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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


     

WHO Response to the Report of the 3rd Meeting of the Strategic and Technical Advisory Committee for HIV/AIDS (May 2006)

 

November 2006

________________________________________________________________

 

1. OVERARCHING RECOMMENDATION

·        Strategic plan for universal access 2006-2010

The STAC noted the need for a new strategic framework for WHO's HIV/AIDS work. A strategic plan for WHO's contribution to scaling up towards universal access to HIV/AIDS prevention, treatment and care in the period 2006-2010 has now been developed. 

The plan sets out the strategic directions and priority health sector interventions which will guide normative work and technical support across the whole organization, including 30 HQ departments and the 6 regional offices and country offices for the next four years.  The plan promotes a comprehensive health sector response to HIV/AIDS based on a model essential package of health interventions for HIV/AIDS prevention, treatment and care, while at the same time contributing to the broader strengthening of health systems.  The plan includes specific products and services for the period 2006-2007 and indicative activities and deliverables for the period 2008-2010.

The STAC has highlighted the importance of WHO's work in the areas of strategic information; health systems strengthening; HIV prevention in health care settings and expanding the availability and affordability of recommended antiretrovirals.  These four areas are the subject of specific strategic directions in the plan.  These areas are discussed in detail later in this document. 

·        Improving collaboration with other Departments at HQ

The HIV/AIDS plan for 2006-2010 is an organization-wide plan developed in consultation with approximately 30 departments at HQ and with all regional offices.  All the strategic directions in the plan involve cross-departmental collaboration.  The plan represents a sustained commitment in the HIV/AIDS Department to collaboration at HQ and joint planning and management at all levels of the organization.

The STAC's request for specific attention to improved coherence and collaboration between WHO's TB and HIV programmes is addressed in detail in Section 3.4.

·        Financial and human resource needs

The STAC noted its concern about the shortfall in available financial and human resources for WHO's HIV/AIDS work.

WHO has a biennial programme budget planning cycle. The planned budget for the core WHO HIV/AIDS area of work for 2006-2007 is US$273 million with an  estimated additional amount of US$98  million required to support HIV-related activities in other programme areas (including sexual and reproductive health, tuberculosis, nutrition, essential medicines, health technologies and human resources for health).

To fully implement the WHO universal access plan, it is estimated that the budget required for the three-year period 2008-2010 will be US$ 417  million for the core HIV/AIDS area of work and an additional US$ 138  million for other programme areas.   

The amount raised and pledged for the 2006-2007 biennium from 1 January 2006 to date is US$ 170 million.

The fundraising team of the HIV/AIDS Department has been moved to the Office of the Director, HIV/AIDS, which is overseeing efforts to diversity the funding base of WHO's HIV/AIDS programme.  Discussions are under way with, or proposals being prepared for, a number of donors, including the governments of Canada, Sweden and Norway, the Gates Foundation and US CDC. Meanwhile, the organization as a whole is in the process of centralizing its resource mobilization function.  Negotiations are continuing with the Global Fund on a joint policy on resource mobilization for the provision of technical assistance, and it is proposed that this will be discussed at a roundtable meeting of experts in January 2007 and at the Fund's board meeting in April 2007.

·        The "3 by 5" evaluation

The evaluation report is available on the WHO website in English and in French at http://www.who.int/hiv/topics/me/3by5%20Evaluation.pdf and has been disseminated to WHO regional and country offices. Copies were made available at the WHO booth at the International AIDS Conference in Toronto in August 2006.

Numerous actions have been undertaken pursuant to the evaluation's recommendations, and many of these are addressed elsewhere in this document.  A document that addresses in detail WHO's follow-up to each specific recommendations in the evaluation report has been prepared for donors, and can be made available to STAC members.

·        Target-setting

A joint WHO/UNAIDS  Working Group is developing a technical guidance document for countries on establishing universal access targets.   WHO will provide technical support to countries to establish targets in the  four priority areas of antiretroviral treatment, prevention of mother-to-child transmission,  counselling and testing and interventions for injecting drug users. 

·        The public health approach

The STAC has highlighted the importance of further conceptualizing the public health approach and helping countries to implement an essential package of interventions at primary care level.

Since the last STAC, WHO has published an article in the Lancet setting out the key elements of the public health approach[1].  For the International AIDS Conference in Toronto, WHO published an advocacy document which includes a summary of its HIV/AIDS plan for 2006-2010.  The document, which proposes a Model Essential Package for scaling up to achieve universal access, also describes the elements of the public health approach in further detail. (See http://www.who.int/hiv/toronto2006/UAreport2006_en.pdf)

WHO's IMAI products continue to support implementation of the public health approach and the Model Essential Package at primary health care level.  The package has expanded to include a simplified guideline module on TB Care with TB-HIV Co-management and short, harmonized training courses on PMTCT (currently in pre-testing), reproductive choices and family planning for PLHA, and updated provider-initiated testing and counselling training.  A second meeting of partners to support development of the second level learning programme has been held, focussing on a clinical manual and materials to support continuing medical education and updates for medical officers working at district hospital level in resource-limited settings.  Low literacy community health worker materials to support home-based intervention delivery and community treatment and prevention preparedness are in development.

