Evaluation of PEPFAR (2013) / Chapter Skim
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6 Care and Treatment
6 Care and Treatment
Pages 243-342
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From page 243... ...
. All along this continuum there are interventions and efforts supported by PEPFAR: testing and diagnosis as the entry point into care and treatment services; referrals and linkages to care services; the provision of clinical care services, nonclinical support services, and monitoring for those not eligible for antiretroviral therapy (ART)
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From page 244... ...
Although this chapter will focus on PEPFAR's support for the provision of testing, care, and treatment services, it is also important to note that this continuum for care and treatment intersects with other services supported by PEPFAR programming and other opportunities where PEPFAR has a role in facilitating an effective response as well as where interrelated challenges that affect care and treatment can arise. These other program areas are discussed elsewhere in this report, including prevention services (Chapter 5)
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From page 245... ...
This broader context both contributes to and poses challenges for the effectiveness of the HIV response. HIV COUNSELING AND TESTING Early in the HIV epidemic, voluntary HIV testing programs were intended to increase the number of people aware of their HIV status and to serve as an entry point for counseling and other prevention services, both for those who were HIV positive and those who were HIV negative, with the aim of reducing HIV transmission and infection.
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From page 246... ...
PEPFAR provides operational guidance in its annual Country Operational Plan (COP) guidance (OGAC, 2011a,b)
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From page 247... ...
. See Chapter 4 for a more detailed discussion of PEPFAR's budget codes and the available data for tracking PEPFAR funding.
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From page 248... ...
In tracking the number of individuals who have received testing services, for example, there is the potential for double counting of testing clients, some of whom may be accessing testing services repeatedly, either because of a lack of confidence in the results or because they have tested negative but are getting tested periodically because of high, ongoing, or new risks of exposure. In addition, without unique identifiers it is difficult to track whether individuals are being successfully referred for additional services once they have received their test results; the data are largely cross-sectional and do not allow for longitudinal individual follow-up.
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From page 249... ...
Initially most PEPFAR-supported testing was client-initiated testing based in separate testing facilities; later the integration of testing with other key services was recognized as a way to facilitate access to and provide a less stigmatized environment for HIV testing and efforts were made toward more integration with, for example, antenatal care, child health programs, primary health care, and TB services (272-24-USG; 331-28-PCGOV; 272-24-USG; 587-5-PCGOV; 636-17-PCGOV; 396-18-USG)
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From page 250... ...
In addition to the abovementioned use of targeted community-based and mobile testing to reach populations at high risk, interviewees offered such examples of specific efforts as a campaign to offer counseling and testing services in locations and at times that guarantee privacy for men who have sex with men, nighttime mobile testing services to reach sex workers and their clients, a referral system for sex workers to increase their access to testing, efforts to improve referrals and access to testing services specifically for women who inject drugs, and mobile outreach services that include testing for street children (396-44-PCGOV; 196-25-PCNGO; 935-17-USG; 935-16-USNGO; 331-22-PCNGO; 542-11-PCNGO; 196-24-PCNGO; . PEPFAR's support for services for these populations is discussed 542-14-PCGOV)
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From page 251... ...
In some cases interviewees described the targeting of testing services as resulting in some conflict and lack of alignment with national priorities and planning in partner countries. In these cases, generalized testing was typically a priority for the partner government, while PEPFAR was advocating that the most strategic use of available resources for testing would be to prioritize identified high-risk populations or higher-prevalence geographic areas (587-22-USG; 240-2-USG; 396-23-USG)
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From page 252... ...
. Ongoing Challenges with Coverage of HIV Testing Despite the achievements in the scale-up of HIV testing in PEPFAR partner countries, challenges remain in achieving adequate coverage, including low rates of testing and low knowledge of HIV serostatus (particularly among HIV-infected persons)
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From page 253... ...
. One contributing factor to this increased likelihood of testing among women is their greater access to testing services as a result of more frequent contact with health services, such as participation in antenatal care (WHO, 2012d)
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From page 254... ...
