering supportive environment to ensure equitable access to HIV services Core indicators 4.1 Number of countries reporting disaggregation of epidemiological / programme output data and indicators by sex and age. 4.2 Number of countries with people living with HIV and affected people involved in the planning, implementation, monitoring and evaluation of the programme. 4.3 Number of countries with evidence of PLHIV who were denied health services in the past 12 months because of their HIV status.
5. Core indicators for monitoring of the health sector strategy Indicators are listed in monitoring and reporting on the health sector response to HIV/AIDS: Joint reporting tool 2011. The reporting tool has been used to generate standard set of information to monitor and report on progress in the health sector response to HIV/AIDS at national, regional and global levels. Indicators are aligned with related efforts of partner agencies.
Key resources (1) (2) (3) (4) (5) (6) (7) (8) (9) A strategy to halt and reverse the HIV epidemic among people who inject drugs in Asia and the Pacific 2010-2015; Bi-regional Strategy for Harm Reduction 2005-2009; Bi-regional Strategy Towards Elimination of HIV and Congenital Syphilis in Asia Pacific; Conceptual Framework for the Elimination of Paediatric HIV and Congenital syphilis in Asia Pacific 2011-2015; Expanding Access to HIV/AIDS Treatment: A Strategic Framework for Action at Country Level; Global Health Sector strategy on HIV/AIDS 2011-2015, World Health Organization, Geneva, 2011; HIV/AIDS Strategic Framework for South-East Asia Region 2002-2006; National AIDS programme management: A set of training modules, WHO South-East Asia Regional Office, 2007; Planning for the Health Sector Response to HIV/AIDS: Training modules, WHO South-East Asia Regional Office, 2007;
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(10) PMTCT Strategic Vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals, WHO 2010; (11) Priority interventions – HIV/AIDS prevention, treatment and care in the health sector, World Health Organization Geneva, 2010; (12) Regional strategy for the elimination of congenital syphilis; (13) Regional Strategic Plan on HIV/TB; (14) Regional strategy for the prevention and control of sexually transmitted infections 2007-2015, WHO South-East Asia Regional Office, 2007; and (15) UNAIDS: 2011-2015 Strategy – Getting to Zero, UNAIDS, 2010.