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Assessment of the implementation of the regional health sector strategy on HIV 2011-2015.

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Assessment of the Implementation of the Regional Health Sector Strategy on HIV 2011-2015

WHO Library Cataloguing-in-Publication data World Health Organization, Regional O ce for South-East Asia. Assessment of the implementation of the regional health sector strategy on HIV 2011-2015. 1. HIV 2. Health Services 3. Tuberculosis 4. Maternal-Child Health Services 5. Communicable diseases ISBN 978-92-9022-524-9 (NLM classi cation: WC 503)

Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from SEARO Library, World Health Organization, Regional O ce for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: searolibrary@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Photographs included are from the WHO photo library or courtesy of Asian Development Bank. Printed in India

FOREWORD

The WHO South-East Asia Regional Health Sector Strategy on HIV 2011–2015 was endorsed by the Member States of the Region with the aim of securing universal access to HIV prevention, diagnosis, treatment and care towards the achievement of Millennium Development Goal (MDG) 6 and other HIV-related goals. Impressive work has been done, more in some countries, and to a lesser extent in others. HIV prevention programmes have reached more key population groups. Condom use among sex workers is reaching high levels in some countries. More people living with HIV have been tested and linked to health services. Approximately 1.2 million people living with HIV (PLHIV) were receiving antiretroviral treatment in 2014, with a regional coverage of 36%. Countries with dual epidemics of HIV-TB have made substantial progress in implementing collaborative activities. However, major gaps remain: only half of the people living with HIV know their status. The coverage of HIV treatment for prevention of mother-to-child transmission (PMTCT) remains

low. Stigma and discrimination, though lower than before, continue to hamper access to services for populations that need them the most. Health systems capacity, while better than before, still needs to be augmented to realize the goal of ending AIDS by 2030. As we move from MDG to the era of Sustainable Development Goals, sustained and focused efforts will be needed to fast track the HIV prevention, care and treatment interventions towards an AIDS-free world and HIV-free generation. Reviews and evaluations are cornerstones of evidence-based planning and programming. The observations and recommendations of this review will help inform the next set of strategies and interventions for WHO support to Member States in realizing the common goals. It would help in designing contextual intervention packages that use the framework of universal health coverage and service delivery mechanisms that are integrated and responsive to the emerging health-care needs of all populations, especially those most in need.

Dr Poonam Khetrapal Singh Regional Director WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

CONTENTS 10 12 7 Acronyms Executive summary Introduction

13 14

Looking back, looking ahead The Regional Health Sector Strategy on HIV, 2011–2015

16 18

Methodology Major findings

19 19 20

Coherence of the global, regional and national strategies Health sector response to HIV and support from WHO Strategic direction 1: Optimizing HIV prevention, care and treatment outcome

20 26 27 28 36 38 42

1.1 HIV prevention among key population 1.2 Antiretrovirals for prevention PEP: post-exposure prophylaxis; PrEP: pre-exposure prophylaxis 1.3 Prevention of mother-to-child transmission of HIV and congenital syphilis 1.4 Blood and injection safety 1.5 Expand HIV testing and counselling 1.6 Optimize antiretroviral therapy

49 52

Strategic direction 2: Strengthening strategic information systems for HIV and research Strategic direction 3: Strengthening health systems for effective integration of health services

52 52

3.1 Integration of HIV services with TB, maternal and child health, harm reduction and viral hepatitis treatment services 3.2 Sustainable financing

54 56 60

Strategic direction 4: Fostering a supportive environment to ensure equitable access to HIV service Impact of the Regional Strategy Lessons learnt and the way forward

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

FIGURES

Figure 1. Vision, goals and guiding principles of the Figure 2. Regional Strategy key interventions populations AIDS response

14 15 21 35

TABLES Table 1. Table 2.

AIDS at a glance 2010-2015

National HIV strategies and their alignment with the WHO Regional Health Sector Strategy on HIV 2011-2015

13 19

Figure 3. Condom use (percentage) among key Figure 4. Percentage of infants born to HIV-positive birth

Table 3.

women receiving a HIV test within 2 months of

Table 4a. STI services for key populations in the Table 4b. WHO support to STI services for key Region

Condom programmes for key populations

20 22 22 24 24 26 27 29 34 35 36 37 38 42 43 43 45 46 49 51 54 59 59

Figure 5. Percentage of key populations who and know their results living with HIV

received an HIV test in the last 12 months

Table 5a. Harm reduction for people who inject drugs Table 5b. WHO support for harm reduction interventions

population

Figure 6. ART coverage (percentage) among people Figure 7. Domestic vs. international funding for the Figure 8. HIV prevalence in five countries with Figure 9. HIV prevalence among key populations Figure 10. HIV infections and AIDS related deaths concentrated epidemics AIDS response

44 53 57 58 59

Table 6. Table 7. Table 8. Table 9.

Antiretroviral prophylaxis for prevention HIV testing for pregnant women living with HIV services

WHO action: support for PrEp and PEP Antiretroviral therapy for pregnant women

Table 10. WHO support to countries for PPTCT Table 11a. Blood and injection safety policies Table 12. HIV testing and counseling

BOXES Box 1. Box 2.

Country action: Indonesia: For female sex workers, lokalisasi approach in condom promotion works

Table 11b. WHO support for blood and injection safety 23 Table 13. WHO support for testing and counseling Table 14. Antiretroviral therapy eligibility criteria 25 Table 15. Antiretroviral therapy centres antiretroviral therapy therapy Table 16. WHO support for improved access to Table 17. Adherence and retention for antiretroviral Table 18. Serological and behavioural surveys of key 32 Table 19. WHO support to countries to strengthen Table 20. Punitive laws strategic information systems populations

Country action: Piloting opioid substitution therapy with methadone in Dhaka, Bangladesh

Box 3.

Country action: Sri-Lanka: Success story of managing syphilis infection among pregnant women

Box 4.

Country action: Bhutan: Integrated HIV, primary health care package

syphilis and hepatitis B testing facilities in a Country action: Timor-Leste: breaking down barriers to HIV testing for key populations Country action: Myanmar: Antiretroviral therapy coverage expansion

Box 5. Box 6. Box 7. Box 8. Box 9.

40 47 48 50 55

Table 21. New HIV infections

Table 22. AIDS related deaths

Country action: Nepal: Targeting universal coverage for ARV treatment by 2015 the 90-90-90 targets ahead of time WHO action: service integration Country action: Thailand: On track to reach

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

ACRONYMS

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

EXECUTIVE SUMMARY

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

The World Health Organization (WHO) South-East Asia Region is home to a quarter of the world’s population and includes two of the world’s most populous countries: India and Indonesia. The 11 countries that comprise the Region have huge social, economic and physical differences, which account for the wide variations in the HIV epidemics across the Region. The epidemic and the health sector response varies widely among and within Member States. Over 99% of people living with HIV (PLHIV) are in five countries: India, Indonesia, Myanmar, Nepal and Thailand. In 2011, when the Regional Health Sector Strategy on HIV, 2011–2015 was launched, the overall adult HIV prevalence in the South-East Asia Region was low – just 0.3% – but this figure belies the huge number of people affected. There were an estimated 3.5 million people living with HIV, including 1.2 million women aged 15 years and above. Despite a declining trend, an estimated 200 000 people became newly infected with HIV while 170 000 died of AIDS-related causes by end of 2010. Certain population groups have long been disproportionately burdened with the disease, and faced stigma and discrimination serious enough to impede their access to HIV services. At the end of 2010, about 675 000 PLHIV were receiving antiretroviral therapy (ART) – just 20%1 of the estimated total PLHIV. Coverage of ART among people living with HIV varied from 5% in Indonesia to 50% in Thailand. The WHO Regional Health Sector Strategy on HIV, 2011–2015 was developed with the overarching aim of assisting Member States to achieve universal access to prevention, diagnosis, treatment and care, which would contribute to the achievement of Millennium Development Goal (MDG) 6 and other healthrelated goals. The Strategy described the future directions and focus of work for HIV programmes and WHO in the health sector response to the HIV epidemic. The Regional Health Sector Strategy’s targets were consistent with the WHO Global Health Sector Strategy for HIV 2011– 2015, but focused on the priorities of 10 countries of WHO’s South-East Asia Region, and built on what had been achieved prior to 2011. In turn, the key elements of the Regional Strategy were adopted at the national level and tailored to country conditions across the Region. Seven of the Region’s countries have national strategies that straddle the time frame of the 2011–2015 WHO Regional Strategy.