. Interviewees in partner countries described how PEPFAR has supported programs to implement and scale-up EID by using strategies such as the integration of EID into other services and the improvement of laboratory access, capabilities, technology, and training, including the use of dried blood spot collection to obtain samples for testing.
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From page 255... ...
. A study in South Africa showed that early diagnosis and early initiation of antiretroviral therapy reduced early infant mortality by 76 percent and HIV progression by 75 percent (Violari et al., 2008)
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From page 256... ...
. Linkages from HIV Testing to Care and Treatment Getting patients who have accessed testing services and been found to be HIV positive successfully enrolled in care and treatment is essential to improving HIV outcomes; indeed, the availability and awareness of successful care and treatment is one of the contributing factors to the successful scale-up of testing.
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From page 257... ...
. These challenges are consistent with the perspectives of interviewees in PEPFAR partner countries.
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From page 258... ...
However, challenges remain in achieving adequate coverage of testing services, especially in scaling up and improving access to testing for infants and children and testing for pregnant women who do not attend antenatal care or deliver in health facilities. For those who test positive, challenges also remain in consistently ensuring they are linked to care and treatment as well as to pre vention services to reduce HIV transmission.
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From page 259... ...
The PEPFAR-issued guidance for care and support services includes HIV/AIDS Palliative Care Guidance for the United States Government InCountry Staff and Implementing Partners and Guidance for United States Government In-Country Staff and Implementing Partners for a Preventive Care Package for Adults (OGAC, 2006a,c)
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From page 260... ...
NOTES: HPV = human papillomavirus; ITNs = insecticide-treated nets; PCP = Pneumocystis jiroveci pneumonia; STIs = sexually transmitted infections; TB = tuberculosis. SOURCE: Adapted from IOM and NRC, 2010.
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From page 261... ...
Data are presented in constant 2010 USD for comparison over time. As defined in the FY 2011 COP guidance, PEPFAR funding for Care includes budget codes for Adult Care and Support, Pediatric Care and Support, TB/HIV, and OVC.
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From page 262... ...
Of the total number provided with clinical care services, 10 percent were children under the age of 15. A small number of other centrally reported output indicators for TB/ HIV, cotrimoxazole, and food/nutrition services were also available to the committee and will be presented in the sections that follow on the specific sub-areas of activities within care and support.
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From page 263... ...
This indicator is defined to include support, preventative, and clinical services from facilities and/or community/home-based organizations. Individuals eligible for care services include people living with HIV/AIDS; family members, caregivers, or other household members living with an HIV-positive individual; children orphaned by HIV (<18 years old)
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From page 264... ...
. Data correspond to indicator C2.1.D: Number of HIV-positive adults and children receiving a minimum of one clinical care service (subset of C1.1.D)
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From page 265... ...
In addition to its support for service delivery, PEPFAR has also contributed to systems-level efforts in partner countries. PEPFAR facilitated the initiation or modification of partner country national policies, guidelines, protocols, and standard operating procedures related to care and support (166-13-PCGOV; 461-18-USG; 166-9-ML/OBL/USACA/USNGO/PCNGO/PCPS; 272-7-USG; 240-2-USG; 396-29-PCGOV; .
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From page 266... ...
to reduce progression to active tuberculosis in HIV-positive patients; and by controlling TB infections in health care facilities. The third objective is to reduce the burden of HIV in patients with tuberculosis by providing HIV testing and counseling for patients with TB; by introducing HIV prevention interventions for patients with TB, including condoms and behavior change interventions; by introducing cotrimoxazole preventive therapy for TB patients who are HIV positive, which has consistently reduced the risk of death and improved survival for co-infected patients when administered during routine tuberculosis care; and by linking to and enrolling those TB patients who are HIV-positive in HIV care and treatment services, including initiation of ART irrespective of CD4 count (WHO, 2012f)
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From page 267... ...
. PEPFAR-supports TB/HIV efforts through technical assistance to develop and strengthen national guidelines, policies, systems, and operational tools and through support for direct delivery of services, including exams; clinical monitoring; related laboratory services; TB screening; the diagnosis, treatment, and prevention of TB in PLHIV; and HIV testing and clinical care of patients in TB service locations (OGAC, 2010b)
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From page 268... ...