Currently, 11 countries are using adapted IMAI tools to scale up HIV prevention, care and treatment through clinical and management  training; mentoring and other follow-up after training; and other interventions to strengthen district networks. Seven countries are presently undertaking their initial management training and training of trainers (clinical and counselling facilitators and PLHA expert patient-trainers).  Seventeen countries are completing adaptation of the tools, of which three have used the IDU-adaptation of the IMAI materials which provides the integrated primary care approach to IDU management which the STAC has called for.  The WHO patient monitoring system is now being used in a dozen countries and is beginning to yield ART outcome date including simplified cohort data in several countries.

·        Mechanisms for greater involvement of NGOs

To improve partnership development at country level with civil society, the Partnerships unit has been moved into the Operational and Technical Support unit in the HIV/AIDS Department, which provides the HQ link with partnership activities in country and regional offices.

·        Strengthening AFRO

Measures to address resource, structural and procedural constraints at AFRO are being implemented, under the guidance of a new regional adviser for HIV/AIDS and STIs. A retreat of all AFRO country and regional staff was to take place in November 2006, addressing among other issues the development of a regular performance monitoring schedule. AFRO has significantly improved its rate of obligating funds, with all funds for the 2006-07 biennium now obligated.

Sub-regional teams are being established in AFRO to ensure that technical assistance is readily available, close to countries and tailored to specific sub-regional needs.

2.      DETAILED RECOMMENDATIONS

2.1       HEALTH SYSTEM STRENGTHENING

Health Systems Strengthening strategy for the whole of WHO is currently being revised by the Evidence and Information for Policy cluster through a consultative process involving senior management and in consultation with disease-specific programmes.

Health systems strengthening is one of the five strategic directions of the WHO HIV/AIDS plan for 2006-2010.  A new Health Systems Strengthening (HSS) unit has been created in the HIV/AIDS Department to address this area of work, focusing on the areas of procurement and supply management; strategies for sustained financing; human resources for health and laboratory strengthening.  The team is currently developing a comprehensive plan of work and will work closely with counterparts in the Evidence and Information for Policy cluster (Department of Human Resources for Health) on the Treat, Train, Retain initiative; with the Health Systems Financing Department, on health financing, and with the Health Technology and Pharmaceuticals cluster (Department of Technical Cooperation for Essential Drugs and Traditional Medicine and the Department Procurement and Supply Management on issues related to HIV drugs and diagnostics).

More detail on the specific areas of work of the HIV/AIDS Department is provided below (See 3.5 for procurement and supply management).

·        Health financing

Recognizing the importance of sustainable health financing to achieve universal access, a health financing team has been created within the HSS unit. The team will be composed of two staff including a senior health economist, and will work in close collaboration with other key departments (Health Systems Financing in the EIP cluster) and partners, including UNAIDS and the World Bank.

The strategy of the HIV/AIDS Department in the field of health financing is currently being defined, taking into account the STAC recommendations. A consultative meeting will be organized in Q4/06 or Q1/07 to discuss and refine this strategy.  For the time being, two main areas of work are considered, in line with the STAC recommendations:

o       Guidance for countries on creating fiscal space to ensure sustainability and predictability of financing for components of the health system that require long term investment, with a focus on human resources for health (in collaboration with the World Bank).

o       Participation in Unitaid, including information provided by AMDS on cost of drugs and demand forecasting to inform Unitaid policies.

o       Technical support to countries for implementing a free access policy for HIV treatment at the point of service delivery (See 3.7)

·        Human resources for health

    

The STAC has acknowledged WHO’s focus on human resources for health and expressed its support for the "Treat, Train and Retain" (TTR) strategy.

TTR is a partnership with the International Labour Organization and the International Organization for Migration, under the aegis of the Global Health Workforce Alliance (GHWA), and was launched in August 2006. Task forces for the three components of TTR and for financing of human resources for health have been constituted. The three task forces have a WHO inter-cluster representation and include partner agencies and Institutions (ILO, IOM, WB, IMF, professional associations, academic Institutions, countries). Work plans have been developed  by each task force. The activities in the work plans have been partially funded by the Global Health Workforce Alliance ($300,000); the US Government ($1,000,000) and the Italian Government ($400,000). GTT has also committed funds to this work.

