(WP)HSI/ICP/HSI/3.5/001 Report series number: RS/2003/GE/31(PHL) English only
REPORT
MEETING OF HIV/AIDS/STI PROGRAMME MANAGERS
25-26 November 2003 Manila, Philippines
Convened by
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines
NOTE
The views expressed in this report are those of the participants in the Meeting of HIVIAIDSISTI Programme Managers and do not necessarily reflect the policies of the Organization.
This report has been prepared bY the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Meeting of · HIV/AIDSISTI Programme Managers from 25 to 26 November 2003 in Manila, Philippines. ·
CONTENTS
SUMMARY 1. INTRODUCTION 1.1 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Participants and resource persons .. .. .. .. .. . . .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. .. . . . 1.3 Organization of the meeting .. .. .. ...... .. .. .. . .. ... .. .. .. .. .. . .. .. .. .. .. .. .. . . .. . . . .. 1.4 Welcome statement .. . .. .. .. .. . .. . .. .. .. .. .. .. .. . .. . .. . .. .. . .. .. ... .. .... .. . .. . .. . .. ... 1.5 Opening of the meeting ..... . . .. .. .. .. .. . . .... .... .. . .... .. . .. . . . .. . .. . ... .. . .. . .. . .. .. 2. PROCEEDINGS ... ......... .. . ........................ ....... ........................ .... .... 2.1 Epidemiology and surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 2 3 3 3 3 3 5 6
2.2 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 Care and treatment........... ......................... ........... . .. ... . ..... . ............
2.4 Global Health-Sector Strategy on HIV /AIDS............... ..... ................... .. 8 2.5 Global Fund to Fight AIDS, Tuberculosis and Malaria .. .. .. .. .. .. .. .. . .. .. .... ... 9 2.6 Partners session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 7 Country priorities for action for HIVI AIDS/STI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3. CONCLUSIONS ANNEXES: ANNEX 1 -PROGRAMME OF ACTIVITIES ANNEX 2- LIST OF PARTICIPANTS, CONSULTANT, OBSERVERS/REPRESENTATTVES AND SECRETARIAT I0
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Keywords: Sexually transmitted diseases I Acquired immunodeficiency syndrome I HIV infections I Tuberculosis
SUMMARY
The Meeting of HIVIAIDSISTI Programme Managers was held at the Regional Office for the Western Pacific in Manila, the Philippines from 25 to 26 November 2003 with expectation that by the end of the meeting, participants would have:
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reviewed and exchanged updated epidemiological information on the HIV/AIDS/STI epidemic in Asia; shared and analysed successes and constraints encountered with the implementation of Global Fund projects in Asia; reviewed and exchanged updated information on HTV/AIDS care, in particular on International Treatment Accesses Coalition development in Asia; reviewed and exchanged updated information on prevention activities with vulnerable groups in Asia (STI management, 100% condom use programme, harm reduction among injecting drug users); identified priorities for HIV/AIDS/STI prevention and care, during 2004-2005; identified the country actions to reach the goal of treating three million people with HIV/AIDS by the end of2005; and reviewed the document "Global Health-Sector Strategy for HIV/AIDS
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2003- 2007". The programme included technical presentations and open forum discussions in the areas of Epidemiology and Surveillance, Prevention, Care and Treatment, the Global Health Sector Strategy on HIV/AIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Partners and country participants also made general presentations on their current activities and future plans. Meeting participants reached a number of conclusions including consensus that the HIV/AIDS pandemic continues to expand in most of the Region's countries and is a threat to all that should not be underestimated. It was further concluded that prevention activities should be reinforced in all countries and should now be complemented by major new attention to the provision ofHIY/AIDS care and treatment in pursuit of the goals of the WHO 3 by 5 Initiative (treating three million people living with HIV /AIDS by 2005). There was widespread recognition at the meeting regarding the vital role that partners and the Global Fund now play in national HIV I AIDS programmes.
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1. INTRODUCTION
The Meeting of HIVIAIDSISTI Programme Managers was held at the Regional Office for the Western Pacific in Manila, the Philippines from 25 to 26 November 2003. I .1 Objectives
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To review and exchange updated epidemiological information on the HIV I AIDS/STJ epidemic in Asia. To shared and analyse successes and constraints encountered with the implementation of Global Fund projects in Asia. To review and exchange updated information on HlV/AIDS care, in particular on International Treatment Accesses Coalition development in Asia. To review and exchange updated information on prevention activities with vulnerable groups in Asia (STI management, 100% condom use programme, harm reduction among injecting drug users; To identity priorities for HIV/AIDS/STI prevention and care, during 2004-2005. To identity the country actions to reach the goal of treating three million people with HlV/AIDS by the end of2005. To review the document "Global Health-Sector Strategy for HIV/AIDS 2003 - 2007".
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(5) (6)
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The detailed programme of the meeting is attached as Annex 1. 1.2 Participants and resource persons
There were a total of 10 participants, representatives from the HIV IAID SISTI Programme Management Offices, from Brunei Darussalam, Cambodia, Japan, the Republic of Korea, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines, Singapore, and VietNam. Also attending the meeting were 10 observers/representatives from Asian Harm Reduction Network, Asian Development Bank, Australian Agency for International Development, U.S. Centres for Disease Control and Prevention ofthe Global AIDS Programme, ESTHER, Family Health International, and the UNAJDS South-East Asia Pacific Intercountry Team (UNAJDS/SEAPICT). The Western Pacific Regional Office provided technical and operational support for the meeting. The list of participants, consultants, temporary adviser, observers and secretariat staff is attached as Annex 2.