A combination of desk review and country-level questionnaires were used to evaluate the output, outcomes and impact of the WHO Regional Strategy. The data used for this report are subject to a range of limitations and constraints that prevent this evaluation from being comprehensive. However, it pulls together the best available evidence, with a focus on WHO’s contribution, for the purpose of offering better technical support to countries during the upcoming 2016–2021 Regional strategy and action plan. Five years on, most countries have adapted the WHO global and regional HIV strategies and guidelines on HIV prevention, care and treatment. Access to and coverage of HIV services have expanded substantially in many countries: 1.39 million people living with HIV, or 39% of the total number estimated, were receiving ART at the end of 2015. Overall, the epidemic in the Region has stabilized. The Regionwide prevalence remains at 0.3%. Despite a 44% reduction in new infections from 2001 to 2015, new HIV infections have plateaued between 2010 and 2015. Major gaps exist in HIV services, and health system weaknesses impede delivery of these services. Only about half of the people living with HIV know their status. The coverage of ART and antiretrovirals (ARVs) for prevention of mother-to-child transmission (PMTCT) is still far too low at the regional level. Stigma and discrimination are still widespread in society and in health-care settings, which hinder access to much-needed health services by the most affected and vulnerable populations. The capacity of the health system in many countries is yet to be strengthened adequately to deliver services. Only a substantial shift in efforts will make it possible to reach the fast-track goals and fulfil the targets of the Sustainable Development Goals. Recommendations for future action include: continuing political commitment and resources for HIV prevention, care and treatment; recognizing the inherent linkages between the AIDS response and efforts to achieve universal health coverage; harnessing the power of affected communities to reach key populations with HIV services with a targeted approach; being inclusive to ensure that all stakeholders are involved; and strengthening data collection and use at the granularity level for programmatic actions.

The denominators of ART coverage are the estimated number of PLHIV in all situations and in different years of this report. It should be noted, however, that the CD4 count thresholds are different in different years according to WHO recommendations.

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

INTRODUCTION

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Table. 1. HIV at a glance in the WHO South-East Asia Region, 2015 vs 2010

Looking back, looking ahead The World Health Organization (WHO) South-East Asia Region is home to a quarter of the world’s population and includes two of the world’s most populous countries: India and Indonesia. The 11 countries that comprise the Region could hardly be more geographically, demographically and politically diverse. The huge social, economic and physical differences have also led to wide variations in the HIV epidemics across the Region. In 2011, when the Regional Health Sector Strategy on HIV, 2011–2015 was launched, the overall adult HIV prevalence in the South-East Asia Region was low – just 0.3% – but this figure belies the huge number of people affected. There were an estimated 3.5 million people living with HIV (PLHIV), including 1.2 million women aged 15 years and above. Despite a declining trend, an estimated 200 000 people became newly infected with HIV, while 170 000 died of AIDS-related causes in 2010. Between 2011 and 2015, the epidemic and the health sector response varied widely among and within Member States. Over 99% of PLHIV were in five countries: India, Indonesia, Myanmar, Nepal and Thailand. These countries, with HIV epidemics concentrated among key populations (KPs), such as sex workers (SWs), men who have sex with men (MSM) and people who inject drugs (PWID), also had a high tuberculosis (TB) burden. In 2011, the HIV prevalence among adult populations was below 1% in all countries except Thailand. Indonesia, Myanmar and Thailand had significant HIV epidemics among PWID. In the remaining countries (Bangladesh, Bhutan, Maldives, Sri Lanka, Timor-Leste), the HIV epidemics were at a low level. The Democratic People’s Republic of Korea has not reported any cases so far. Certain population groups – female sex workers (FSWs), MSM, PWID and transgender people – have long been disproportionately burdened with the disease, and faced stigma and discrimination serious enough to impede their access to HIV services. At the end of 2010, about 674 000

PLHIV were receiving antiretroviral therapy (ART) – just 20% of the estimated total. Coverage of ART among PLHIV varied from 5% in Indonesia to 50% in Thailand. Despite the progress to that point, much remained to be done to sustain the HIV response beyond 2011 and rapidly scale up access to prevention, treatment and care. What was clear was the need to embed the HIV response in the broader global health and development agenda, recognize its role in achieving broader health outcomes, and utilize the inherent linkages between HIV and other aspects of health, such as TB, maternal child health, and sexual and reproductive health and rights. Thus, the Regional Health Sector Strategy on HIV, 2011–2015 was developed by the WHO Regional Office for South-East Asia to guide the health sector response to HIV in Member States to achieve universal access to prevention, treatment and care services. Five years on, the epidemic in the Region has stabilized. The Regionwide prevalence remains at 0.3%. The estimated number of PLHIV increased slightly to 3.5 million in 2015, including 1.3 million women aged 15 years and above. Five countries with concentrated HIV epidemics still account for 99% of the regional HIV burden, and heterogeneity between and within countries still exists. There were 180 000 new HIV infections and 130 000 AIDS-related deaths in the Region in 2015. Despite a 44% reduction in new infections from 2001 to 2015, new HIV infections have plateaued between 2010 and 2015. New HIV infections and AIDS-related deaths declined in India, Nepal, Myanmar and Thailand, but showed a rising trend in Indonesia. On the other hand, AIDS-related deaths increased 6% from 2001 to 2010, but decreased from 2010 to 2015, which may indicate an impact of increased ART coverage. While HIV prevalence declined among FSWs, prevalence among other KPs remains stubbornly high and rising. However, the scale up of ART was impressive during this period – 1.39 million PLHIV were receiving treatment at the end of 2015. Thailand and Myanmar showed significant expansion in access to ART for PLHIV. Regionwide antiretroviral (ARV) coverage increased to cover 39% of PLHIV (Table 1). 13

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Fig. 1. Vision, goals and guiding principles of the AIDS response

As the period covered by the Regional Strategy ends and a new regional plan of action for 2016–2021 is in development, it is time to assess Member States’ key achievements in the AIDS response, and identify the gaps and challenges they face; the extent to which WHO’s Regional HIV Strategy has been incorporated into national HIV responses, and the impact of WHO’s work on the countries’ HIV responses. The WHO Regional Office for South-East Asia conducted a review of implementation of the Regional HIV Strategy, with the following objectives: 1. Review, assess and evaluate the progress towards achieving the stated goals and targets of the Regional Strategy and the outcomes; 2. Assess how WHO has contributed to achieving the goals and targets, and contributed to Millennium Development Goal (MDG) 62 and other health-related MDGs3, particularly in the areas of advocacy, policy guidance and technical support to Member States; 3. Identify technical challenges, issues and gaps in implementing the Regional Strategy at country and regional levels; and 4. Make recommendations for the development and implementation of the next Regional HIV Strategy 2016–2021.

The Regional Health Sector Strategy on HIV, 2011–2015 The WHO Regional Health Sector Strategy on HIV, 2011– 2015 was developed with the overarching aim of assisting Member States to achieve universal access to prevention, diagnosis, treatment and care, which would contribute to the achievement of MDG 6 and other health-related goals. The Strategy described the future directions and focus of work for HIV programmes and WHO in the health sector response to the HIV epidemic. Its targets and strategic directions were consistent with the WHO Global Health Sector Strategy for HIV, 2011–2015, but focused on the priorities of the 11 countries of WHO’s South-East Asia Region and built on what had been achieved prior to 2011 (Fig. 1).

MDG 6: Combat HIV/AIDS, malaria and other diseases. Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS. Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it. Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. 3 MDGs 3, 4, 5 and 8. 2

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

The Regional Strategy has four main strategic directions and key interventions, with country actions and WHO contributions to address specific aspects of each intervention (Fig. 2). This assessment focuses primarily on key interventions as stipulated in strategic directions 1 and 2 due to the limited data available on interventions for the other two strategic directions. Fig. 2. Key interventions in the Regional Strategy

Optimizing HIV prevention, care and treatment outcomes;

STRATEGIC DIRECTION 1:

Strategic direction 1

1.1 Prevention to key populations - Condom promotion - Sexually transmitted infection (STI) services - Harm reduction 1.2 Antiretrovirals (ARVs) for prevention 1.3 Elimination of mother-to-child transmission of HIV and syphilis - HIV testing - ARVs for mother–child pair - Early infant diagnosis 1.4 Blood and injection safety 1.5 Expansion of HIV testing and counselling 1.6 Optimizing antiretroviral therapy - Access to treatment for all people living with HIV - Reduction in comorbidities - Adherence and retention in treatment - Treatment monitoring

Strengthening strategic information systems for HIV and research;

STRATEGIC DIRECTION 2:

Strategic direction 2 2.1 2.2 2.3 2.4

Surveillance among key populations Programme monitoring and evaluation HIV drug-resistance monitoring Implementation research

Strengthening health systems for effective integration of health services; and

STRATEGIC DIRECTION 3:

Strategic direction 3 3.1 Enhance service delivery - Community-based - Task-shifting 3.2 Integration of services 3.3 Sustainable financing

Fostering a supportive environment to ensure equitable access to HIV services.

