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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.
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.
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.
***
A. Reid et.al. Lancet Infect Dis 2006; 6:483-95
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