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1.3
Organization ofthe meeting
The meeting was held in the Conference Hall of the Western Pacific Regional Office of WHO from 25 to 26 November 2003. Methods used in the meeting included presentations and plenary discussions. 1.4 Welcome statement
Dr Shigeru Omi, WHO Regional Director, delivered the opening and welcoming remarks to participants ofthe IDV/AIDS/STI Programme Managers Meeting. He noted that since the 2001 meeting of programme managers in Melbourne, there had been a number of landmark events including the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria; the launching ofthe 3 by 5 Initiative; and the adoption ofthe Global Health Sector Strategy on HIV/AIDS by the May 2003 World Health Assembly. Political support for prevention interventions has also grown remarkably, especially for those directed at vulnerable high-risk populations like sex workers or injecting drug users. Dr Omi observed also that there had been a dramatic increase in the number of individuals who are developing AIDS and dying, placing ever-increasing demands on individuals, families, communities and health systems. He stressed that the availability and rational use of antiretroviral drugs (ARVs) are extremely important and that prevention and treatment are complementary and inseparable. Dr Omi expressed confidence that the 3 by 5 Initiative would be a great assistance in pursuing the goal of universal and equitable access to care for all in need. He welcomed all participants to what he understood would be an intensive experience with productive discussions covering a wide range of topics. He officially opened the meeting. 1.5 Opening ofthe meeting
Dr Bernard Fabre-Teste, WHO Regional Adviser for Sexually Transmitted Infections, including IDV/AIDS (HSI), invited participants and observers to introduce themselves. He then ran through an overview of the objectives of the meeting and the agenda. Dr Omi proposed and the participants agreed by acclamation that Dr Mean Chhi Vun (Cambodia) and Dr Hajah Rahmah Haji Mohd Said (Brunei Darussalam) would be Chair and Vice-Chair respectively for the first day of the meeting and that Dr Chansy Phimphachanh (Lao People's Democratic Republic) and Dr Ernesto Villalon (Philippines) would similarly serve as Chair and Vice-Chair for the second day. Dr Robert Fischer, Short-term Consultant (STC), was selected Rappm1eur for both days of the meeting.
2. PROCEEDINGS
2.1 2.1.1
Epidemiology and surveillance session Global overview
Dr Bernard Fabre-Teste presented a global overview on HIVI AIDS with emphasis on the regional situation and priority areas of work. According to the most recent data from UNAJDS/WHO, it was now estimated that 40 (range: 34-46) million adults and children worldwide were believed to be living with HIV /AIDS. Countries of the Asian and Pacific region continue to be heavily affected. At the end of2003, for South Asia, South-East Asia, East Asia and the Pacific, it was recognized that about 6.6 million adults and children were
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living with 1-IIVI AIDS including between 760 000 and 1.3 million newly infected persons during the year. It has been fUI1her estimated that between 362 000 and 648 000 adults and children died in these regions during the year. As the largest WHO region, the Western Pacific Region was also one of high risk at experiencing even greater impact from HIV/AIDS. To address this threat, the WHO Western Pacific Regional Office has identified five priority areas of work, including: (1) surveillance, monitoring and evaluation; (2) HIV targeted interventions with vulnerable groups; (3) HIV/AJDS care and suppmi; (4) TB/IDV; and (5) safe injecting and blood safety. 2.1.2 Western Pacific Region
Dr Nguyen Thi Thanh Thuy, Epidemiologist, HSI/WPRO, presented a summary of the epidemiology ofl-IIV IAID SISTI in Asia and the Pacific as well as the status of and plans for surveillance systems in the countries. Dr Thuy stressed that there was great diversity in the epidemic level, transmission modes and risks ofHIV transmission within the region. Several countries are now experiencing a "generalized" epidemic while the majority have a "concentrated" epidemic focused in groups at high risk. She recognized that most Asian and Pacific countries currently have low prevalence levels of HIV IAIDS. However, it was also recognized that many countries are exposed to the threat of a more widespread epidemic because of the presence of a number of important risk factors, such as high STI rates and risk behaviours and other factors relating to vulnerability. Although the epidemic is yet increasing in most countries, Dr Thuy drew attention to the fact that several countries now have good surveillance data documenting a decrease of epidemic spread ofiDV among sex workers and their clients (e.g. Thailand and Cambodia). Dr Thuy explained the different kinds of surveillance systems and elaborated on the key issues in data collection. She also gave an update on the current status ofi-IIV surveillance systems in Western Pacific Region countries and outlined the strategies that WHO Western Pacific Regional Office will use to support the development of surveillance systems in countries, especially plans to set up "second generation systems" where necessary. Dr Thuy especially stressed the importance of using surveillance to target and monitor interventions.
Open forum In the discussion that followed these two presentations, there were questions from several countries about whether it was advisable to conduct surveys among antenatal clinics populations in areas with very low HIV prevalence. Some countries do while others do not. Dr Thuy explained that WHO generally felt it was more useful to concentrate surveillance systems in groups of high risk. Where antenatal care (ANC) data were gathered, it was important to make sure that it was repeated over time. She also suggested that linking with the data systems associated with blood donations was also a cost-effective way to obtain a good idea ofHIV prevalence in the general population. Another participant expressed the desire that WHO develop some system and/or method in which to clearly and rigorously quantify the "vulnerability factor" in different countries that facilitate the spread ofHIV. In the discussion, another participant expressed the opinion that STI prevalence was really the most appropriate factor in assessing a country's vulnerability. Dr Thuy reminded the group that a large number of factors relate to vulnerability and the risk of expanding epidemic situations. It was also suggested in the discussions that, in light ofthe 3 by 5 Initiative and increasing attention to patient care, surveillance and monitoring and evaluation systems, there
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is a need to pay more attention to tracking issues like mortality and prevalence of opportunistic infections. 2.2 2.2. 1 Prevention session Overview
Dr Bernard Fabre-Teste began this section of the programme with an overview on the importance of both targeting and scaling-up prevention efforts where HIV transmission is actually occurring. With proper targeting of prevention efforts, it is estimated that 30 of the 45 new HIV infections projected to occur between now and 2015 could be averted. UnfOJtunately, it is also estimated that fewer than one in five people have access to basic prevention programmes and that prevention programmes often misdirected and overlook the importance of groups at high risk of acquiring and spreading HIV. Closing this gap between sources of transmission and targets for interventions is the imp01tant challenge of the future. 2.2.2 Injecting drug use and harm reduction
Mr Reginald Gray Sattler, Short-term Professional, Harm Reduction, reported on HIV and injecting drug use and harm reduction activities in the Western Pacific Region. Mr Sattler noted that illicit drug use and injecting drug use are increasing globally. Injecting drug use, however, was clearly the riskiest for drug users both because of exposure to HIV (and other infections) and because of the risk of overdose. The experience of a number of countries in the Region has shown that there can be an explosive increase in HIV prevalence among drug users. Wives and sexual partners of injecting drug users are also highly vulnerable to exposure to HIV infection. Three major approaches to addressing the problems of drug use (supply, demand and harm reduction) work best when combined. The key to limiting the spread ofHfV, however, is found in harm reduction strategies which have been demonstrated to be effective. Thus far, the harm reduction initiative of the WHO Western Pacific Regional Office has had missions and meetings in Cambodia, China, the Lao People's Democratic Republic, Malaysia, the Philippines and VietNam, and it has built partnerships with a number of bilateral and multilateral partners. It has been proposed to expand activities widely including the development of a Bi-Regional Strategic Plan (Western Pacific Regional Office- South-East Asia Regional Office).