STRATEGIC DIRECTION 4:

Strategic direction 4

4.1 Gender equality and health equity 4.2 Strengthen links between HIV programme and other health areas 4.3 Resource mobilization

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

METHODOLOGY

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Implementation of the WHO Regional Strategy was evaluated through a combination of desk review and country-level questionnaires sent to both national programme managers/ technical staff and to WHO country offices. Documents reviewed included technical documents, national HIV strategies/plans, and other relevant guidelines and policies on specific aspects of the HIV response, as well as national AIDS programme country progress reports through the Global AIDS Response Progress Reporting (GARPR)4. Each national programme manager or responsible officer completed a questionnaire detailing policies, developments and progress in HIV prevention; testing and counselling; treatment, care and support; strategic HIV information; and health systems and HIV. WHO country office staff also completed a questionnaire on the technical support, activities and deliverables provided by WHO country and regional offices, as well as headquarters. Country offices also provided examples of their successful HIV interventions. This report sought to assess the relevance, effectiveness, efficiency, impact and sustainability of the Regional Strategy. In assessing relevance, the exercise sought to elucidate whether or not the Regional Strategy and WHO support to countries was in line with the priorities of Member States, and consistent with the Global Strategy. In terms of effectiveness, the review looked at the extent to which the Strategy had been put into action at country level. The data for this section are derived from quantitative and qualitative surveys completed by national programme managers and WHO country offices on the HIV response. To assess efficiency, the review sought to ascertain the degree of progress towards achieving universal access

to prevention, care and treatment services. The information presented in this section is derived from regional and national data on the HIV epidemic and response, 2011–2015. A “traffic light” grading system was used to summarize progress made under each major area of the HIV response. The grading is subjective in nature, but aims to visually highlight achievements, challenges and varied responses across countries. • Green: denotes met/on track to meet targets; good programme coverage; and/or evidence of successful implementation of interventions. • Yellow: denotes progress is lagging; targets could still be achieved with intensified and accelerated action; and/or coverage and quality of programmes need to improve. • Red: denotes targets are unlikely to be met; and substantial overhaul of the response may be required. Crosshatched “traffic lights” indicate that there are significant variations in the response, including in quality and equitable coverage, and across countries/regions. The data used for this report are subject to a range of limitations and constraints that prevent the evaluation from being comprehensive. Some of the questionnaires were not complete, and some responses might be subjective and need to be validated or updated; the epidemic estimations as generated by Spectrum modelling might need to be interpreted with caution, especially for huge countries such as India and Indonesia. Community system and response have not been assessed systematically. Nevertheless, the report pulls together the best available evidence, with a focus on WHO’s contribution, for the purpose of offering better technical support to countries under the forthcoming 2016–2021 Regional strategy and action plan.

Unless otherwise noted, the data for this report are from GARPR 2011–2015, which are available at: http://www.aidsinfoonline.org/devinfo/libraries/ aspx/Home.aspx

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

MAJOR FINDINGS

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Table 2. National HIV strategies and their alignment with the WHO Regional Health Sector Strategy on HIV, 2011–2015

Coherence of the global, regional and national strategies

In turn, the key elements of the Regional Strategy have been adopted at the national level, tailored to country conditions across the Region. Seven Member States have national strategies that straddle the time frame of the 2011–2015

The Regional Health Sector Strategy on HIV, 2011–2015 for South-East Asia is consistent with the WHO Global Health with the same aims: to halt and reverse the spread of HIV as part of the broader MDGs; and for the health sector to Sector Strategy on HIV/AIDS, 2011–2015. It was developed

WHO Regional Strategy (Table 2). Nepal’s strategy adopts

components that are entirely in line with the Regional Strategy, but all the other six countries closely match it, with only one or two areas where they do not fully match. In 2013, the Minister of Health of Indonesia endorsed a new regulation in the HIV AIDS Control Programme, substituting the one endorsed in 2002. The new regulation became the turning point for implementation of the National AIDS Control Programme within the national health system. Further, in 2015, the updated National HIV AIDS Action Plan 2015–2019 was developed in line with the Global Strategy.

collaborate with other sectors in order to tackle the social, epidemic and access to health services.

economic, cultural and environmental issues that shape the

In line with the WHO Global Health Sector Strategy, the

Regional Strategy takes as its basis the fact that HIV is an agenda. Its four strategic directions match those of the Global Strategy.

integral part of the broader global health and development

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Strategic direction 1: Optimizing HIV prevention, care and treatment outcome 1.1 HIV prevention among key populations 1.1.1 Condom promotion for key populations The condom programme has been the cornerstone of HIV prevention interventions to KPs. Of the five countries with concentrated epidemics, four (India, Indonesia, Myanmar and condom use among MSM and FSW (Table 3). Table 3. Condom programmes for key populations in countries with concentrated epidemics among key populations

Thailand) have mature condom programmes for KPs, with high Reported condom use among KPs varies widely across the use is relatively high in India Indonesia, Myanmar, Nepal

Region (Fig. 3). Among MSM, for example, reported condom and Thailand, but below 50% in Bangladesh and Sri Lanka. Condom use among SWs is generally higher, with reported use above 90% in India5, Myanmar, Sri Lanka and Thailand.

However, condom promotion programmes targeting PWID have not had strong results: India reports the highest rates for the Region, at 77% condom use with paid sex partner at last sex.

National Integrated Biological and Behavioural Surveillance 2014–2015, National AIDS Control Organization (NACO), India. http://naco.gov.in/ upload/2016%20Data/SIMU/IBBS%20Report%202014-15.pdf (accessed on 15 May 2016).

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Fig. 3. Reported condom use (percentage) among key populations (latest available data, 2010–2014)

MSM: men who have sex with men; PWID: people who inject drugs | Source: Global AIDS Response Progress Reporting data, 2011–2015

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1.1.2 Screening and treatment for sexually transmitted infections

at hotspots, which also act as referral spots for HIV testing

and counselling, and STI treatment services. To improve the coverage of STI screening and treatment, WHO has helped low-epidemic countries update their guidelines, and provided technical and financial support. In India, WHO has supported efforts to strengthen the strategic information system for STI (Table 4b).

Screening and treatment services for sexually transmitted

infections (STIs) among KPs are widely available in four of

the five priority countries in the Region (Table 4a). Indonesia clinics and specifically FSWs via mobile clinics. Myanmar

conducts routine screening targeted at priority provinces, STI provides HIV services for FSWs, MSM and PWID, include

awareness-raising and HIV education through drop-in centres

Table 4a. STI services for key populations in the Region

Table 4b. WHO support to STI services for key population

ART: antiretroviral therapy; STI: sexually transmitted infection

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Box 1. Indonesia: For female sex workers, lokalisasi approach in condom promotion works Condom promotion interventions were conducted in five brothel-based sex work settings. They were aimed at empowering FSWs to increase their use of condoms and access to health services, and to promote a demand for condom use among high-risk men in sex work. In a review of five reportedly high-performing lokalisasi (localization) interventions, interviewees (FSWs, owners and managers of • • Community engagement through working groups leads to better results in all of these areas. A combination of good condom promotion programming, clinical services with regular check-ups, sustained outreach and involvement of SWs and other stakeholders is important for better results.

sex establishments, health workers and outreach teams) at four of the five study sites graded the degree of condom support or very good (see Table). The majority of respondents rated empowerment, enabling and coverage aspects as strong. and usage, and use of STI/HIV services and access as strong

Condom use during last sex with a client increased in the past decade in four of the five study sites and, as a consequence, the prevalence of HIV/STIs isdeclining.

Lessons learnt • Structural barriers to condom use still exist, e.g. tax incentives to conceal SWs in some areas and owners who still support clients who refuse to use condoms. • Control of sexual transmission of HIV and STIs is feasible in direct sex work settings in Indonesia.