The  plan of action for TTR is based upon the following general approaches: mapping of existing evidence and experience; identification of the barriers and needs; development and dissemination of coherent policies and internationally agreed upon standards of practice;  establishing clear targets and indicators to monitor implementation. The plan is based upon a multi-sectoral approach to tackle the human resource crisis in the context of HIV/AIDS and includes strategies for the improvement of working conditions; salary increases; pre-service training; and task shifting.

The prioritization of ART for health workers (including community health workers and lay providers  who deliver HIV services) constitutes the main element of the "Treat" component of TTR. The Treat task force is also working on how to remove barriers to health workers accessing other HIV and TB services. Particular attention is being given to the issue of extremely drug-resistant TB (XDR-TB). The WHO Medical Service is part of the "Treat" task force to advocate for and help increase access to HIV/AIDS services for WHO staff.

3.2       PREVENTION

·        Strategy

The priority given to intensifying HIV prevention in the health sector is reflected in Strategic Direction 2 of the WHO HIV/AIDS plan 2006-2010 and in the creation of the new Prevention in the Health Sector (PHS) unit in the HIV/AIDS Department.

The STAC has emphasized the need for "a clear vision, a strategic roadmap and tools development" in this area. This is partly addressed by the WHO HIV/AIDS plan for 2006-2010. In addition, the HIV/AIDS Department is developing a strategy for the prevention of sexual transmission of HIV in the health sector and guidelines on prevention and care for people living with HIV/AIDS.

·        Targets

The STAC wishes to see WHO adopt a more proactive role in helping set numerical targets for HIV prevention. WHO's role in assisting countries to set prevention targets will initially focus on interventions for injection drug users and the prevention of mother-to-child transmission.

·        Comprehensive approach

The HIV/AIDS Department continues to support the use of evidence to guide interventions to prevent HIV and strongly endorses harm reduction for injection drug users, interventions for sex workers and the use of condoms. Additional evidence is needed before WHO can endorse male circumcision as an HIV prevention strategy.

·        Division of labour

The HIV/AIDS Department has continued to work closely with its UNAIDS partners to clarify the UN Division of Labour in the area of prevention. Specifically, the department continues to explore the best division of responsibilities with UNODC (IDUs) and is participating in the newly-established IDU Reference Group on HIV/AIDS Prevention and Care among IDUs in Developing and Transitional Countries (See Section 3.6).

WHO works closely with the Department of Reproductive Health and Research (RHR) and the Department of Child and Adolescent Health (CAH) in the area of HIV prevention.  RHR has a formal Memorandum of Understanding with UNFPA on providing technical support to countries (called The Strategic Partnership Programme), and UNFPA is one of the co-sponsors of HRP, the Special Programme of Research, Development and Research Training in Human Reproduction (also embodied in a formal, signed Memorandum of Understanding).

WHO is also working as one of the members of the expanded Inter Agency Task Team (IATT) on PMTCT (includes UNICEF, UNAIDS, UNFPA, the World Bank, CDC, USAID, Clinton Foundation, EGPAF, FHI, Columbia University and GFATM) to expedite the scale-up of national PMTCT programmes. On World AIDS Day 2006 the IATT will launch a global strategy calling for the elimination of HIV in infants and an HIV- and AIDS-free generation. Further to this strategy, the IATT will undertake a series of regional and sub-regional workshops to help countries set realistic targets and plan for scale-up of comprehensive PMTCT programmes.  The first of these was to occur in Africa in November 2006.

3.3       TESTING AND COUNSELING

 Since the 2006 STAC meeting, the HIV/AIDS Department has been developing draft Guidelines for Provider-Initiated HIV Testing and Counselling.  WHO and UNAIDS held a meeting with representatives from governments, NGOs, and other UN agencies in July 2006 to review and comment on the draft guidelines. The guidelines are currently being revised and will be posted on the WHO website for additional public comment in the last quarter of 2006. It is anticipated that the final guidelines will be published in the first quarter of 2007.

Many of the recommendations made by the STAC will be addressed in the new guidelines, including the importance of integrating PITC into existing health services, such as antenatal and sexual and reproductive health services; the need to prevent stigma and discrimination and to protect human rights, and the basic package of services that needs to be available where PITC is implemented.  The new guidelines will reflect the special needs of most-at-risk populations.

A parallel process has been initiated for the drafting and review of guidelines that are specific to provider-initiated HIV testing and counselling for children.  These will include guidance on special counseling and communication needs for children.

The STAC's opposition to mandatory testing is already reflected in the 2004 UNAIDS/WHO Policy Statement on HIV Testing, a position that will be maintained in any new guidelines.