2.2.3
I 00% Condom Use Programme
Ms Gaik Gui Ong, Technical Officer, HSI, rep01ted to the participants on progress that has been made with the 100% Condom Use Programme (1 00% CUP). She reviewed the history of the 100% CUP in both Thailand and Cambodia, highlighting surveillance data which in Thailand showed a dramatic reduction in STI and HfV and a concurrent increase in condom use rates linked to the initiation ofthe programme in 1989. Similar data were also reviewed with the 100% CUP that was piloted in Sihanoukville Province of Cambodia in 1998. At present, the following countries are implementing the 100% CUP: China, the Lao People's Democratic Republic, Mongolia, Myanmar, the Philippines and VietNam. Ms Ong also reviewed the number of guidelines, video, training course and other supporting materials that WHO had produced in supp011 of the 100% CUP. For the future, two additional publications are in progress. WHO has plans to continue to advocate for the programme, to help mobilize local and external resources and to support improvements in the monitoring and evaluation of the programme.
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2.2.4
Blood safety
Dr Ju Yungping, STC, made a presentation on blood safety, the challenges and responses, in the WHO Western Pacific Region. He noted that attention to the HIV testing of blood began in the mid-1980s, but it was quickly recognized as insufficient in itself to control HIV spread without also comprehensive attention to blood donor selection and more rational use of blood and blood products in medical care. Inadequate blood supplies and use of paid or replacement donors continue to be a challenge for many countries in the Western Pacific Region. Dr Junping reviewed the progress that had been achieved in some countries of the Region and stressed the need for all to implement the WHO Quality Management Project (QPM), including the establishment of the External Quality Assessment Scheme (EQAS) on transfusion transmissible infections and blood group serology.
Open forum The participant from WHO China reported that unsafe injecting drug use practices were a major factor in HIV transmission in that country. He stated that harm reduction interventions were now working better in China although the need was great and even more effort was needed. With regard to the 100% CUP, he reported that drafting of National Guidelines for the programme will soon be finalized and should be thereafter approved. It is hoped that the 100% CUP will be expanded to between I 00-200 new counties as part of the "China Cares" project and through integrating with other existing international projects. The participant from Japan explained that sex work was illegal in Japan and that, in any case, most sex workers were freelance. He wondered about the applicability of the 100% CUP in these circumstances. Representatives from both the Lao People's Democratic Republic and Cambodia explained that sex work was also illegal in their countries but that the 100% CUP worked on a more practical public health level, i.e. working with local authorities rather than confronting issues of the legality or illegality of prostitution. The representative from the Lao People's Democratic Republic and a participant from Mongolia also reported that the great majority of sex work in these two countries were also dominated by freelance workers and that, with modifications, the programme appears to be working well in these two very new programmes. The representative from the Philippines noted that condom use was also generally low in the Philippines. He felt that more attention should be paid to educating the clients of sex workers on the need to use condoms and that condoms should also be made available to sex workers without charge. The participant from WHO Cambodia encouraged all countries to consider closer linkages between the HIV programme and national or local blood transfusion services. 2.3 Care and treatment
In introducing this section of the meeting, Dr Fabre-Teste reminded the patiicipants that following the Programme Managers meeting there was going to be a two-day detailed consultation on the 3 by 5 Initiative. The presentation of this very important issue planned for the Programme Managers was really only intended to be a general introduction to issues. He invited any or all participants to join in the 3 by 5 consuliation if they wanted more information on the subject. A brief presentation was made by Professor Robyn McDermott from the School of Public Health and Tropical Medicine, Cairns, Australia who was at the WHO Regional Office consulting with another technical unit. Dr McDermott suggested that care of AIDS could
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benefit from the "systems method" that had been developed for another chronics disease, Type 2 diabetes. She warned that health care practitioners frequently focus exclusively on "clinical services" in disease care when in fact, for the long-term care situations, the governmental and policy environment and the impact of the disease on communities also demands close attention . 2.3 .1 Overview of the 3 by 5 Initiative
Dr Gilles Poumerol, HIV, WHO Headquatiers, gave a brief overview of the 3 by 5 Initiative (treat 3 million persons with HIV/AIDS by 2005). He stressed that the HTV pandemic was one ofthe greatest health crisis in human history with a cumulative total of30 million deaths to date and driven by 15 000 new infections and 8000 new deaths daily. In spite of this bleak picture, there was hope now with combination antiretroviral (ARV) drugs (ART). ART has proven feasible in resource-poor settings especially with the increase of funding and international sensitivity to the unacceptable human rights implications of this therapy being widely accessible in developed countries though accessible to only 8% of people in need in developing countries (2% in Africa.) In launching this initiative, WHO had identified "urgency" as one of the leading guiding principles underlining the necessity of "building the ship while sailing into battle". A strategic framework has been identified and, importantly, WHO is streamlining procedures and redeploying human and financial resources to support the initiative. Dr Kenji Tamura, HIV, WHO Headquarters, continued with an overview of the 3 by 5 Initiative stressing the role of the International HIV Treatment Access Coalition (IT AC) will play. He elaborated on the origins ofiTAC and the enlarging network of partners it has developed (totalling almost 140 in October 2003 with strong representation from pharmaceutical industries). Though the ITAC actually antedated the 3 by 5 Initiative, the ITAC is now thoroughly integrated with the "3 by 5" with WHO providing the secretariat of the organization. The ITAC has working groups, covering such areas as information exchange, training and quality of care, which are especially devoted to developing global training materials, a technical expertise inventory, website management, a technical think tank, a international health and community-base services twinning/exchange programme and advocacy. 2.3 .2 Regional perspective on HJV/AIDS care