Looking to the future • Assess and strengthen interventions in other lokalisasi as an immediate priority to slow sexual transmission. • Consider offering routine screening and treatment to pimps, regular partners (and regular clients if possible) who often do not use condoms and are a likely source of reinfection for SWs. • Strengthen the capacity to analyse and use routine data, including condom distribution and use trends; analysis of screening data on cervicitis, syphilis and pelvic inflammatory disease; analysis of data on attendance rates and outreach contacts. • Build capacity at the national and provincial levels to conduct trend analysis using survey data to validate findings from routine monitoring.

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1.1.3 Harm reduction – opioid substitution therapy and needle and syringe programme

allocated US$ 1 million for methadone maintenance therapy

(MMT). Indonesia has a harm reduction programme for PWID in of the OST programmes given the lack of data on people in need of OST. Needle and syringe programmes (NSPs) are has been limited in countries (Table 5b).

Of the 10 Member States, all but three have an opioid

place in priority areas only. It is difficult to evaluate the progress

substitution therapy (OST) programme in place for PWID (Table 5a). Thailand has 140 OST sites across the country, including some community-based sites. Myanmar has recently scaled up its service provision for PWID – in 2014, the government

ongoing in six of the 10 countries. WHO support in this area

Table 5a. Harm reduction interventions for people who inject drugs

In priority provinces HIV testing and one-stop services at some sites c Includes community-based sites a b

Table 5b. WHO support for harm reduction interventions

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Box 2. Piloting opioid substitution therapy with methadone in Dhaka, Bangladesh Bangladesh’s HIV epidemic is concentrated among KPs, mainly PWID, and available evidence points to risk behaviours among (UNODC), and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) are working jointly with the Government of Bangladesh to introduce OST for PWID. A pilot programme was launched in 2010 to reduce risk Services offered via MMT clinic included: • general medical services • counselling • psychiatric and support services • free HIV testing and treatment • this population. The United Nations Office on Drugs and Crime least four months. In some cases, earlier attempts to recover using conventional detoxification and rehabilitation services had failed. Other notable features of the pilot have been a

high retention rate (80%) and the requirement for relatively low an average dose of 49 mg in the maintenance phase. Looking to the future

doses of methadone for stabilization. Clients were stabilized on

behaviours, psychological distress and drug dependency.

It is expected that another MMT clinic will be started soon at a drop-in centre providing NSPs and other harm reduction services to PWID in Dhaka. This will be supported by the

Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), managed by Save the Children and implemented by CARE Bangladesh, with technical assistance from ICDDR,B

referral for TB screening and treatment.

and UNODC. Based on the success of the OST pilot project, OST programme in its health sector programme as well.

The pilot programme helped to successfully wean away 11 clients from drug dependence and remain drug-free for at

the Ministry of Health and Family Welfare has incorporated the

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1.2 Antiretrovirals for prevention Even though recommendations on post-exposure prophylaxis (PEP)6 have been available in all countries for years, there are limited data on its implementation (Table 6). PEP is implemented nationwide in India, Thailand and Myanmar,

while implementation is limited in Indonesia and Sri Lanka. In without ART services. As evidence emerged, WHO recently

India, due to supply chain issues, PEP is not available at sites recommended ARV pre-exposure prophylaxis (PrEP)7 as an

additional HIV prevention tool. Thailand is planning to scale up PrEP after it has piloted it in three sites. WHO has been supporting several countries in updating their guidelines on PEP and is supporting PrEP research in India and Thailand (Table 7).

Table 6. Antiretroviral prophylaxis: guidelines and implementations Pre-exposure prophylaxis Post-exposure prophylaxis

BANGLADESH BHUTAN INDIA INDONESIA MALDIVES MYANMAR NEPAL SRI LANKA

X X X Implementation science resesarch approved at two sites X Implementation science research planned X X X X

Recommended Recommended Recommended for health staff and victims of sexual assault ¥ Implemented nationwide Recommended for health staff Limited implementation Receommended for health staff and in case of sexual exposure to HIV Recommended for health staff and victims of sexual assault ¥ Implemented in health facilities Recommended Recommended for health-care workers and rape victims, and following condom rupture for serodiscordant couples Limited implementation in private sector Recommended ¥ Implemented nationwide Recommended for health-care workers and rape victims

THAILAND TIMOR-LESTE

Since the early 1990s, in many countries ARV medicines have been prescribed for PEP following occupational exposure to HIV. This practice has since been extended to non-occupational situations, primarily for cases of sexual assault (http://www.who.int/hiv/pub/guidelines/PEP/en/, accessed 17 May 2016). 7 PrEP is the use of an ARV medication to prevent the acquisition of HIV infection by uninfected persons. PrEP may either be taken orally, using an ARV drug available for treatment of HIV infection (tenofovir plus emtricitabine), or topically as a vaginal gel containing tenofovir. The efficacy of oral PrEP has been shown in four randomized control trials and is high when the drug is used as directed. The efficacy of the gel has been shown in one trial and is moderate (http://www.who.int/hiv/topics/prep/en/) 6

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Table 7. WHO support for implementation of PrEP and PEP

PEP: post-exposure prophylaxis; PrEP: pre-exposure prophylaxis

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1.3 Prevention of mother-to-child transmission of HIV and congenital syphilis Thailand leads the Region in prevention of mother-to-child transmission (PMTCT) of HIV. By 2015, the country had successfully reduced mother to child transmission of HIV to implementation of HIV and syphilis testing, Option B+ and hospitals. With such a strong and successful PMTCT

1.91%. The country’s PMTCT programme comprises universal early infant diagnosis (EID), implemented in all government programme already in place, Thailand has met all EMTCT criteria in accordance with the global criteria, and been validated elimination of mother to child transmission of HIV lagging behind.

and syphilis in June 2016. However, the other countries are

1.3.1 HIV testing and counselling for pregnant women Bhutan, India, Myanmar and Thailand all provide universal access to provider-initiated testing and counselling (PITC) Sri Lanka and Timor-Leste prioritize HIV testing in highstrategy, HIV testing in antenatal care (ANC) is low in all scaling up PMTCT services. for pregnant women, while Bangladesh, Indonesia, Nepal, prevalence areas (Table 8). Regardless of the HIV testing countries except Thailand, posing a unique challenge for

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Table 8. HIV testing for pregnant women

Source: UNAIDS Global AIDS Response Progress Reporting, 2011–2015 ANC: antenatal care; PITC: provider-initiated testing and counselling * Coverage is defined as the number of pregnant women receiving an HIV test as a percentage of estimated number of pregnant women.

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Box 3. Sri Lanka: Success in managing syphilis infection among pregnant women Almost 95% of pregnant women in Sri Lanka register for antenatal services before 12 weeks of pregnancy and 99.8% to mothers with syphilis are given prophylactic penicillin. If have institutional deliveries. During the past two decades, the markedly, and remained at 0.02% among pregnant women from 2010 to 2014. congenital syphilis cannot be excluded, babies are admitted to the paediatric ward for daily penicillin injections for 10 days. Smooth functioning of the programme depends on the

annual number of newly diagnosed cases of syphilis decreased

involvement of several stakeholders, and the links between maternal and child health and STI clinics are maintained through regular reviews and in-service training. Continuing an essential component of the programme.

The Ministry of Health has long identified management of syphilis among pregnant women as a significant public health issue, and testing has been offered since the 1950s. When a pregnant woman registers for ANC in the public health services, syphilis testing is offered as part of routine

advocacy among key players, including the authorities, is also

screening. When pregnant women test positive for syphilis, they are referred for repeat testing and treatment, and they and their partners are followed up until delivery. All babies born

There is still room for improvement, notably the quality of and reporting of stillbirth data related to syphilis.

testing, reporting and data management in the private sector,

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Box 4. Bhutan: Integrated HIV, syphilis and hepatitis B testing facilities in a primary health-care package Although Bhutan continues to report a low prevalence of HIV, there has been a consistently increasing trend of new HIV infections reported every year. The average annual number of reported cases over the past five years is 25 cases. This and counselling services in all the hospitals, and the freeincrease has been attributed to the scaling up of HIV testing standing voluntary counselling and testing (VCT) centres in four major towns. With a dedicated VCT focal person, the integrated with maternal and child health clinics, with the HIV testing and counselling facilities in hospitals have been primary aim of ensuring that every pregnant woman is offered a package service of testing for HIV, syphilis and hepatitis B. the Ministry of Health decided to integrate HIV testing and counselling into primary health-care services.