Initial discussions have taken place with the CDC Global AIDS Program about the couples' counselling training that it is developing.  WHO's current intention is either to either endorse the CDC approaches or to develop guidelines based upon them.

3.4       HIV AND TUBERCULOSIS

·        Joint activities

The Stop TB and HIV/AIDS Departments are now meeting regularly on joint planning, resource mobilization and on technical policies, including the response to XDR-TB in high HIV prevalence settings. The TB work of the HIV/AIDS Department will be greatly facilitated by the imminent secondment of an HIV/TB technical officer from CDC.

In addition, a former Stop TB Department medical officer has been seconded to the UNAIDS Secretariat to further expand that agency's promotion of TB/HIV scale-up and country-level engagement, and is collaborating closely with WHO TB and HIV/AIDS Departments and other partners.

Discussions have taken place regarding potential joint HIV-STAC and TB-STAG meetings, though scheduling will not permit this in 2007.  The possibility of inviting TB-STAG and HIV-STAC members to observe each others' meetings is also being explored.

At the international AIDS conference in Toronto, a Stop TB TB/HIV Working Group meeting focused on scale-up acceleration in Africa of joint TB/HIV interventions. A TB/HIV satellite symposium was also co-sponsored by WHO, and a WHO-led paper on TB/HIV collaboration was published in Lancet Infectious Diseases just before the conference.[2]

Within the HIV/AIDS Department, all relevant treatment guidelines have had TB sections updated.  New challenges include toxicity and drug-drug interactions with second-line (bPIs) and possibly with second-line TB drugs for XDR-TB.   The HIV/AIDS Department has contributed actively to algorithms for smear negative pulmonary and extra-pulmonary TB, and these are in final stages of work.  The Stop TB Department has borrowed the HIV/AIDS Department guideline approach fully, as advised by their STAG.

·        Extremely drug resistant TB (XDR-TB)

The XDR-TB emergency visibly highlights the need for stronger collaboration between the TB and HIV/AIDS Departments. The new TB post in the HIV/AIDS Department is expected to facilitate this collaboration.

The Global Task Force on XDR-TB, which met for the first time in October 2006, was organized in just three weeks with more than 100 participants from all regions of the world attending. The meeting was hosted by the Stop TB Department with assistance from the HIV/AIDS Department and support from the Stop TB Partnership. At the meeting, WHO was requested to continue coordinating the global effort on XDR-TB through the Task Force, and to continue its work with countries on emergency response plans, a call that was endorsed by senior WHO management.

To prevent XDR-TB, the Task Force underlined the need for TB control to be strengthened in countries as outlined in WHO's new Stop TB Strategy.
The Task Force also made specific recommendations on drug-resistant TB surveillance methods and laboratory capacity measures; implementing infection control measures to protect patients, health care workers and visitors (particularly those who have HIV); access to second-line anti-TB and antiretroviral drugs for countries; communication and information-sharing strategies related to XDR-TB prevention, control, and treatment including co-management with antiretroviral therapy; and research and development of new TB drugs, vaccines and diagnostictests.

South Africa was among the first countries to request assistance to strengthen its national emergency XDR-TB response and the additional challenges posed to it  by HIV.   WHO's initial emphasis at country level will be in supporting seven of the 14 SADC countries.

3.5       AMDS AND ANTIRETROVIRAL THERAPY

To ensure that its work links with other health systems activities, the AIDS Medicines and Diagnostics Service has been relocated to the new Health Systems Strengthening unit in the HIV/AIDS Department.

·        Division of labour

It is noted that the AMDS is a network of partners dealing mainly with procurement and supply management and strategic information on the cost and price of drugs.  The work of AMDS therefore does not cover all WHO activities related to HIV drugs and diagnostics. In particular, prequalification is hosted by the Medicines POlicies and Standards (PSM) Department in the Health Technology and Pharmaceuticals cluster. Issues related to intellectual property, TRIPS and patents are mainly dealt within the Department of Technical Cooperation for Essential Drugs and Traditional Medicine (TCM). AMDS collaborates extensively with these departments in their work.

·        Prequalification

The STAC's concerns about resource constraints that have hindered the progress of the prequalification (PQ) programme have been largely resolved with a large grant from the Gates Foundation and the inclusion of PQ in UNITAID funding. UNITAID funding will enable a more active engagement with manufacturers of key products (including paediatric ARVs and second-line ARVs) for which an insufficient number of appropriate formulations have been prequalified. UNITAID funding will also enable more extensive post-marketing sampling and testing, as well as initiation of prequalification for APIs. 

·        Pricing and access

The AMDS is working to improve access to first- and second-line and pediatric ARVs through improved strategic information products, including the development of a global observatory for HIV commodities to assist ARV procurement and supply in countries, and the production of yearly global ARV forecasts to stimulate production.  Senior WHO staff participated in discussions with pharmaceutical companies on drug pricing convened by the UN Secretary General in May 2006.