Dr Masami Fujita, Medical Officer, HSI, presented a regional perspective on HIV/AIDS ARV treatment. He stressed that ARV treatment was not easy to do, requiring including care high compliance in sticking to a treatment regimen over a long period, with significant and sometimes life-threatening side-effects. An approach to develop continuum of care (CoC) in resource-poor settings-the Day Care Center (DCC)-has proven to be an effective stratet,ry for meeting the individual and community needs in ART. Examples of how the DCC works were presented from Cambodia, China, Papua New Guinea and VietNam, stressing the extensive linkages that underlie this strategy. 2.3.3 Regional framework to address TB/HIV co-infection
Dr Dong II Aim, Regional Adviser in STOP TB, presented a regional framework to address TB/HIV co-infection. He noted that because 30%-40% of people living with HIV/AIDS (PHA) are also co-infected with TB, HIV is fuelling the resurgence ofTB in the Region. A regional framework for closer collaboration between HIV and TB had been developed that focused on three areas: surveillance, case finding through referral, and treatment and care. Dr Aim felt that the 3 by 5 strategy was facing challenges similar to those of the DOT
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strategy in the early 1990s, but he felt also that close collaboration between the HIV and TB programmes held much promise in the future to reduce the burden ofHIV and to prolong the quality life of PHA. 2.3.4 Access to ARV medicines
Dr Bernard Fabre-Teste made a presentation on "Access to ARV medicines: Issues, challenges and options" that had been developed by Dr Budiono Santoso, Regional Adviser in Pharmaceuticals; Mr Truls Eriksen, STC; and Ms Karin Timmermans, STC. This framework linked access to medicines to four factors: (1) rational selection; (2) affordable prices; (3) sustainable financing; and (4) reliable health and supply systems. Focusing especially on an issue of great importance to the Region, Dr Fabre-Teste detailed the strengths and weaknesses of the three principal methods to procure drugs (restricted tenders, direct negotiations and "special" negotiations). The Trade Related Aspects oflntellectual Property Rights (TRIPS) Agreement of the World Trade Organization (WTO) has largely harmonized patent standards; however, there are still opportunities for countries also to produce ARVs legally.
Open forum The participant from Singapore stressed that HTVI AIDS care in that country paid great attention to the psycho-social aspects of the disease. The participant from Brunei Darussalam also mentioned that, with increased care to AIDS patients, it was important to reinforce training in universal precautions. The participant from the Republic of Korea asked about the status of vaccine development. Dr Poumerol explained the recent phase III vaccine trial in Thailand had not been successful and there was a general consensus that a preventive vaccine (as opposed to a therapeutic vaccine) would probably not be available for another 10 years. The participant from the Lao People's Democratic Republic asked about the issue of drug resistance. In response, Dr Tamura explained that different studies had found that drug resistance developed in 5%-20% of cases. Hard conclusions on this subject were difficult because of the difference in the clinical status of patients and also in the first and second line regimens that have been used. The representative from VietNam stressed that his country was very interested in producing its own ART drugs. A participant from Thailand said that all the drugs being produced there were either "off patent" or that national researchers had modified the formulas sufficient to produce them in accordance with international intellectual property rights agreements. It was noted that drug production in India would be brought into line with TRIPS by 2005. Another participant from an international organization asked about the relationship of the "3 by 5" and the "Clinton Foundation" initiative with AIDS drugs . It was explained that the . Clinton Foundation was indeed a partner of WHO and the IT AC. The representative from Papua New Guinea asked about the sustainability of the 3 by 5 Initiative in 2006. It was advised by others that we all need to "start now" and that the stistainability of the initiative will be based on increased funding that is surely to come (when countries have good plans and capacities) and because the price and complications of ART will surely decrease over time. 2.4 Global Health Sector Strategy on HIV /AIDS
Dr Robert Fischer, STC, presented an overview of the Global Health-Sector Strategy (GHSS) for HIV/AIDS 2003-2007. Looking at the background ofthis WHO initiative, he explained the linkages of the GHSS and several related actions ofthe United Nations, including the UN Millennium Declaration, the Global Strategy Framework on HIV/AIDS, the UN System Strategic Plan for HIV IAIDS 2001-2005, the Declaration of Commitment on HIV/AIDS (UNGASS) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). He noted that the "target audience" of the GHSS was Ministers of Health and senior national policy-makers and that the principal message was that Ministries of .Health must
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take the lead role in planning and implementing the health sectors response to HIV/AIDS based on lessons learnt in the past and incorporating principles embodied in the Strategy. Dr Fischer ran through many of the 34 "Action Points for Health Ministries" that are in the GHSS, showing how they might best be understood as relating to four principle areas: (I) to generally advocate for and use the Strategy; (2) to unde1take a thorough reassessment of existing HIV/AIDS strategies, plans and activities; (3) to develop new mechanisms and plans to better address HIV/AIDS; and (4) to implement these new plans. He reminded the group that the World Health Assembly (WHA) resolution adopting the GI-ISS also called for an interim evaluation of progress made in 2005 and a final evaluation in 2007. Dr Fischer also reminded the group that the WHO Regional Office was prepared to assist with any revision and updates ofNational HIV/AIDS Strategic Plans and that the Regional Office had recently queried countries about their anticipated planning needs. He encouraged countries to respond to the Regional Office in this regard.