The target for the number screened represented 68 percent of the target set for number of clients reached with clinical care services. The denominator (number in clinical care)
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From page 269... ...
PEPFAR-Supported Activities for Integrated TB/HIV Services Interviewees across PEPFAR partner countries recognized high TB/HIV co-infection rates as a critical aspect of the HIV response (196-11-USNGO; 396-12USG; 636-10-PCGOV; 934-5-USG; 542-8-USNGO)
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From page 270... ...
. A major challenge that persists is ensuring the delivery of treatment services needed for those who are identified as co-infected, including loss to follow-up for both TB patients identified as HIV positive and HIV patients diagnosed with TB (935-22-PCGOV; 935-24-USNGO; 935-7-USG; 240-15-USG; 331-30-USPS)
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From page 271... ...
. An implementing partner in one partner country described ‘huge progress' recently with TB/HIV (636-9-USACA)
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From page 272... ...
Other Supportive Clinical Care Services In addition to services for TB/HIV, PEPFAR's care and support portfolio includes support for a number of clinical care services, including the prevention and treatment of other opportunistic infections and HIV/AIDSrelated complications. PEPFAR supports these services through health facilities, discussed here, as well as through home- and community-based care programs (discussed in more detail in the section that follows)
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From page 273... ...
. PEPFAR has provided limited training and laboratory capacity building for diagnosis, and although currently there is limited availability of antifungal prophylaxis, PEPFAR is working with its partner, Supply Chain Management System, and with Pfizer, which runs a fluconazole donation program, to increase access to these drugs for treatment and prevention (OGAC, 2009b)
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From page 274... ...
Several interviewees in partner countries described PEPFAR-supported efforts to integrate cervical cancer screening programs, including offering cervical cancer screening in care and treatment facilities, launching a nationwide human papilloma virus vaccination campaign, and fully integrating a cervical cancer screening program into the ministry of health with a PEPFAR partner providing quarterly oversight and health care professional training for cervical cancer screening and treatment (636-17-PCGOV; 272-20-PCNGO; 461-18-USG; 461-13-USACA; 587-10-USG; 587-13-USG; 587-18-PCGOV)
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From page 275... ...
. Food and Nutrition Support Services HIV infection may cause or intensify malnutrition by reducing appetite, increasing energy needs, and impairing nutrient absorption (OGAC, 2009b)
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From page 276... ...
. Linkages of this kind were described in several interviews in partner countries (240-15-USG; 636-9-USACA; 116-24-USNGO; 331-14-USG; 331-19-USNGO; 331-23-USNGO; 240-3-USG)
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From page 277... ...
and nonclinical services, which are also critical for the health of people who are HIV positive and for their adherence to treatment once initiated. One interviewee emphasized the need for these services, describing that the initiation of HIV treatment can be associated with ‘a cascade of effects -- lack of social support, loss of income, hard to maintain adequate nutrition' (331-8-PCNGO)
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From page 278... ...
Although there is still a need for services for the critically ill, the increased availability of care and treatment services, the move from inpatient to outpatient care, and the generally improved health status of PLHIV have led to a decline in patient populations requiring end-of-life care and to a change in the needs to different kinds of care and support services (272-32/35-PCNGO; 272-7-USG; 240-2-USG; 935-10-USG)
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From page 279... ...
. There were also a few examples involving children and adolescents in which community and nonclinical services were linked with clinical services in health facilities, such as age-specific clubs for children in HIV care and treatment clinics; youth-friendly services for HIV-positive youth that include support groups; education, and programs for youth in school and those not in school; and community workers who focus on helping children stay in treatment (636-17-PCGOV; 935-13-PCGOV; 272-14-PCNGO)
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From page 280... ...
. Interviewees in one partner country described home-based care as not very strong (331-8-PCNGO)
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From page 281... ...
. Social support Social support services supported by PEPFAR may include social and legal protection for PLHIV as well as the training and support of caregivers (OGAC, 2010b, 2011a)
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From page 282... ...