·        Regulatory affairs and intellectual property

The STAC has proposed that WHO provide greater technical assistance for countries and regions to ensure the swift approval (licensing) of essential medicines and diagnostics in countries. TCM is working closely with countries and regional cooperative structures to support their registration processes.

In the area of TRIPS and patents, AMDS is collaborating with the WHO patent landscape project (located in HTP/TCM) in order to increase transparency on patent status of antiretroviral drugs in developing countries.

·        Strengthening PSM systems

With regard to quality assurance of ARVs, there are positive signals concerning allocation of funds for this at country level. While countries too often see expenditure on the PSM system as a cost rather then an investment, UNITAID support for PQ and the mandate of PEPFAR's PfSCM to support countries develop their PSM systems are positive developments.

Some countries, such as Mali, Tanzania, Burkina Faso and Rwanda have made considerable progress towards such improved national coordination of PSM. However, more such efforts are needed, and WHO is willing to facilitate such activities with its partners. This issue has been raised during various meetings of the working group on PSM led by UNICEF on behalf of the Global Joint Problem Solving and Implementation Support Team (GIST).  AMDS continues to require additional financial and human resources to be in a position to pro-actively support countries and programmes to strengthen the procurement and supply management systems.

The STAC recommended that response plans for dealing with stock-outs be regionally integrated. PAHO has led the way in this area by implementing the "Strategic Fund".  Joint negotiations and/or bulk procurement options were also discussed during the 2006 Regional Committee meeting in EMRO.

Treatment for health workers is addressed in Section 2.1

 3.6       HIV PREVENTION AND CARE FOR INJECTING DRUG USERS

·        Key partnerships

Under the current UNAIDS Division of Labour, UNODC is the lead agency on HIV prevention for IDUs. As suggested by the STAC, a representative of UNODC will be invited to the next STAC meeting if IDU is an agenda item.

WHO continues to organize consultation meetings with key experts and partners, usually alongside events such as the International Conference on the Reduction of Drug Related Harm. The meeting in Belfast in 2004 played an important role in guiding WHO's harm reduction programme of work and a similar event is planned for the next conference in Warsaw in May 2007.

In addition, key experts are regularly consulted and invited on an ad hoc basis for specific issues. WHO technical tools and guidelines, including the Evidence for Action series and Policy Briefs are prepared by technical experts and are sent to a wide audience for comments and feedback.

With funding from the Drosos Foundation, WHO is supporting the establishment of the Middle East and North Africa Harm Reduction Network and three Harm Reduction Knowledge Hubs (In Iran, Lebanon and Morocco) which should be operational by early 2007.

·        Task Force

On the STAC's recommendation to establish an IDU Task Force, WHO understands that the STAC is concerned about lack of access to care for IDUs and barriers to implementing harm reduction programs in countries, and wants to know how WHO, together with other partners, may contribute to changing this.

It is anticipated that a new inter-agency initiative will substantially address these concerns.  Working closely with WHO and UNAIDS, UNODC is currently in the process of establishing of a new IDU Reference Group on HIV/AIDS Prevention and Care among IDUs in Developing and Transitional Countries. The Reference Group will be supported by a new Secretariat, to be operational by 1 January 2007.    The overall objective of the Reference Group is to advise relevant UNAIDS co-sponsors as well as other members of the existing Interagency Task Team on Injecting Drug Use on effective approaches to HIV/AIDS prevention and care among injecting drug users. The Reference Group should, among other things, minimize overlap or conflicting approaches within the UN system.

·        Human resources

WHO has recruited a dedicated staff member to work on harm reduction and IDU within the HIV/AIDS department at HQ. The focal point coordinates harm reduction and IDU related programmes and activities within the organization (other departments in HQ, the Regional Offices and a number of high burden country offices),  with our partners (in particular UNAIDS and UNODC) and key stakeholders.

·        Methadone and buprenorphine

In September 2006, WHO organized a two day meeting on the implementation of a program to improve Access to Controlled Medications. Among the program's objectives is that access to controlled medications such as methadone and buprenorphine should improve at country level, including through adaptation of national essential drugs lists. Information about pricing, registration, formulations and producers should also become more widely available for public use.

The programme will be operated by WHO. Daily operations will be led by the WHO Department of Medicines Policy and Standards, Quality and Safety: Medicines unit (PSM/QSM). The Steering group will include the HIV/AIDS Department as well as the Cancer Control Programme (CPH/CPM) and the of Mental Health and Substance Abuse unit (MSD/MSB)

·        Strategy for scaling up services for IDU

Harm reduction is a priority intervention in the WHO plan for universal access 2006-1010. Proposed activities include continuing to develop and update the Evidence for Action series for harm reduction interventions (one for prison settings will be ready for publication in the next few months) as well as a tool kit for establishing, managing and scaling up needle and syringe programmes.