Open forum The initial reaction of several participants to this presentation was disbeliefthat they had not yet heard of this important strategy and fear that their Ministers also had not heard of it. In general discussion it was made clear that, in fact, the Ministers of Health themselves had been the ones who adopted the GHSS at the World Health Assembly. A representative from another international organization spoke in strong support of the GHSS, stressing that the health sector is in fact ahead of some other sectors in identifYing its role and strategy for confronting HIV/AIDS. Upon reflection, several countries observed that some recent policy and strategies that had been developed in their countries seemed to be consistent with the GHSS. It was suggested that the GHSS, and especially the "Core Components" was a good "check list" against which to evaluate current national plans. 2.5 2.5.1 Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) Global overview
Mr Stephane Rousseau, Short-term Professional, presented a global overview of and experiences learned with the GF ATM. In the first two years of operation, the fund has approved over $65 million of grants for HIV I AIDS in the Region. He reviewed the labourintensive steps in the pre- and post-grant and implementation stages along with issues related to GFATM-specific entities such as the Country Coordinating Mechanisms (CCM), Local Fund Agent (LFA), Principal Recipient (PR) and Sub-Recipient (SR). Mr Rousseau stressed that countries should feel free to ask GF A TM staff about any questions they may have although they should not forget that the Global Fund is principally a financing mechanism and thus is often not qualified to answer technical questions. He recognized that there was some concern about the level of disbursements from the Global Fund but reminded everyone that the fund used a system of "result based disbursements" ("raise it, spend it, prove it") which would appear slow at the earlier stages of project implementation. Finally, Mr Rousseau ran through the list of countries in the Region that were qualified for the 4 111 funding round , noting that several had a 20% co-financing requirement. 2.5.2 Procurements
Mr Peter King, Supply Administrative Officer, made a very brief presentation on the procedures that the Western Pacific Regional Office uses in assisting countries in the procurements on behalf of Global Fund projects. It uses a "reimbursable system" in which (unlike its name might suggest) funds must be deposited with WHO, based on WHO estimates
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ofthe cost of the procurement, before orders are place. Mr King warned that the procedure does take time and that delays are not uncommon. 2.5.3 Monitoring and evaluation
Dr Michael Voniaris, STC, STOP TB, made a presentation on the Monitoring and Evaluation (M&E) Plan for the Principal Recipients of the GFATM. He reminded the group that the M&E plan should cover finances and programme separately, the latter of which comprises both routine monitoring and regular evaluation. A flow-chart was presented on bow these different monitoring and evaluations would be cycled. 2.5.4 Case studies
Case studies dealing with the implementation of first and second rounds of GFA TM-funded projects were presented from Mongolia, the Lao People's Democratic Republic and Cambodia. Key points that were made in these presentations include: (I) working with the GFATM is a process of"learning by doing" since many guidelines and procedures were not well defined yet; (2) the size of the GFA TM projects quickly makes them a "major donor" and can present the Ministry of Health with major new responsibilities to manage and monitor resources on a "big scale"; (3) a variety of agencies are needed to assist with procurements, depending on the type of items to be purchased; (4) procurements can be slow and complicated when sub-recipients have prepared budgets based on inaccurate estimates of costs; and (5) initial disbursements usually come a little late so projects should probably be modest in their first quarter targets.
Open forum In the general discussion it was stressed that the programme and financial evaluations of GFATM projects need to be coordinated and that the CCM should see both. There was a question about whether the assessment of GF A TM project proposals were shared with anyone other than the principal applicant. Mr Rousseau assured the group that only the applicant was advised of the results, including specifics as to why an application may have failed. There was an appeal by staff of the Western Pacific Regional Office for countries to let them know what their plans were for the fourth round so that staff could "gear up" to help. Dr Poumerol reminded the group that they should consider targeting fourth round projects on programme needs to accomplish goals of the 3 by 5 Initiative. 2.6 Partners session
At the invitation of the Chairman, brief presentations on their activities and plans were made by partners participating in the meeting including: Asian Development Bank (Ms Maryse Dugue), Asian Harm Redudion Network (Dr Bijan Nassirimanesh), Centres for Disease Control and Prevention Global AIDS Program (Mr Jack Spencer), Family Health International (Dr Jeanine Bardon), UN AIDS-South-East Asia and Pacific Intercountry Team (Mr Tony Lisle), Australian Agency for International Development (Dr Robyn Biti), ESTHER (Dr Helene Degui) and UNICEF (Mr Robert Bennoun).
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Open forum In general discussion, a number of countries remarked that the assistance of international partners was a crucial and very much appreciated contribution to HTV/ATDS/STI programmes. One international observer expressed the opinion that managing all the "donors" was a big problem for countries and that there was a need to provide for strong leadership in coordinating these donors. Representative from two other countries specifically invited more participation from partners in their countries. 2.7 Country priorities for action for HIV/ATDS/STI
National representatives at the meeting made brief presentations on the status of HIV IAID SISTI in their countries and on future programme priorities. Presentations were n~ade by Brunei Darussalam (Dr Hajah Rahmah Haji Mohd Said), Cambodia (Dr Mean Chhi Vun), China (Dr Zhao Pengfei at the request of and after consultation with Dr Wang Xiaochun), Japan (Dr Go Tanaka), the Republic ofKorea (Dr Hur Young Joo), the Lao People's Democratic Republic (Dr Chansy Phimphachanh), Mongolia (Dr Amindavaa Oyunbileg), Papua New Guinea (Dr Esorom Daoni), the Philippines _ (Dr Ernesto E.S. Villalon), Singapore (Ms Ho LaiPing) and VietNam (Mr Phan Cong Chien). In these presentations, most countries identified "gaps" or strategic priority needs in three areas: surveillance, prevention and care. The great majority of countries saw a need to improve national surveillance systems on HIV/AIDS (China, Cambodia, the Republic ofKorea, the Lao People's Democratic Republic, Mongolia, Papua New Guinea and VietNam), many emphasizing variously the need for reinforcing laboratory capacity to support serosurveys, expanding the number of sentinel sites and sample sizes, linking surveillance data better with programme planning and initiating more second generation surveillance systems and behavioural surveys. Improving STI prevention and treatment programmes (China, the Lao People's Democratic Republic, Mongolia, the Philippines) and expanding condom promotion (China, the Lao People's Democratic Republic, the Philippines, the Republic of Korea) were the most common areas of need recognized by countries in the area of prevention . All countries with recently initiated 100% CUPs were seeing a need to expand these programmes as soon as feasible. Other areas of need in national prevention efforts included more public awareness about HIV/AJDS prevention and improved programme efforts in harm . reduction, blood safety, MTCT and areas that focus on youth and vulnerable groups. The need to increase the availability and accessibility of ARV drugs is a universal problem for the Region's developing countries. These countries, too, saw this problem in their broad programmatic dimensions, mentioning specifically gaps in existing care policies, systems to provide for comprehensive family and community care and support for systems for people with AIDS (PWA), treatment for opportunistic infections, drug procurement and regulatory infrastructure and measures to combat stigma and discrimination.