Standard operating procedures were developed, including guidance on procurement and supply chain management. Additional health workers were trained in all four regions and

20 districts on the use of rapid diagnostic tests for HIV, syphilis of the United Nations Development Assistance Framework and WHO support.

and hepatitis B. Supplies were made available with the support workplan, and training costs were met through the Global Fund

The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates for Bhutan put the cumulative number of cases at 500 in 2009 and 1100 cases by the end of 2013. However, as of late 2015, there were only 470 cases. Considering the

Three months later, the HIV testing and counselling services current practices in the primary health-care centres and

were initiated in basic health units. The next step is to review strengthen services based on the findings. Bhutan aspires services by the end of 2016.

estimated number and the total diagnosed as of date, there is

to achieve universal coverage of HIV testing and counselling

still a detection gap of almost 36%. With this in mind, in 2013,

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1.3.2 Antiretroviral therapy for pregnant women living with HIV Option B+ is a policy in all the countries. While some countries

at varying stages of implementation across the Region

(Table 9)8. Thailand leads the way with over 98% coverage

are implementing it nationwide, others have opted for a phased

followed by Myanmar at 88% in 2015, up from 33% in 2010. India and Nepal have lower coverage at 47% and 41%, respectively. Indonesia achieved only 11% ART coverage for PMTCT in 2015.

implementation starting with high-prevalence areas. Option B+ is

Table 9. Antiretroviral therapy for pregnant women living with HIV

Source: UNAIDS Global AIDS Response Progress Reporting, 2011–2015 * Coverage is defined as the number of HIV-positive pregnant women receiving antiretrovirals as a percentage of the estimated number of HIV-positive pregnant women 8

Option B+: lifelong ART for all HIV-positive pregnant women regardless of CD4 count

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Fig. 4. Percentage of infants born to HIV-positive women receiving an HIV test within 2 months of birth

Source: UNAIDS aidsinfoonline

1.3.3 Early infant diagnosis Countries in the Region face numerous challenges to scaling up

EID (see Annex. Only Thailand has made major strides in EID for making testing available in all government hospitals (Fig. 4). In there have been recent improvements in Bangladesh and Sri districts, but is grappling with limited availability of virology testing due to high costs and human resource constraints.

HIV, increasing coverage from 61% in 2011 to 91% in 2014, and most other countries, coverage remains extremely low, although Lanka. Indonesia is conducting pilot studies for EID in selected

Similarly, in India, procurement and availability of testing kits

for infant diagnosis is a challenge. Nepal is currently collecting out to Bangkok for diagnosis. There are plans to expand EID in Indonesia, where demonstration pilots are currently being districts.

blood samples from five service sites, which are currently sent

implemented, including pilot dried blood spot testing in selected

WHO has provided considerable support to all countries to strengthen their PMTCT services, especially for updating guidelines and implementing Option B+. WHO has also provided support for monitoring and evaluation (M&E), data system development and pilot projects (Table 10).

Table 10. WHO support to countries for PMTCT services * ANC: antenatal care; CS: congenital syphilis; MCH: maternal and child health; PMTCT: prevention of mother-to-child transmission

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1.4 Blood and injection safety All countries have developed blood and injection safety policies and practise these. Four countries report 100% compliance WHO has provided support to countries to strengthen their programmes (Table 11b). with the policy of screening all blood units for HIV (Table 11a).

Table 11a. Blood and injection safety policies

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Table 11b. WHO support for blood and injection safety

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1.5 Expand HIV testing and counselling HIV testing and counselling policies differ across countries – India, Maldives, Myanmar and Thailand offer HIV testing for HIV testing in high-prevalence areas and/or for high-risk all populations while the remaining countries have prioritized populations (Table 12). The use of rapid testing kits enables same-day results, and access to these tests kits has been Table 12. HIV testing policy and implementation in the Region

scaled up. Community-based counselling and testing is also promoted in many countries to increase accessibility. Most countries use a three-test algorithm. In Thailand, 80% of estimated PLHIV have been diagnosed, and the country is

on track to achieve the UNAIDS 90–90–90 target of 90% of diagnosed is 67% in India and 66% in Nepal.

PLHIV diagnosed by 20209. The estimated proportion of PLHIV

Source: WHO Regional Office for South-East Asia country fact sheets * Diagnosed is defined as the number of people living with HIV who have been diagnosed positive as a percentage of the estimated number of people living with HIV ANC: antenatal care; KP: key population; MCH: maternal and child health; OI: opportunistic infection; OST: opioid substitution therapy; NGO: nongovernmental organization; PITC: provider-initiated testing and counselling; STI: sexually transmitted infection; TB: tuberculosis; VCT: voluntary counselling and testing 9

UNAIDS 90–90–90 targets: 90% of the estimated PLHIV diagnosed, 90% of diagnosed PLHIV on ART and 90% of PLHIV on ART with viral suppression

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Fig. 5. Percentage of key populations who received an HIV test in the past 12 months and know their results

HIV testing for key populations varies widely across the Region, according to the latest available surveillance data from 2011 to 2014 (Fig. 5). Rates of HIV testing for SWs are highest in India and Myanmar at 71%, but stand at only 50% in Thailand, a country that in the past has been upheld as a strong example of brothel-based condom programming. Testing rates for this KP in both Sri Lanka and Bangladesh are lagging behind other countries in the Region. India has also achieved relatively high levels of HIV testing for PWID (68%), MSM (70%) and SWs (71%), but elsewhere the results are less impressive.

Source: UNAIDS aidsinfoonline (latest available data between 2011 and 2014) MSM: men who have sex with men; PWID: people who inject drugs WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA 39

Box 5. Timor-Leste: Breaking down barriers to HIV testing for key populations Timor-Leste is classified as a low-prevalence country for HIV. Current estimates suggest that there are approximately 542 However, for a small country with 1.17 million people, the people living with HIV, with an adult prevalence of 0.09% . 10

The National AIDS Programme worked together with the

nongovernmental organization (NGO) Fundasaun Timor Hari’i and representatives from KP groups on which hotspots to target and where HIV testing could be facilitated. The next step was to train counsellors and technicians from the community who could conduct HIV testing in a field setting, put systems in and data collection. An initial pilot in the capital Dili provided districts: Dili, Baucau, Covalima, Bobonaro and Oecusse.

situation can change rapidly if there is even a small gap in proportion of PLHIV is higher among KPs than among the

programming11. Typically, in low HIV-prevalence settings, the general population. If this is not reflected in the available data, it suggests that those at increased risk are not being reached care and support. with HIV testing services, which are the gateway to treatment,

place and implement a quality assurance system for HIV testing excellent results and the initiative was then scaled up to all five

This was the case in Timor-Leste, where uptake among FSWs control programme, with active support from WHO, piloted

and MSM was low. In response, the national HIV/AIDS and STI community-based HIV testing for KPs in five districts of TimorMSM because they were reached at their place of work or in hotspots. Overall, this led to a 300% increase in HIV testing, from 8416 tests in 2013 to 33 768 in 201412.

Leste from April 2014. This led to the testing of 3809 FSWs and

The following factors led to better uptake of testing services: • trained peer counsellors and testing technicians from the community • static and mobile testing facilities • flexible operating hours • linkages with drop-in centres • group counselling and testing • stable staffing.

National HIV/AIDS and STI Control Programme, Ministry of Health, Timor-Leste. Global AIDS Response Progress Report, 2015. Provisional total 2015. General Directorate of Timor-Leste, October 2015 (http://www.statistics.gov.tl/the-ceremony-launching-preliminary-results-of-censuspopulation-and-housing-2015/, accessed on 28 November 2015). 12 National HIV/AIDS and STI Control Programme, Ministry of Health, Timor-Leste. Global AIDS Response Progress Report, 2015, page 21. 10 11

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

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Countries across the Region have called upon WHO for from reviews of existing services, epidemic modelling, programme implementation in Myanmar (Table 13).

support in expanding HIV testing and counselling services, and training on M&E in Indonesia, to technical support for

pregnant women and serodiscordant couples. Myanmar and which recommends ART at the level of the 2010 WHO

Sri Lanka additionally recommend ART for all KPs. Indonesia, guidelines, offers ART irrespective of CD4 count for KPs and in geographical areas with a high prevalence. Provision of ART is being decentralized in some countries, including Indonesia and Myanmar (Table 15). With high levels of ART coverage in place, three of the country’s national health insurance schemes now offering harmonized and full access to ART. Thailand’s focus has been on ensuring equity of access, with all

1.6 Optimize antiretroviral therapy 1.6.1 Access to treatment for all people living with HIV Of the 10 countries, two (Thailand and Maldives) recommend with the latest 2015 WHO guidelines (Table 14). Seven