With regard to HIV treatment and care, WHO has revised the IMAI manual for both first and second level health care providers which include specific chapters on the management of IDUs in both 'Acute care including IDU management 'and 'Chronic HIV care with ARV therapy and prevention including IDU/HIV co-management'. Furthermore, WHO has developed a number of protocols for ART which include specific chapters on the management of IDUs and HIV care and issues of comorbidity (hepatitis and TB). In addition, EURO, SEARO and WPRO are developing specific ART guidelines for IDUs. SEARO has also developed guidelines for primary care for IDUs for the region.

WHO is also working currently on developing guidance for countries to set targets and to monitor and evaluate progress regarding harm reduction interventions and access to care and treatment for IDU.

3.7       EQUITY

Free HIV/AIDS care at the point of service delivery is now included in the public health approach promoted and published by WHO.

The next proposed step is to develop guidelines for countries to design and implement free care policies at the point of service delivery. The development of these guidelines will be based on a situational analysis and a documentation of best practices. Technical support is currently being provided to 5 countries in Africa to cost free care policies and explore financing options; this will also inform the development of guidelines.

Additional equity and access activities in HIV/AIDS are underway in the EIP cluster (Health Equity unit) and the FCH cluster (Gender and Women's Health) and will be reported on at a later time.

    

3.8       STRATEGIC INFORMATION

·        Estimates methodologies

WHO is aware that the changing of estimated numbers of cases of HIV can be confusing, particularly when the estimates are revised downward at the same time as WHO and UNAIDS continue to emphasize the severity of the HIV epidemic.  However, the assumptions, methodologies and data used to produce estimates are improving and evolving over time, and at any one time are the product of the best information and modelling that can be applied across countries in a consistent way.

WHO released a background document explaining WHO/UNAIDS epidemiological data collection methodologies on its website. The document entitled "Understanding the latest estimates of the 2006 report on the global AIDS epidemics" has been distributed to the mass media and the general public as part of a press kit accompanying the 2006 Report on the Global AIDS Epidemic by UNAIDS launched at the UN High Level meeting on AIDS, 30 May 2006. (See http://www.who.int/hiv/mediacentre/news60/en/index.html)

WHO also reported on the progress of the antiretroviral treatment scale up on low- and middle-income countries at the XVI International AIDS Conference in Toronto, Canada in August 2006. The estimated number of 1.65 million people receiving ART was announced in the WHO Advocacy Report "Towards universal access by 2010" (See http://www.who.int/hiv/toronto2006/WHOUAreport2.pdf). A simple fact sheet on the global ART estimates was also released and distributed through press events, meetings, as well as the website (See http://www.who.int/mediacentre/news/releases/2006/pr38/en/index.html).

WHO and UNAIDS continue improving the methodology, and the HIV/STI Estimates Reference Group met again in late 2006 to review and adjust the current estimates process.

·        Collaboration to strengthen the evidence base for the public health approach

To guide research efforts on the public health approach, in early 2007 the HIV/AIDS Department will host in a two-day conference on research needs for scaling up HIV care and prevention.  International research organizations and funders will participate.

In response to countries' needs for standardized tools that facilitate the collection and analysis of data, the HIV/AIDS Department has begun to develop generic tools on a number of key topics, including adherence, testing, stigma, and the link between treatment and prevention. These are designed to define the essential information needed across settings, and to facilitate the adaptation and implementation of data collection and analysis. WHO is also supporting projects in five African countries to put in place a process of priority setting and build capacity for operational research, and has initiated work with the Global Fund to build on these two projects in order to encourage the inclusion of operational research in proposals to the Global Fund and to other donors.

The HIV/AIDS Department is already collaborating with a number of organizations that conduct or support operational research. Support has been obtained from the US National Institutes of Health for a multi-site project designed to gather evidence on testing and counselling in order to better understand the factors that hinder or facilitate the uptake of testing and counseling in diverse settings, and using different models for the provision of services. Additional discussions and collaborations are under way in a number of research areas with the Doris Duke Foundation, the Clinton Foundation, Harvard University, ANRS, the London School of Hygiene and Tropical Medicine, the University of Amsterdam and local research institutions in the five countries in which the HIV/AIDS Department is supporting operational research. In all these partnerships, WHO's comparative advantage is as a convener and facilitator of research rather than as an implementer of research projects.