Open forum Following the presentations, there was a discussion of general conclusions and recommendations that could be drawn from the meeting and the country priorities. This discussion led to consensus on a number of points presented below.
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3. CONCLUSIONS
The following conclusions were agreed upon : Epidemiology and surveillance illY/AIDS and STfs continue to impact heavily on the countries of the Asian and Pacific (1) Region. At the end of2003, for South-Asia, South-East Asia and East-Asia and the Pacific, it was recognized that about 6.6 million adults and children are living with HIV/AIDS, including between 760 000 and 1.3 million newly infected persons during the year. It has been further estimated that between 362 000 and 648 000 adults and children died in the regions during the year. It was recognized that most Asian and Pacific countries currently have low population (2) prevalence levels of illY I AIDS. However, it was also recognized that many countries are exposed to the threat of a more widespread epidemic because of the presence of a number of important risk factors (e.g. high prevalence of STis and risk behaviours such as men who have sex with men, engaging in unsafe injecting drug use practices or low level of consistent condom use) or other vulnerability indicators (e.g. population mobility, poor economic and educational status, or sex work). In view ofthis threat, it is recommended that dangers of this pandemic to the Region's countries not be under-estimated. (3) Ongoing and improved surveillance in the Asian and Pacific Region have made it increasingly clear that there is great diversity in the levels of HIVI AIDS incidence and prevalence, predominant modes of transmissions and impact of risk factors and behaviours between the different countries in the Region and even within the same coimtry. It is recommended that attention be paid by all to strengthening national surveillance programmes and linking findings with the planning and evaluation of interventions. Prevention (4) It was recognized that there have been important advances in HIV/AIDS prevention programmes since the last Programme Managers Meeting in 2001. IDU harm reduction plans and activities have moved ahead in China and Viet N.am. Situation assessments and recommendations for reducing the threat of HIVI AIDS to IDUs have also been completed in Malaysia and the Lao People's Democratic Republic. The 100% CUP is being implemented in China, the Lao People's Democratic Republic, Mongolia, the Philippines, and VietNam, in addition to the more mature programme in Cambodia. Linkages between HIV/AIDS and national transfusion safety programmes are well established in some countries although all HIVI AIDS programmes are encouraged to strengthen these ties where appropriate. Care and treatment (5) Participants at the Programme Managers Meeting welcomed initial information about the 3 by 5 Initiative, recently launched by WHO, as a first phase toward assuring equitable access to HIV /AIDS care to all in need. Establishing continuum of care involving clinical and public health services, PHA community and NGOs is a comerstone for success in the provision of ART. Appreciating that WHO will need to concentrate on four countries heavily affected by HIV/AIDS in the Region (Cambodia, China, Papua New Guinea and VietNam), it was strongly recommended that WHO be attentive to its commitment to provide technical
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cooperation to all countries in the area of care and treatment and to assure that all programme and technical documents are disseminated widely. (6) While welcoming the challenge, necessity and fundamental equity of the 3 by 5 Initiative, pmiicipants took special note ofthe WHO Regional Director's opening remarks that the demands on nationallllV I AIDS programmes had now been doubled. Attention to prevention activities will need to be maintained and strengthened with the understanding that prevention and care are both complementary and inseparable components in the response to HIVIATDS . Global Health-Sector Strategy for HIVIAIDS
(7) The importance of the Global Health-Sector Strategy for HIV/AIDS 2003 -2007 (GHSS), endorsed by the 2003 World Health Assembly, was highlighted during the meeting. It was recommended that all countries work to include the foundations of the strategy in future HIVIAIDS planning and programming and also to be prepared for future evaluations ofGHSS and related United Nations initiatives. Global Fund to Fight AIDS, Tuberculosis and Malaria (8) The great importance and contribution ofthe Global Fund to Fight AIDS, Tuberculosis and Malaria were acknowledged during the meeting. Through the first two years of operations it was recognized that over $65 million of grants have been approved by the fund for HJVIAIDS-related projects within the Region. There have been fruitful learning experiences by both the Fund and Principal Recipients in how best to operationalize the GF ATM-funded projects. It was recommended that countries continue to share these experiences in future meetings and that WHO expand assistance to countries in the development of future GF ATM proposals. Partners (9) Country representatives were very appreciative of the wide range of technical and financial support that partner agencies and networks provide to national and regional programmes. It was recommended that countries make sure that they have good donor policy and coordinating mechanisms in place so that they may benefit even more from the expanded partner participation in HIV IAIDS programmes. Country priorities for action
(1 0) In the presentations of country programmes, it was recognized that there were several problematic "gaps" that appeared common in many countries. These included : (a) (b) (c) (d) limited capacity at the local level to sustain and expand prevention programmes; inadequacy of services to youth and high STI prevalence levels; unavailability of care; and weaknesses in monitoring and evaluation programmes and surveillance systems.
(11) It was recommended that WHO and partners target their support to countries especially to address these gaps.
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Next meeting (12) It was recommended that at the next meeting of Programme Managers, an agenda item should be included to review progress or shortfalls that have been made with regard to the conclusions and recommendations ofthis meeting.