ART irrespective of CD4 count for all PLHIV, which is consistent countries recommend ART at the level of the 2013 WHO

The number of people on ART is increasing across the Region but ART coverage among all PLHIV remains woefully low in 64% coverage in 2015 (Fig. 6). most countries, with the exception of Thailand, which achieved

guidelines – CD4 count <500 cells/mm3 and irrespective

of CD4 count for PLHIV coinfected with TB or hepatitis B, Table 13. WHO support for testing and counselling

HTC: HIV testing and counselling; ICTC: integrated counselling and testing centre; PHC: primary health centre; ToT: train the trainers 42 ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Table 14. Eligibility criteria for antiretroviral therapy

Table 15. Number of antiretroviral therapy centres and sites

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Fig. 6. ART coverage (percentage) among people living with HIV

Source: UNAIDS aidsinfoonline

Treatment coverage continues to vary widely across the Region and reflects the degree of political commitment, financial resources and programme efficiency in the respective countries. Thailand and India are increasingly funding their AIDS response domestically, but donor funding – risky and unpredictable – dominates the financing landscape

for updating their national guidelines. WHO also supported implementation science research in some countries, implementation of the national guidelines. and provided funding, training and technical support for

for Myanmar, Nepal and Bangladesh. Thailand, Nepal and

Thailand does not recommend routine CD4 count for ART

Myanmar have significantly increased treatment coverage, but in Indonesia only 9% of estimated PLHIV are receiving ART. India, the world’s largest producer of generic ARVs, has been only 44% of all those in need (2015 data).

monitoring, while most of the countries recommend it every 6 months, in line with the WHO recommendation. Routine viral load (VL) monitoring is recommended in all countries except treatment failure. WHO supported India’s National AIDS India and Myanmar, where VL is done in cases of suspected Control Organization (NACO) in prioritizing PLHIV for VL testing (validating viral testing through the GeneXpert machine), and in developing a phased implementation plan for roll-out of VL of reagents for CD4 and VL testing.

able to get 925 000 PLHIV on treatment, but they account for

Expanding ART coverage is one of the main areas where

WHO played a significant role (Table 16). WHO disseminated its treatment guidelines and provided support to countries

testing. In Myanmar, WHO supported emergency procurement

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Table 16. WHO support for improved access to antiretroviral therapy

ART: antiretroviral therapy; ARV: antiretroviral; DFAT: Department of Foreign Affairs and Trade; KPs: key populations; PrEP: pre-exposure prophylaxis; PvP: pharmacovigilance programme; PWID: people who inject drugs; SUFA: strategic use of ARVs; TasP: treatment as prevention

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1.6.2 Adherence and retention Overcoming the challenge of treatment access is a significant achievement, but retaining people on treatment can be a struggle for countries. Several countries in the Region have taken steps to address this. India, for example, launched an intensified loss-to-follow-up tracing drive, together with community-based organizations across the country (Table 17). NGOs and community-based groups also play a key role

in retaining patients in Indonesia, Myanmar and Nepal. The 12-month retention rates are high in all countries (>70%).

WHO supported a wide range of initiatives in India to improve NACO for pharmacovigilance and data validation. WHO also

adherence to and retention on ART. WHO provided support to provided support for building the capacity of state officials in and strategies to plug the losses at each site.

preparing and analysing the retention cascade for their states,

Table 17. Adherence and retention support for antiretroviral therapy

Data indicate 12 months retention. ART: antiretroviral therapy; NACO: National AIDS Control Organization; NGO: nongovernmental organization; PLHIV: people living with HIV 46

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Box 6. Myanmar: Expanding coverage of antiretroviral therapy Since the start of the national ART programme in 2005, Myanmar has made impressive achievements in scaling up The country planned to attain universal ART coverage for all eligible patients by 2015 through rapid adaptation of the global guidance followed by strategic planning and programming as has begun orientation of partners according to the WHO and roll-out. a key feature of ART scale up. The National AIDS Programme Consolidated Guidelines of 2015 to prepare for early adaptation

ART across the country. In 2014, approximately 85 600 PLHIV (out of an estimated 190 000 PLHIV) were receiving ART, with 000 people were on ART. an ART coverage of 45%, as compared to 2009, when only 21

The HIV response has contributed to community and public building, decentralization of services, coordination between laboratory capacities along with equipment to carry out

health systems strengthening through human resource capacity civil society and the public health system, and strengthening investigations for monitoring patients. The response also programmes.

Further actions are needed in terms of diagnostics and

treatment simplification through decentralization of services and improved quality of care. This will strengthen linkages between testing and treatment and retention in care.

encompasses close collaboration between the HIV and TB

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Box 7. Nepal: Targeting universal coverage with ART by 2015 Nearly 39 000 people of all ages were estimated to be living with HIV in Nepal in 2014. Nepal’s ART programme was initiated at two centres in 2004. By 2014, there were 53 sites with the highest number of PLHIV. aspects of the planning and implementation of ART services. In addition, social care units were established at ART sites tracing loss to follow up, and conducting adherence counselling to those on treatment. with the engagement of PLHIV advocating positive prevention,

providing ART to 10 407 PLHIV, with a focus on those districts

Nepal’s scale up has been successful for several reasons: • political commitment, partners’ support, adaptation of WHO recommendations, use of fixed-dose combinations since 2009; • enhanced capacity of health staff for clinical management and counselling; • phasing out of ARVs with many side-effects; • increased supply of CD4 machines to clinics; • establishment of HIV testing and counselling sites targeting KPs; • uninterrupted supply of ARVs to sites; • implementation of TB/HIV collaborative activities; and • scaling up of ART to reach unreached populations based Another innovative approach that contributed to increased provision of ART was the involvement of KPs in various on the size estimation of KPs.

Expansion of ART services has not only contributed to HIV

control activities, but it has also empowered the national and through provision of equipment and additional cold room facilities.

district health systems in laboratory and logistics management

Looking into the future, Nepal is planning to adopt the

recommendations of the latest guideline on ART, that is, test and treat all who are diagnosed. Measures will be taken to implement community testing and scale up PMTCT to cover all pregnant women by 2015, which is nearly 700 000 women.

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Strategic direction 2: Strengthening strategic information systems for HIV and research Between 2010 and 2014, strategic information on the HIV epidemic and response in the Region has improved. HIV prevalence surveys were conducted among KP groups in eight countries. The five countries with concentrated epidemics have conducted periodic serological and behavioural surveys in recent years (Table 18), which provide important information on the epidemic, and offer an important basis for programme from the Global AIDS Response Progress (GARP) reporting have also improved but STI surveillance is lagging behind. monitoring and evaluation. STI estimation and programme data

Table 18. Serological and behavioural surveys of key populations

BBS: HIV biobehavioural surveillance; HSS: HIV sentinel surveillance; IBBS: integrated HIV biobehavioural surveillance

All countries in the Region measure and monitor the continuum of activities by WHO have focused on HIV cascade analysis programmes in countries. The Asia Pacific regional metrics services, jointly published by the WHO South-East Asia

Region and Western Pacific Region, provides useful guidance for measuring and tracking the HIV cascade of services in the Region. A regional workshop on strategic information on analysis, data use and coordination have been significantly strengthened through these capacity-building activities.

of HIV care and treatment services at the national level. A series and use of data to improve the HIV testing, care and treatment on monitoring the cascade of HIV testing, care and treatment

HIV, hepatitis and STI was organized in 2015. Data collection,

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Box 8. Thailand: On track to reach the 90–90–90 targets Thailand is making good progress towards achieving the 90–90– with HIV knew their HIV status; 76% of people with diagnosed 90 targets . In 2014, an estimated 80% of 440 000 people living 13

the way forward, including expanding HIV testing services, and immediate treatment to all people who are diagnosed with HIV. The analysis has also intensified prevention efforts, including (NHSO) and the National AIDS Programme have agreed to information that they collect14. provision of PrEP to KPs. The National Health Security Office systematic sharing, analysis and use of the HIV case-based

Cascade analysis has helped Thailand develop strategies for

HIV infection had been linked to services; among those people

receiving ART, 96% had achieved viral suppression. The analysis of the fast track targets in 2020.

indicates that Thailand will likely reach the 90–90–90 targets ahead

Source: National Health Security Office Thailand, 2015

13 90–90–90: by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained ART; and 90% of all people receiving ART will have viral suppression. 14 Thailand National Operational Plan Accelerating Ending AIDS, 2015–2019. Thailand National AIDS Committee

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

For example, Indonesia has developed guidance for monitoring the national Strategic Use of ARVs (SUFA) project based on the Metrics for monitoring the cascade of HIV testing, care

[SIHA] in Indonesia). India also collects regular programme data through an electronic database. In Myanmar, an individualbased HIV patient monitoring and case-based surveillance (such as DHIS2), which is planned in the context of overall Thailand, a web-based national routine clinical monitoring

and treatment services n Asia and the Pacific. This recognizes the importance of case-based surveillance to generate quality data for monitoring the cascade of HIV services. Cascade introduced at the district level. monitoring, already conducted at the national level, is being

system is being actively explored using an electronic platform health information systems strengthening in the country. In system is established, which is implemented in all government hospitals and some private hospitals under health insurance schemes. Also, Thailand has launched the “AIDS Zero Portal” that consolidates complex data from existing sources at one place and translates it into simplified, interactive, visualized real-time, easy-to-use information.