Of note is the HIV/AIDS Department's work over the last year with the ART-LINC group, a research consortium including 22 clinical sites in the developing world for delivering HIV care. Funded by the NIH and ANRS, this initiative aims to document prognoses of HIV infected people treated with ART and to compare experience between different delivery modes. WHO is preparing to sign a Memorandum of Understanding with ART-LINC in 3 main areas:

·        Joint work-planning for prioritizing analysis of data gathered through the collaborative programmes in order to document outcome and impact of scaling up ART in low- and middle-income countries

·        Using a network of cohorts coordinated through ART-LINC to plan and implement special studies on the outcome and impact of scaling up ART

·        Capacity-building activities to create communities of practice involving professionals in charge of collecting data and maintaining databases at site level, in order to ensure highest possible data quality .

This agreement potentially provides a mechanism for WHO and ART-LINC to address strategic information priorities raised by the STAC, such as rates of adherence and mortality and drug toxicity. Similar arrangements will be explored with the new IeDEA initiative from NIH and the Columbia University Mailman School of Public Health to address PMTCT related issues.

·        Research registry

Participants at a recent pre-Toronto meeting organized by Harvard University and the Doris Duke Foundation agreed that developing a knowledge management process for sharing information on operational research proposals and results was needed. Although WHO does not currently have the human and financial resources for implementing it, this will be an agenda item for the consultation described above in order to identify partnerships and potential resources for this project.

·        Monitoring, evaluation and reporting

Among UN institutions, WHO is responsible for monitoring the health sector's response to HIV/AIDS in the context of universal access.  The World Health Assembly has committed WHO to publish an annual report on the health sector's response. The report will document progress on availability, coverage and impact of priority health sector interventions in HIV/AIDS (ART, PMTCT, testing and counselling, prevention in health care settings, interventions for most-at-risk populations, health information systems). A list of core indicators will be finalized after consultation with regional offices and key partners. A first report will be published early 2007.

Regarding PMTCT uptake and outcomes, there is a need to strengthen monitoring and evaluation, particularly links between PMTCT and  ART;  improving data quality on prophylaxis uptake, and tracking outcome in infants. The following activities have been undertaken by WHO in the area of PMTCT M&E:

·        Review of Indicators: WHO, UNICEF and CDC reviewed existing M&E guidelines related to PMTCT, ART, and HIV care and support to reflect the comprehensive package of services, recent technical revisions to recommendations on ART care and support required, and to better reflect the program needs of children.  An update of progress and developments was to be shared at this year's annual MERG meeting in November 2006.

·        Field-testing and strengthening PMTCT M&E in countries: Experiences from pilot countries in testing new indicators will be documented so that lessons can be drawn for future implementation in other countries.  This is a joint project with UNICEF and other partners involved in PMTCT and M&E at the country level.

·        Development of generic tools to capture data: Based on existing tools and current programmatic recommendations on PMTCT, WHO is in the process of developing a generic set of tools that will adequately capture PMTCT monitoring.   These should be integrated with existing tools where appropriate and capture information to monitor PMTCT programs as well as other routine information required for related services (ANC, labour and delivery, child clinics).

In addition, the WHO work plan up to the end of 2007 includes evaluation studies related to PMTCT in order to explore:

o       Integration of PMTCT in MCH interventions.

o       links between ANC/PMTCT and ART and child services

o       issues surrounding ARV prophylaxis uptake

o       monitoring and outcome measures related to PMTCT

Regarding ART outcomes, WHO considers the collection of quality outcome and impact data a priority, particularly to build long-term commitment from donors and other stakeholders.

WHO has developed and support implementation of an ART patient monitoring system, integrated with IMAI.  Fifteen countries have adapted and implemented it or are in the process of doing so.  To date, Ethiopia, India, Malawi and the Western Cape province of South Africa have provided patient ART outcome data using this system or a similar one.  Other countries are slowly building capacity to collect group cohort data.

In addition to continuing to support basic patient monitoring systems and cohort analysis in countries, WHO has a work plan to support the ability of all countries to collect and report outcome data. This includes coordinating consensus around standardization of outcome variables; developing guidelines and protocols to collect and report ART outcome data using existing paper and electronic systems; developing simple electronic systems to extract outcome data from ART registers at sample sites; developing pilot protocol in three countries; and hiring a short term staff member to coordinate these activities and liaise with partners.

·        Evaluation of the Collaborative Fund for HIV Treatment Preparedness

The evaluation of the first year of operation of the Collaborative Fund for Treatment Preparedness, supported by WHO, has been completed and was publicized with WHO participation at the International AIDS Conference in Toronto. The findings of the evaluation show that WHO's investments in the Fund have been very important in he developmental phase. As a result, a number of significant new funders have made pledges of support, and WHO has pledged a further investment pending the availability of financial resources.