Tiine 08:00 08:30
WPR/ICP/HSI/3.5/001/HSI(4)/2003.la PROVISIONAL TIMETABLE MEETING OF HIV/AIDS/STI PROGRAMME MANAGERS 25-27 November 2003. Manila. Phili Tuesday, ·25 Novemher Wednesday, 26 November Time Thursday, 27 November T~e Registration Opening ceremony - RD speech -Objectives of the meeting - Introduction of participants - Selection of Chair - Photo Session 08:00 Global Fund session - Global overview and regional issues and experiences, lessons learned - Procurement through WHO - M&E, Plan for the Principal Recipient Case studies from implementing Rl/R2 countries -Cambodia -Lao Peoples Democratic Republic -Mongolia -VietNam -Open forum Coffee break
08:00
Open participation at the informal consultation on 3x5
09:15 09:30
Coffee break Epidemiology and surveillance session - Overview- Global epidemic and regional context - HIV/AIDS Epidemic in Asia and the Pacific and HIV surveillance in the Western Pacific Region -Open forum Prevention session -Targeting and scaling-up prevention programmes - Harm reduction among IDUs - 100% condom use programme - Blood safety -Open forum Lunch Care and treatment session - ITAC and "3x5" initiative - Regional update - Access to HIV drugs - HIVI AIDS and TB -Open forum Coffee break Global Health Sector Strategy on HIV/AIDS session - Overview of Global Health Sector Strategy - From document to action -Open forum WPRO cocktails
10:15 10:45
10:00 10:30
Coffee break
Partners session Presentation by participating agencies on their activities
Open participation at the informal consultation on 3x5
10:30
Vl
12:00 13:30
12:00 13:30
Lunch Country priorities for action for HIV/AIDS/STI prevention and care and support needs [1} - Country presentations
12:00 13:30
Lunch
Open participation at the informal consultation on 3x5
15:00 15:30
15:00 15:30
Coffee break Country priorities for action for HIV/AIDS/STI prevention and care and support needs [2] -Continued Conclusion and recommendations Closinu
15:00 15:30
Coffee break
Open participation at the informal consultation on 3x5
16:00
.......
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t':d
~
17:00
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ANNEX2
LIST OF PARTICIPANTS, CONSULTANT, OBSERVERS/REPRESENTATIVES AND SECRETARIAT Participants
Brunei Darussalam
Dr Hajah Rahmah Haji Mohd Said, Senior Medical Officer of Health and Head Disease Control Unit, Department of Health Services, Ministry of Health, Bandar Seri Begawan BB391 0 Tel: 673-2-382755; Fax: 673-2-382755; HIP: 673-871 6201 E-mail: rahmahms@brunet.bn or dghealth@brunet.bn Dr Mean Chhi Vun, Director, NCHADS, No 170, Preach Silvanouk Avenue. Phnom Penh, Tel: (855) 16 830241 Fax: (855) 23 216515. Email: mchhivun@online.com.kh Dr Go Tanaka, Deputy Director, Specific Disease Control Division, Health Service Bureau, Ministry of Health, Labour and Welfare, 1-2-2, Kasumigaseki, Chiyoda-ku, Tokyo 100-8916, Tel: 81 3 3595 2403, Fax: 81 3 3501 2532 Email: tanaka-gou@mhlw.go.jp Dr Chansy Phimphachanh, Director, National Committee for the Control of AIDS Bureau, Km 3 Thadeua Road, Vientiane, Tel: (856) 21 315500; Fax: (856) 21 315127 Email: ncca@laotel.com Dr Amindavaa Oyunbileg, Project Coordinator, GF A TM supported projects in IDV and Malaria, Ministry ofHealth Room 212 Olympic Street- 2, Ulaanbaatar- 48 Tel: 97611326155, Fax: 97611326155 Email: aids@railcom.mn Dr Esorom Daoni, Technical Advisor, HTVI AID SISTI Department ofHealth, P.O. Box 807, Waigani National Capital District, Waigani Tel: (675) 3013737, Fax: (675) 3254944 Email: edaoni@health.gov.pn Dr Hur Young Joo, Deputy Director, Disease Control Division Ministry ofHealth and Welfare, 1, Joongang Dong K wanchean Citv. Tel: (822) 503 7543. Fax: (822) 504 1100 Email: drhur@mohw.go.kr
Cambodia
Japan
Lao People's Democratic Republic
Mongolia
Papua New Guinea
Republic of Korea
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Annex 2
Philippines
Dr Ernesto E.S. Villalon, Program Manager of the National AIDS and STI Prevention and Control Program (NASPCP) Bldg 13, Department of Health, San Lazaro Compound Sta. Cruz, Manila. Tel: 743-8301 Joe. 2350. Fax: 711-6808 Email: eris usa@hotmail.com Ms Ho Lai Ping, Senior Medical Social Worker and Section Head, Department of Care & Counselling Ministry of Health, College of Medicine Building 16 College Road, Singapore 169854~ Tel: (65) 63577489. Fax: (65) 63577490 Email: lai peng ho@ttsh.com.sg Mr Phan Cong Chien, Drug Administration, Ministry of Health, 138A Giang Vo St., HaNoi. Tel: 84 4 823 0794 Fax: 84 4 823 4758. E-mail: chienpc@yahoo.com
Singapore
VietNam
2. CONSULT ANT Dr Robert Darrell Fischer. 3/39 Shanti Niketan, New Delhi 21. India. Tel: (91-11) 2412-1929 Email: robeitfischer@mantraonline.com
3. OBSERVERS/REPRESEN TATIVES Asian Harm Reduction Dr Bijan Nassirimanesh, AHRN Executive Board Committee, Asian Harm Reduction Network P.O. Box 235, Prasingha Post Office, Chiangmai, Thailand 50200. Fax: 66 53 894113 Email: bijan@ahrn.net Ms Maryse Dugue, Project Specialist (Health) Pacific Operations Division, Pacific Department Asian Development Bank. 6 ADB A venue Mandaluyong, Metro Manila. Tel: 632 632 5155 Fax: 632 636 244. Email: mdugue@adb.org Dr Robyn Biti, HIV/AIDS Policy Officer United Nations & Commonwealth Section Australian Agency for International Development (AusAID), GPO Box 887, Canberra ACT 2601 Australia. Tel: 61-2-6206 4257. Fax: 61-2-6206 4925
Asian Development Bank
Australian Agency for International Development