The Region is increasingly leveraging the use of information

technology to improve the current information management

systems. Health information systems in countries are moving

from paper-based to electronic systems for data collection and

reporting (e.g. HIV/AIDS and STI web-based application system

Table 19. WHO support to countries to strengthen strategic information systems

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Strategic direction 3: Strengthening health systems for effective integration of health services 3.1 Integration of HIV services with TB, maternal and child health, harm reduction and viral hepatitis treatment services Thailand leads the Region in terms of integration of HIV with other health services. PMTCT services have been in place as part of maternal and child health care since 2003; there clinics also conduct screening for hepatitis B and C. The

3.2 Sustainable financing The latest available data from eight countries show that domestic resources account for more than 50% of the AIDS Bhutan. The extent of domestic funding also varies widely

funding in only four countries: Thailand, India, Sri Lanka and across the Region, from 87% in Thailand (2011 data) to <4% in HIV response, but data show a significant decline in financing. Moreover, HIV is not included in the country’s universal health in their universal health coverage strategy. coverage strategy. Indonesia and Myanmar have included HIV

is routine HIV screening for TB patients and vice versa. HIV process of integration is under way in some other countries

Nepal (2007 data) (Fig. 7). In India, the government finances the

such as in Myanmar, where HIV and TB collaborative services and a one-stop service under the MMT programme are being In Indonesia, HIV screening is available for TB patients, with isoniazid preventive therapy available in some districts. scaled up with the aim of complete country coverage by 2016.

WHO action: service integration • In India, WHO conducted advocacy to review the country’s AIDS policy and establish a road map for integration of HIV into the mainstream health system after 2017. • In Indonesia, WHO supported resource mobilization for TB and HIV collaborative activities, and the initial implementation of isoniazid preventive therapy. • In Thailand, WHO provided financial support for the Thai National AIDS Foundation for community engagement.

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Fig. 7. Domestic versus international funding for the AIDS response

Source: aidsinfoonline.org, 2015 53

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Strategic direction 4: Fostering a supportive environment to ensure equitable access to HIV services Equitable access to HIV services is an issue of human rights While Bangladesh, India and Nepal have amended their laws to create a third gender option on official documents, lack of recognition for transgender people creates major obstacles to accessing health care, including HIV services. In India, reaching MSM, PWID, FSWs and prisoners (Table 19). and gender equity. Although none of the key countries in the

Region have laws that present obstacles for women and girls to to overcome gender inequalities that put girls and women at an

access HIV services, they do not have any institutional measures increased risk of HIV and restrict their access to services. In terms of the human rights of KPs, stigma and discrimination continue to undermine the HIV response across the Region.

Indonesia, Myanmar and Thailand, laws present obstacles to

Table 20. Existence of punitive laws in countries of the Region

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Box 9. India: WHO as a catalyst for updating national HIV strategies and guidelines WHO has played both a technical and advocacy role in multiple facets of India’s HIV response. WHO developed a tool to help the state health societies plan procurement of test kits and penicillin, and also supported the revision of the training manual for health-care workers to include the latest updates on elimination of parent-to-child transmission of HIV and syphilis. WHO has been instrumental

WHO supported the updating and implementation of India’s national ART guidelines, based on the WHO 2013 HIV treatment recommendations. It assisted with estimates of ARV drug requirements for the programme and with assessments of ART centres to better understand the gaps and challenges training of physicians on the new guidance. These changes

in developing the M&E framework for elimination of congenital health management information system.

syphilis and integrating key syphilis indicators into the broader

in ART provision across the country. WHO also supported the in the national ART guidelines led to earlier treatment with a treatment adherence.

As a result of WHO’s advocacy for implementation of the 2015 WHO consolidated testing services guidelines, a national consultation was organized by the National AIDS Council to of 90% testing coverage.

one-pill-a-day fixed-dose combination, which in turn improved

revise the national HIV testing guidelines to support the target

India’s efforts to eliminate parent-to-child transmission of HIV

and syphilis were also supported by WHO, with changes to the national policy so that it was in line with WHO’s recommended Option B+ – lifelong ART for pregnant women living with HIV. WHO also advocated for the nationwide scale up of the programme, as more than half of the pregnant women living with HIV are in low-prevalence areas.

WHO contributed indirectly to the massive scale up of the ART programme in India. With 850 000 patients on ART in 2015, world. HIV drug resistance has to be monitored nationwide and measures have to be taken to prevent the emergence India has become the second largest ART programme in the

of resistance. In this respect, WHO has been instrumental in building national capacity to collect and use early warning indicators for HIV drug resistance and other indicators surveillance of HIV drug resistance. for quality improvement, and in defining a road map for

In 2014–2015, WHO supported the estimation of syphilis

prevalence in pregnant women and related adverse outcomes strategy and operational guidelines for the elimination of

in India, which was used as a basis for developing the national congenital syphilis. The new guidelines were launched in

February 2015. HIV and syphilis testing are now included as part of the essential ANC service package, and there is an action plan for integrating these in 2015.

These national guideline updates and related service delivery AIDS-free generation” in India.

changes provide an unprecedented opportunity to “achieve an

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

IMPACT DURING IMPLEMENTATION OF THE REGIONAL STRATEGY

HIV prevalence trends HIV prevalence among the adult population (15 years and above) remained low and stable across the Region. India, and 0.2%, respectively, which have remained almost the Myanmar and Nepal have prevalence rates of 0.26%, 0.8% same since 2011. In Indonesia (0.5% prevalence in 2015), HIV prevalence shows a rising trend. HIV prevalence in Thailand is 1.6% and has declined from 2% in 2001 (Fig. 8).

attained the global standard of 200 needles per year distributed to every PWID, and Thailand is the only country able to show evidence of a decline in incidence among PWID, at 19% in 2014 versus 25% in 2012. Data from Myanmar show a

relatively stable but high-level epidemic, ranging from 18% to 23% between 2011 and 2014. Elsewhere, prevalence among Indonesia. PWID ranges from 6.3% in Nepal to 7.14% in India, to 36.4% in

For MSM, prevalence between 2011 and 2014 across the five in Myanmar. FSWs showed high levels of condom use during

Data on HIV prevalence among the three main KPs at increased risk of HIV (FSWs, PWID and MSM) are shown in Fig. 9. Existing data show that PWID have the highest prevalence in all five countries. Although there is an established, evidencefor PWID, condom usage and implementation of NSPs and OST continue to be low. Only India and Bangladesh have based comprehensive package of HIV prevention interventions

countries ranged from a low of 3.8% in Nepal to a high of 6.6% their last sexual encounter and consistent condom use in some countries, but they remained a KP regionwide. India recorded was in Thailand at 9.2%. the lowest prevalence among FSWs at 2.8%, while the highest

Fig.8. Trends in HIV prevalence in the five countries with concentrated epidemics

Data source: For India: NACO, MOH India, India HIV Etimations 2015. Other countries: UNAIDS/WHO, Global HIV Estimates, 2016.