. Interviewees in partner countries indicated that this area of intervention is important.
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From page 283... ...
. Conclusion: PEPFAR has made a tremendous contribution to a wide variety of clinical and nonclinical care and support services, beyond the provision of antiretroviral therapy, through a scale-up of services and programs in facilities and communities and through support for partner country policies, guidelines, and protocols.
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From page 284... ...
ANTIRETROVIRAL THERAPY Global Context for the Scale-Up of Antiretroviral Therapy The rapid scale-up of ART in the past decade resulted from intense advocacy efforts, unprecedented political commitments at the highest levels, dramatic reductions in the cost of antiretroviral drugs, and record increases in donor country foreign assistance dedicated to HIV/AIDS. It represents
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From page 285... ...
. The global political commitment that emerged from the 2001 UNGASS on HIV/AIDS also led to an unprecedented increase in financial commitments to combat the pandemic, including the establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund)
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From page 286... ...
. The financial support of PEPFAR and the Global Fund, reductions over time in the cost of ART, robust political commitments, and efforts to strengthen health systems that support service delivery have combined to allow for the rapid scale-up of HIV programs in low- and middle-income countries.
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From page 287... ...
In addition, PEPFAR supports both care and treatment services through its health systems strengthening activities, which are described in detail in Chapter 9, where discussion of workforce training, laboratory services, and supply chain management can be found. Although not discussed in detail in this chapter, these systems-level activities are nonetheless an integral part of treatment programs and of supporting the continuum of care for HIVpositive patients.
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From page 288... ...
. In its 2010 HIV treatment guidelines, WHO updated its recommendation for ART initiation and is now recommending that all HIV-positive adults and adolescents, including pregnant women, start antiretroviral drug treatment if their CD4 counts are less than 350 cells/mm3 (compared to the previous recommended level of less than 200 cells/mm3)
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From page 289... ...
Funding History for PEPFAR-Supported Treatment Programs PEPFAR's activities for treatment are captured within the budget codes for ARV Drugs, Adult Treatment, and Pediatric Treatment. Figure 6-5 shows the funding over time in these budget codes in both the dollar amount and as a proportion of all PEPFAR funding.
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From page 290... ...
290 TABLE 6-10 Adult and Pediatric Treatment Guidelines Adoption by Country Adopted WHO Adult ART Adopted WHO 2010 Adult Pediatric ART 2010 Pediatric ART Country Guidelines Issued in: ART Recommendations? a Guidelines Issued in: Recommendations?
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From page 291... ...
ART = antiretroviral therapy; WHO = World Health Organization. xxxx = year unknown.
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From page 292... ...
Data are presented in constant 2010 USD for comparison over time. See Chapter 4 for a more detailed discussion of PEPFAR's budget codes and the available data for tracking PEPFAR funding.
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From page 293... ...
. Despite this scale-up in government support, the proportion of a government's contribution to ARV procurement and to treatment varies among countries, and one major theme that emerged about funding from interviewees in many PEPFAR partner countries was that external donor resources, especially PEPFAR and the Global Fund, provide a significant proportion of treatment costs.
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From page 294... ...
See Chapter 4 for a more detailed discussion of PEPFAR's budget codes and the available data for tracking PEPFAR funding.
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From page 295... ...
Because so many treatment programs in PEPFAR partner countries receive joint funding to varying degrees from the Global Fund, it is important to note that the total number of individuals directly supported on ART includes an estimated overlap of individuals receiving ART with support by both PEPFAR and the Global Fund. This overlap estimate is also included in the treatment results reported by the Global Fund.
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From page 296... ...
. Taken together, the data provided by CDC reflects Track 1.0 programs in a subset of 13 PEPFAR partner countries that receive a large proportion of PEPFAR treatment investment; the total funding for these 13 countries represented over 90 percent of the total planned/approved treatment funding from FY 2005 to FY 2011 (OGAC, 2005, 2006g, 2007c, 2008b, 2010c, 2011d,e)
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From page 297... ...