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Annex 2
Centers for Disease Control and Prevention Mr Jack Spencer, CDC-GAP Cambodia Global AIDS Program American Embassy, Box P, APO AP 96546 Phnom Penh. Cambodia. Tel: (855) 23 216 436 Mobile: (855) 12 902 644. Fax: (855) 23 911 923 Email: jns1@cdc.gov ESTHER Dr Helene Degui, Ministry of Social Affairs, Labour and Solidarity, Ministry of Health, Family and Disabled People, Delegation to European and International Affairs, 8 Avenue de Segur75350 Paris, France. Tel: (00 33) 140 56 73 85 Fax: (0033)615 149169 Dr Jeanine M. Bardon, Acting Regional Director Asia Regional Office, Family Health International Arwan Building, 8th Floor, 1339 Pracharat I Road Bangsue, Bangkok 10800, Thailand. Tel: 662 587 4750. Fax: 662 587 4758 Dr Chawalit Natpratan, Country Director PHI/IMPACT Cambodia, Family Health International Institute for HIV I AIDS, 11, St. 3 02 Sangkat Boen Keng Kang 1, Chamcarmorn Phnom Penh, Cambodia. Tel: (855) 23 211 914 Fax: (855) 23 211 913. Email: chawalit@fhi.org.kh or natpratac@tl1i.org.kh
Family Health International
South-East Asia and Pacific Intercountry Team (UNAIDS/SEAPICT)
Mr Tony Lisle, Team Leader, UNAIDS SEAPlCT 3rd Floor, United Nations Bldg, Rajadamnern Nok A venue, Bangkok 10200 Thailand. Tel: 662 288 2498. Fax: 662 288 1092 Email: lislet@un.org Ms Maria Elena Borromeo, UNAJDS Country Coordinator, Philippines, Room 212, NEDA sa Makati Building, 106 Amorsolo Street, Legaspi Village 1229 Makati City. Philippines. Tel: (63-2) 840-0732 Fax: (63-2) 892-0611 to 25 Extension 266 Email: ma.elena.borromeo@undp.or g
UN AIDS
4. SECRETARIAT
WHO/WPRO
Dr Bernard Fabre-Teste, Regional Adviser, Sexually Transmitted Infections, including HlV/AIDS World Health Organization, Regional Office for the Western Pacific, United Nations Avenue 1000 Manila, Philippines. Tel. No.: (632) 528 9714 Fax No.: (632) 521 1036. E-mail: fabretesteb@wpro.who.int
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Annex 2 Dr Masami Fujita, Medical Officer, Sexually Transmitted Infections, including HIV/AIDS World Health Organization, Regional Office for the Western Pacific, United Nations Avenue 1000 Manila, Philippines. Tel. No.: (632) 528 9719 Fax No.: (632) 521 1036. Email: fujitam@wpro.who.int Ms Gaik Gui Ong, Technical Officer, Sexually Transmitted Infections, including IllV I AIDS World Health Organization, Regional Office for the Western Pacific, United Nations Avenue 1000 Manila, Philippines. Tel. No.: (632) 528 9718 Fax No.: (632) 521 1036. E-mail: ongg@wpro.who .int Mr Reginald Gray Sattler, Short Term Professional Sexually Transmitted Infections, including HIV/AIDS World Health Organization, Regional Office for the Western Pacific, United Nations Avenue 1000 Manila, Philippines. Tel. No.: (632) 528 9731 Fax No.: (632) 521 1036 Email: sattlerg@wpro.who.int Dr Nguyen Thi Thanh Thuy, Medical Officer, Epidemiologist, Sexually Transmitted Infections, including HIV/AIDS, World Health Organization Regional Office for the Western Pacific United Nations A venue,_fhilippines. Tel.No.: (632)5289717. FaxNo.: (632)5211036 Email: thuyn@wpro.who.int
WHO/Cambodia
Dr Veronique Bortolotti, Short-term Professional, HSI World Health Organization, No 177-179 corner Pasteur (51) and 254, P.O. Box 1217, Sangkat Chaktomouk, Khan Daun Penh, Phnom Penh Cambodia. Tel: (855) 23 216610;23 216942 Fax: (855) 23 216211. Email: bortolottiv@cam. wpro. who. int Dr Oscar Barreneche, World Health Organization No 177-179 corner Pasteur (51) and 254 P.O. Box 1217, Sangkat Chaktomouk Khan Daun Penh, Phnom Penh, Cambodia Tel : (855) 23 216610; 23 216942 Fax: (855) 23 216211 Email: barrenecheo@cam. wpro . who . int
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Annex 2
WHO/China
Dr Zhao Pengfei, Project Coordinator, HSI World Health Organization, 401, Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District Beijing 1000600, China. Tel: (8610) 6532 7189 to 92 Fax: (8610) 6532 2359. Email: zhaopf@chn.w pro.who.int Dr Chen Hong, National Programme Assistant, HSI Project Coordinator, HST, World Health Organization 401, Dongwai Diplomatic Office Building 23, Dongzhimenwai Dajie Chaoyang District Beijing 1000600, China. Tel: (861 0) 6532 7189 to 92 Fax: (861 0) 6532 2359. Email: chenh@.chn.wpro.who.int
WHO/Mongolia
Dr Wiwat Rojanaphitayakorn, Short-term Professional WHO, Mongolia, Ministry of Health, Government Building-S Ulaanbaatar, Mongolia. Tel: (976) 11-32 7870 Fax: (976) 11-32 4683. E-mail: wiwatr@mog. wpro.who.int Dr Yves Renault, WHO Representative in Papua New Guinea World Health Organization, P.O. Box 5896, Boroko, NCO, Papua New Guinea Tel: (675) 325 7827. Fax: (675) 325 2035 Email: renaulty@png .wpro.who.int Dr Dominique Ricard, Medical Officer, HSI World Health Organization, 63 Tran Hung Dao Street Hoan Kiem District, HaNoi, VietNam Tel: (844) 943 3734; 943 3736. Fax: (844) 943 3740 Email: ricardd@vtn. wpro. who.int Dr Gilles Poumerol, Responsible Officer, Regions of SouthEast Asia and Western Pacific, Technical Support Team/Departm ent ofHIV/AIDS, World Health Organization CH 12111 Geneva 27, Switzerland Email: poumerolg@who. int Dr Kenji Tamura, Medical Officer, Department ofHIV/AIDS FCH/HIV/CRE , World Health Organization Headquarters Office in Geneva, Avenue Appia 20 1211 Geneva 27, Switzerland Tel: (41 22) 791-164. Fax: (41 22) 791 4834 E-mail: tamurak@who.int
WHO/Papua New Guinea
WHO/Viet Nam
WHO/Headqu arters