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

Fig. 9. HIV prevalence among key populations, 2009–2014

New HIV infections The estimated number of new HIV infections plateaued over the period 2009–2015 in the Region. India, Nepal, Myanmar and Thailand demonstrated a 19-50% reduction in new HIV infections in 2015 compared to 2009. These countries also recorded a reduction in new HIV infections among children.

presentation of PLHIV for ART. For example, in Myanmar, the a result, treatment as prevention (TasP) has not been fully exploited. median CD4 cell count at baseline was 128 cells/mm315. As

AIDS-related deaths AIDS-related deaths have been declining over the years in the Region (Fig. 10), but vary widely among countries (Table 21). AIDS-related deaths peaked at 210 000 in 2005 and declined to

However, in Indonesia, there was an increase in new infections, particularly in paediatric HIV infections, during the same period (Fig. 10). This is indicative of gaps in the AIDS response, and the unsatisfactory coverage of HIV testing and treatment. In India, although there was a 66% reduction in new infections

130 000 in 2015 (28% decline since 2009). While India, Myanmar, Nepal and Thailand have all recorded reductions in AIDS-related in Indonesia, from 14 400 in 2009 to 35 300 in 2015. deaths since 2009, the number of deaths has more than doubled

from 2000 to 2015, there were 86 300 new infections in 2015, to 2015 NACO data (TABLE 20). One of the factors is the late 58

including 10 400 new HIV infections among children, according

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Fig.10. New HIV infections and AIDS related deaths in the Region.

Table 21. Estimated new HIV infections and paediatric infections in five countries

Note: Percentages in green show % decrease in new HIV infections from the 2009 baseline and percentages in red show % increase in new HIV infections from the 2009 baseline.

Table 22. AIDS-related deaths in the five high-burden countries

Note: Percentages in green show % decrease in new HIV infections from the 2009 baseline and percentages in red show % increase in new HIV infections from the 2009 baseline.

Oo AS, Myint MK, Soe KT, Thu A, Aung Y, Thant KZ. Clinical outcomes of patients on anti-retroviral therapy. Myanmar Health Science Research Journal. 2015;27(2):94–9.

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

LESSONS LEARNT AND THE WAY FORWARD

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Countries have made progress in implementing the Regional HIV Health Sector Strategy 2011–2015. Most countries have adapted the WHO global and regional HIV strategies and

five years. Although the AIDS response in the South-East Asia Region has not been optimal in some countries, it has also undeniably demonstrated that it is possible to successfully Regionwide, major gaps exist in HIV services. A “business as usual” approach will lead to more of the same. Only a fast-track goals and fulfil the targets of the Sustainable Development Goals (SDGs).

guidelines on HIV prevention, care and treatment. The access and coverage of HIV services have expanded substantially in many countries: 1.39 million PLHIV, or 39% of the total number estimated, were receiving ART at the end of 2015. Overall, the epidemic in the Region has stabilized. The Regionwide prevalence remains at 0.3%. New HIV infections and AIDS-related deaths have declined slightly or plateaued over the period.

implement the programme and achieve the desired results.

substantial shift in efforts will make it possible to reach the

Major gaps exist in HIV services: only about half of those who are infected with HIV have been diagnosed, and only 39% of PLHIV were on ART by the end of 2015; access to and

The fast-track targets set for 2020, based on the fast-track strategy, are ambitious when viewed against the current situation. There must be a steep decline in the number of new HIV infections and deaths to achieve the 2020 targets. This demands continued political commitment, leadership and governance for national HIV programmes.

coverage of HIV prevention services for KPs, particularly for of punitive laws for some behaviours poses barriers to and constraints in access to services by KPs.

PWID and MSM, continue to be low; the continuing existence

There is much to learn from the AIDS response over the past

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

1. The HIV response is inextricably linked to universal health coverage Universal health coverage (UHC) is an aspirational goal – all rehabilitative and palliative health services they need, and people can access and use the promotive, preventive, curative, which are of sufficient quality to be effective, without suffering HIV for 2016–2021positions the HIV responses in the context of UHC, they need to decide their own approach and define the package of benefits. The HIV response, in the long run,

2. Communities are at the centre of the HIV response Key populations comprise not just FSWs, PWID, MSM and TG. Other groups that are particularly at risk for HIV in this Region include prisoners, documented and undocumented migrant

financial hardship. The WHO Global health sector strategy on of UHC. As countries commit to achieving the ambitious goal

workers, and mobile populations. Children and adolescents are underserved by the current AIDS response. KPs at increased risk of HIV are by their nature hard to reach, and for those living with HIV, it is challenging to retain them throughout the to a sustained, successful HIV response, including legal environments, and cultural, social and political factors.

prevention and treatment cascade. There are multiple barriers

has to be part of the UHC package when governments design their UHC strategies and packages, which should include the continuum of HIV prevention, care and treatment services.

For interventions targeting KPs, actively involving the affected community in the design, implementation and monitoring of programmes substantially increases the likelihood that they

will succeed. As HIV becomes a chronic manageable disease, with those most in need of services. This approach can reduce

services can be decentralized to where the health system interacts costs, improve reach, and reduce HIV risk and vulnerability. HIV

interventions can also be expanded to incorporate broader health and social outcomes. This scale up must occur across the entire must address the stigma, discrimination and legal barriers that increase vulnerability to HIV. continuum of prevention, testing, care and treatment services, and

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

3. Expansion of HIV testing services is the key to achieving the fast-track goals To achieve the UNAIDS three 90s fast-track goals, HIV testing and infants born to HIV-infected mothers. The latest WHO treatment guidelines recommend immediate ART after a services must be radically expanded to KPs, pregnant women

4. Continuing political commitment and sustainable financing are crucial for long-term success Recognizing the importance of the HIV response for universal health coverage and achievement of the SDGs, governments must overcome HIV fatigue and maintain their political

diagnosis of HIV. However, only about half of the PLHIV know their HIV status, and HIV diagnosis proves to be one of the major bottlenecks for the HIV responses in many countries. recommends strategies to scale up HIV testing services,

commitment to HIV prevention and control. The current heavy reliance on external sources of funding for the AIDS response is not sustainable, due to a combination of shrinking aid budgets and growing economic prosperity, which is reducing

WHO has published guidelines on HIV testing services, and including HIV testing through trained lay providers. Countries populations through innovative approaches. To achieve the

the number of countries eligible for certain sources of funding,

need to explore ways of expanding HIV testing among different goal of elimination of mother-to-child transmission, HIV testing of pregnant women has to be expanded, and EID has to be be provided in a timely manner. provided so that HIV prophylaxis and treatment services could

such as from the Global Fund. Countries must examine ways to compensate for this, including an increase in domestic funding and exploring innovative funding mechanisms.

Meanwhile, continued efforts must be made to sustain resource allocation for HIV and consolidate existing gains. At a time when external funding for HIV is waning, more domestic funding is required.

It is also crucial to continue to lobby for affordable ARV drugs and related commodities, and to use improved procurement mechanisms and ensure greater availability of generics to maximize cost–effectiveness.

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA

5. The AIDS response must target locations and communities guided by the most granular and robust data Thirty years into the AIDS response, there is a substantial body of evidence to demonstrate which biomedical interventions characterized by concentrated HIV epidemics, it is vital to and critical enablers are the most effective. In a region largely target the AIDS response to the most affected communities

6. Everyone must be invited Both the public and private sectors of the health system have a role to play in ensuring the success of the AIDS response. This can help to address health system bottlenecks and build the capacity of health systems to scale up testing, uptake of and retention in treatment, procurement and supply system, to bridge the gulf between the public and private sectors, sharing.

laboratory system and human resources. This requires efforts particularly in the area of data and information collection and

and locations. This can be best achieved by working directly

with the affected communities, which should be guided by data gathered with sufficient granularity to allow for disaggregation by age, gender and geographical location.

HIV has never been merely a health issue. In many ways, it is fundamentally a human rights issue. Despite progress in breaking down the barriers to access for HIV services, stigma, discrimination and punitive laws all continue to undermine the Region’s AIDS response. As well as its key role as a technical stakeholders have powerful roles to play as advocates for a and normative agency, WHO together with other partners and rights-based, people-centred approach to the AIDS response. It is crucial to address structural barriers to service access through strong partnerships between the government and civil society, invest more in training and capacity building of support for community-based organizations.

Data collection continues to be very weak in many settings in the Region. This is a severe impediment to an effective AIDS response. By harnessing available information and

communication technology tools, health information systems

can be improved to ensure more accurate and comprehensive management, and continuity of care across multiple settings and locations.

epidemiological data, stronger health systems with more robust

community health workers, and provide financial and technical

The successful implementation of the Regional Action Plan for HIV will contribute to the attainment of the post-2015 health promotes a long-term, sustainable response, which will be responses. goal – SDG 3 in the Region. UHC provides a framework that bolstered by strengthening health systems and community

ASSESSMENT OF THE IMPLEMENTATION OF THE REGIONAL HEALTH SECTOR STRATEGY ON HIV, 2011–2015

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 1 novembre 2016

Source Organisation mondiale de la santé