Not only did the total quarterly enrollment increase steadily until 2011, but also the number of newly enrolled ART patients each quarter increased rapidly through 2009, at which point new enrollment began to level off and even drop slightly. The decrease in new enrollment even as total enrollment continued to increase could in theory be explained by a decrease in individuals newly in need of ART; however, this is not the case in most PEPFAR partner countries.
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From page 298... ...
Data in these countries on men and women who are in need but not receiving care and treatment would make it possible to compare coverage rather than simply numbers enrolled. Within this limitation, it is feasible to observe that the reasons for this imbalance would likely be consistent with the observations described previously in this chapter that men may not be accessing testing and subsequent referrals for enrollment in care and treatment services as readily as women.
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From page 299... ...
ing, primarily because of increased access for pregnant women who are enrolled in ART through the entry point of antenatal care and PMTCT services (WHO, 2012d)
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From page 300... ...
300 TABLE 6-14 Newly Enrolled Adults in ART by Sex (Annual, FY 2005–FY 2011) (in Thousands)
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From page 301... ...
Many of these may be children with HIV infection from maternal transmission who survived even without therapy in the early period that is critical for identifying HIV infection and initiating treatment. The greatest increase
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From page 302... ...
302 TABLE 6-15 Newly Enrolled Children in ART (FY 2005–FY 2011) (in Thousands)
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From page 303... ...
and supported partners that were leaders in pediatric care and treatment (240-19-USACA; 272-22USG; 396-25-PCGOV; 396-42-PCGOV; 636-17-PCGOV; 396-56-USNGO; 461-13-USACA)
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From page 304... ...
. Other interviewees described PEPFAR as working closely with the partner country government and with other external donors, such as the Clinton Foundation (240-19-USACA; 935-6-USACA; 396-21-USG)
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From page 305... ...
However, in the provision of treatment at the facility, district, and sub-partner levels, adherence and retention have been monitored by implementing partners who need the data to assess the delivery of ART and the quality of care and treatment.
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From page 306... ...
The following section presents perspectives from interviewees in partner countries that further inform the issues of retention and adherence in the context of implementing PEPFAR-supported programs.
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From page 307... ...
by population and by the year ART was started in a subset of patients in nine PEPFAR partner countries. NOTE: Red bars correspond to 95% confidence intervals.
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From page 308... ...
308 EVALUATION OF PEPFAR 1.00 0.9 Survival Distribution Function Estimate 0.8 0.7 0.6 0.5 0.4 0.3 Pediatrics 0.2 Adult Females Adult Males 0.1 0.0 0 12 24 36 48 60 72 84 Months on ARV 1.00 Pediatrics n=21,298 0.96 Adult Females n=143,493 Survival Distribution Function Estimate Adult Males n=71,784 0.92 0.88 0.84 0.80 0.76 0.72 0 12 24 36 48 60 72 84 Months on ARV FIGURE 6-10 Proportion of patients on ART that remain in care on ART over time by Figure 6-10.eps population in a subset of patients in nine PEPFAR partner countries NOTES: A decreasing proportion of patients on ART that remain in care reflects increasing loss to follow-up. Bottom panel shows expanded view of top panel.
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From page 309... ...
CARE AND TREATMENT 309 1.00 0.9 Survival Distribution Function Estimate 0.8 0.7 0.6 0.5 2004 0.4 2005 2006 0.3 2007 2008 0.2 2009 2010 0.1 2011 0.0 0 12 24 36 48 60 72 84 Months on ARV 1.00 2004 n=2,054 2005 n=11,722 2006 n=22,156 Survival Distribution Function Estimate 0.96 2007 n=30,715 2008 n=42,010 2009 n=44,993 0.92 2010 n=47,660 2011 n=35,266 0.88 0.84 0.80 0 12 24 36 48 60 72 84 FIGURE 6-11 Proportion of patients on ART that on ARV in care over time by year of ART Months remain initiation in a subset of patients in nine PEPFAR partner countries. NOTES: A decreasing proportion of patients on ART that remain in care reflects increasing loss to follow-up.
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From page 310... ...
. In addition to the need for food security among some partner country populations in general
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From page 311... ...