·        Communications

In order to provide timely and efficient access of information to its stakeholders, WHO has been utilizing several electronic dissemination methods as well as mail distribution and face-to-face meetings and presentation to stakeholder audiences.  

o       Website: WHO HIV/AIDS website (www.who.int/hiv) has been regularly updated with news, press releases, updates on events, publications and stories of communities affected by HIV. The website has been accessed by an average 2 000 visitors a day, according to WHO web statistics review.  Developing multilingual websites and publications is a WHO-wide challenge due to increasing costs, however, the HIV/AIDS Department releases as much content as possible in WHO's other official languages.

o       Electronic briefing of staff in headquarters, regions and countries: To improve internal communication of WHO's HIV/AIDS staff working in various offices, the department disseminated periodic e-kits to brief the staff on important advocacy and communications tactics to ensure one-WHO voice and equal distribution of information to global WHO partners and stakeholders. 

o       Mail distribution: WHO HIV/AIDS Documentation centre has been distributing WHO publications, technical guidelines and training manuals to practitioners, health workers, NGOs and ministries of Health, basing on electronic publication request forms received through the website.

o       Generic email for public enquires: WHO has a generic email address hiv_aids@who.int for public comment and enquiries on WHO's activities and s. Hundreds of questions have been answered by WHO HIV/AIDS technical staff to doctors, patients from countries, as well as comments and suggestions were responded accordingly.

3.9       PARTNERSHIPS AND COORDINATION

 WHO continues to develop and maintain a wide range of strategic collaborations.  Notable among new collaborations in 2006 are the Global Health Workforce Alliance and UNITAID, both of which have secretariats based at WHO.

Links with faith-based initiatives also continue to grow.  In mid-2006, WHO hosted a global dialogue engaging faith-based health service providers, governmental and nongovernmental health service providers, ethicists and theologians, and people living with AIDS on the notion of "decent care".  Faith Health Assets Mapping has been completed in two African nations and has demonstrated that there are vastly underestimated faith-based services and resources which could contribute to national scale-up, but which are not well misunderstood by local and regional health administrators. Additional health mapping of FBOs will be supported by Norway in 2007, to take place in Namibia, Botswana, Kenya, Tanzania, and Malawi.

 The STAC has requested that the Terms of Reference for its country representatives include the need to "actively build and expand networks and partnerships with civil society organizations."  The Terms of Reference for HIV/AIDS Country Officers already include the following:

 "A key requirement (is the) ability to collaborate/communicate with all relevant stake- holders involved in national scale-up efforts, incl. national authorities, international partners, NGOs and people living with HIV/AIDS;

"A key duty (is) to support the Ministry of Health, non-governmental sector and other key partners in strengthening national capacity;

"Among the key partners at national level (are) Counterparts and technical staff from governmental agencies and partners including non governmental agencies (NGOs)".

To improve partnership development at country level, especially with civil society, the Partnerships unit has been moved into the Operational and Technical Support unit in the HIV/AIDS Department, which provides the HQ link with country and regional offices.

WHO continues its work to support implementation of the Global Task Team recommendations, notably through its role as chair of the Global Joint Problem Solving and Implementation Support Team (GIST).  The GIST aims to help to overcome bottlenecks to the implementation of major financial resources for HIV/AIDS at country level.  The core members of the GIST - WHO, the Global Fund, the UNIADS Secretariat, the World Bank, UNDP, UNFPA and UNICEF - hold monthly meetings though video and telephone conferences to review technical support requests and needs assessments submitted by countries.  Decisions regarding responsibilities for the provision of technical support are made in accordance with the overall framework of the UN Division of Labour.

GIST actions include the coordination and provision of policy, technical and management support, with the close involvement of UN Theme Groups, UN Country Teams and other national and international partners. During the first year of operations, the GIST has undertaken joint time-compressed analysis of implementation bottlenecks and facilitated action in 15 countries, supporting the resolution of country-level technical, management and policy bottlenecks in countries and operational and capacity constraints on the part of international partners.    In November 2006 the GIST was expanded to include bilateral donors and civil society partners.

The work of the GIST complements other UNAIDS Secretariat and cosponsor technical support efforts at regional and country level, including through the Knowledge Hubs established by WHO and partners, as well as UNAIDS Technical Support Facilities. WHO is also working with the United States President's Emergency Plan for AIDS Relief and the GTZ Backup Initiative to ensure that the technical assistance provided by bilateral agencies is consistent with UN system efforts.

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[1] The WHO public health approach to antiretroviral treatment against HIV in resource-limited settings. Gilks C. et al. Lancet 2006: 368:505-10

[2] A. Reid et.al. Lancet Infect Dis 2006; 6:483-95