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Treatment 2.0
Catalyzing the Next Phase
of Scale-up
Decentralized, Integrated and
Community-Centred
Service Delivery
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Background
6.6 million on ART
13 fold increase in six years
Global coverage ~40%
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Achievements and Challenges
 People currently eligible for ART
15 million
 People currently receiving ART (2010)
6.6 million
 ESTIMATED TREATMENT GAP 9 million
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What is Treatment 2.0
 Joint WHO/UNAIDS Initiative
 Catalyse the next phase of treatment: achieve and sustain
universal access and maximize preventive benefits of ART
 Radical simplification and improved efficiencies and
effectiveness of all aspects of care and treatment
 Continue scale up in cost neutral environment while
intensifying advocacy for more resources to end the
epidemic
– doing more with less
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Priority Work Streams of Treatment 2.0
1. Optimize drug regimens
Optimize
drug
regimens
2. Promote diagnostics using point of care and
other simplified technologies
3. Reduce costs
Mobilize
communities
TREATMENT
2.0
4. Adapt delivery systems
POC and
other
simplified
monitoring
5. Mobilize communities, protect human rights
Adapt
delivery
systems
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Reduce costs
What WHO Is Doing
 Overall coordination with UNAIDS
 Provide support to countries to review and adapt T2.0 principles
 Advocacy for commodity price reductions
 Anchor all normative work on treatment and care under the
Treatment 2.0 umbrella
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Optimization of ART, OI treatment and prevention, testing and counselling, PMTCT
Secondary preventive benefits of ART and primary benefit of ARVs (PrEP)
Adherence and retention in care
Nutrition support
TB/HIV
Reduction in stigma, discrimination, protection of human rights
Focus on Priority Work Stream 4:
Adapting Delivery Systems
1. Optimize drug regimens
Optimize
drug
regimens
2. Promote diagnostics using point of care and
other simplified technologies
3. Reduce costs
Mobilize
communities
TREATMENT
2.0
4. Adapt delivery systems
5. Mobilize communities, protect human rights
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Adapt
delivery
systems
POC and
other
simplified
monitoring
Reduce costs
The Cost of Treatment
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Source UNAIDS 2010
The cost of late diagnosis and treatment
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Principles for Adapting Delivery Systems
 Decentralizes
• HIV care into the community
 Integrates
• Prevention, diagnosis and treatment
• Using chronic health care model
 Shifts from stand alone ART services
• ART delivered in primary care, ANC, MCH, TB and drug dependency services
 Expands HIV testing and counseling
• Health sector and community
• Entry point to treatment and prevention
 Strengthens
• Procurement and supply systems
 Links
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Health sector and community-based services
Decentralization
 Sub-Saharan Africa 80% rural communities
 Transport to and from clinic difficult
– limited or no public transport
– roads often impassable
 Best way to deliver care
– decentralization
 Task shifting/sharing is key
– WHO global guidelines 2008
– slow adoption in many settings
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Integration
Linking and integrating health services provides people with
user-friendly care they need, when they need it
Maximizing retention and health outcomes
Slide courtesy of Emily A. Bobrow, PhD,
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Senior Research Officer Elizabeth
Providing better value for moneyMPH
Glaser Pediatric AIDS Foundation
From evidence to recommendations
The GRADE process
Mapping
Internal
reference
group
Agreed
outcomes
External
Guidelines
review
GRC*
group
Systematic
review
*GRC WHO Guidelines Review Committee
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GRADE = The Grading of Recommendations Assessment,
Development and Evaluation
Guidelines
Evaluation framework
1. Equity and human rights
2. HIV outcomes
3. Non-HIV outcomes
4. Cost
5. Systems
6. Socio-economic security
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Critical patient & public health outcomes
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Knowledge of status
Earlier uptake/access to ART
Mortality
Cost efficiencies
Quality of care
Morbidity
Retention
Acceptability
Transmission
HIV testing and counselling PICO
 For people living in generalised or concentrated HIV
epidemics (P), should community HTC be provided by
non-physician providers (I), compared to providing only
facility based HTC and PITC (C), to increase knowledge of
HIV status linked to access to HIV prevention and
treatment (O)?
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Task Shifting PICOS
 For HIV-infected people eligible for ART in generalised or
concentrated epidemics (P), does initiation of ART by
appropriately trained non-physician healthcare workers (I),
compared to initiation by physicians (C), result in comparable
health and programmatic outcomes (O)?
 For HIV-infected people eligible for ART in generalised or
concentrated epidemics (P), does the provision of
maintenance ART by appropriately trained non-physician
healthcare workers (I), compared to the provision of
maintenance ART by physicians (C), result in comparable
health and programmatic outcomes (O)?
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Integration PICOS (1)
 In countries with a high burden of TB/HIV co-infection, (P)
does ART and HIV care services provided at the TB clinic
(I) compared to referral to specialised HIV clinics (C) result
in comparable health and programmatic outcomes (O)?
 In countries with a high burden of TB/HIV co-infection, (P)
does TB diagnosis and treatment at specialised HIV clinics
(I) compared to referral to TB clinics (C) result in
comparable health and programmatic outcomes (O)?
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Integration PICOS (2)
 For pregnant women and infants in generalised epidemics
(P) does initiation or maintenance of ART and HIV care
services within ANC/MCH clinics (I), compared to referral
to specialised HIV clinics (C), result in comparable health
and programmatic outcomes (O)?
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Primary care PICOS
 For HIV-infected people eligible for ART in generalised or
concentrated epidemics, (P), does the initiation of ART and
HIV care in clinics providing general services in the community
(I), compared to referral to specialised HIV clinics for ART
initiation (C), result in comparable health and programmatic
outcomes (O)?
 For HIV-infected people eligible for ART in generalised, or
concentrated epidemics (P), does the provision of
maintenance ART and HIV care in clinics providing general
services in the community (I), compared to referral to
specialised HIV clinics for maintenance ART (C), result in
comparable health and programmatic outcomes (O)?
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Service delivery pilot in Vietnam
Challenges for Vietnam
Late treatment initiation common
 Mortality high in early phase of ART
Limited access and retention
 Stigma, discrimination and punitive laws
Large burden of TB and drug dependence high among PLHIV
 Highly verticalized HIV, TB, MCH programs
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Treatment 2.0 adapted to Vietnam situation
 Pilot implementation in two provinces
– South
– Commitment of provincial authorities for
integrated service delivery
– ART-TB-MCH services for IDU
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Northwest
Emerging epidemic
Mountainous geography and ethnic minorities
decentralization critical to ensure access
 Vietnam Authority of HIV/AIDS Control
 Support from WHO
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Dien Bien
Can Tho
Summary
 Decentralized and integrated service delivery
– into the community and for the community
 Key objectives
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earlier initiation of ART
improved retention in care
improved survival
reduction of new HIV and TB infections over time
 Increased and sustainable ART coverage with the same money
– by increasing efficiency without compromising quality of care
 Synergise prevention and treatment
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Acknowledgements
 Chris Duncombe
 Marco Vitoria
 Shaffiq Essajee
 Reuben Granich
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