. Another strategy that interviewees said they used to improve retention and adherence were improving laboratory services to improve efficiency and reduce wait times for CD4 testing, including implementing point-of-care testing (934-14-PCGOV; 935-7-USG; 935-13-PCGOV)
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From page 312... ...
Besides conferring substantial benefits on survival and quality of life, broad access to antiretroviral therapy in resource-limited settings has, not surprisingly, led to the emergence of both acquired and transmitted drug resistance (Gupta et al., 2012; Stadeli and Richman, 2012)
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From page 313... ...
. Drug resistance surveillance monitoring recently started in one partner country (272-13-USG)
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From page 314... ...
The emergence of HIV drug resistance is cause for greater efforts to improve the effectiveness and expand the implementation of adherence support, treatment-failure and drug-resistance moni toring strategies, and treatment options in resource-limited settings. Impact of PEPFAR-Supported Care and Treatment Programs on Mortality Across countries, many interviewees of all stakeholder types identified the lives saved through HIV care and treatment programs as one of the greatest successes of PEPFAR (935-ES; 636-ES; 461-ES; 240-ES; 331-ES; 116-ES; 166-ES; 272-ES; 396-ES; 934-ES)
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From page 315... ...
CARE AND TREATMENT 315 1.00 0.9 Survival Distribution Function Estimate 0.8 0.7 0.6 0.5 0.4 0.3 Pediatrics 0.2 Adult Females Adult Males 0.1 0.0 0 12 24 36 48 60 72 84 Months on ARV 1.00 Pediatrics n=20,401 Adult Females n=133,646 Survival Distribution Function Estimate Adult Males n=68,259 0.95 0.90 0.85 0.79 0 12 24 36 48 60 72 84 Months on ARV FIGURE 6-12 Survival by population (2004–2011) in a subset of patients in nine PEPFAR partner countries.
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From page 316... ...
316 EVALUATION OF PEPFAR 1.00 0.9 Survival Distribution Function Estimate 0.8 0.7 0.6 0.5 2004 0.4 2005 2006 0.3 2007 2008 0.2 2009 2010 0.1 2011 0.0 0 12 24 36 48 60 72 84 Months on ARV 1.00 2004 n=2,218 2005 n=11,784 2006 n=21,468 Survival Distribution Function Estimate 2007 n=28,721 0.95 2008 n=38,622 2009 n=41,069 2010 n=44,013 2011 n=34,412 0.90 0.85 0.81 0 12 24 36 48 60 72 84 Months on ARV FIGURE 6-13 Survival by year of ART initiation (2004–2011) in a subset of patients in nine PEPFAR partner countries.Figure 6-13.eps NOTE: Bottom panel shows expanded view of top panel.
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From page 317... ...
The enrollment, retention, and mortality outcomes presented in this chapter for patients enrolled in these PEPFAR-supported treatment programs are consistent with the published literature, where men have also been shown to have a higher mortality rate than women when receiving antiretroviral therapy (Chen et al., 2008; Taylor-Smith et al., 2010)
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From page 318... ...
318 EVALUATION OF PEPFAR 1.00 0.9 Survival Distribution Function Estimate 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0 12 24 36 48 60 72 84 Months on ARV 1.00 Females Males Survival Distribution Function Estimate 0.99 0.98 0.97 0.96 0.95 0 12 24 36 48 60 72 84 Months on ARV FIGURE 6-14a Differences between men 6-14a.eps ART in survival (7 countries, Figure and women on 165 clinics)
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From page 319... ...
One of these analyses did not find an effect on health outcomes (Duber et al., 2010) , perhaps due to timeframe and data limitations, but the other analyses indicated a measurable population health impact of PEPFAR on adult mortality in a subset of partner countries (Bendavid and Bhattacharya, 2009; Bendavid et al., 2012)
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From page 320... ...
Finally, as described in more depth in Chapter 4, complete and reliable data on annual PEPFAR expenditures by country were not readily available. Ideally the committee would have designed a model to determine if a bigger annual investment of PEPFAR funding over time, across all PEPFAR-funded partner countries, had led to a greater impact on health.
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From page 321... ...
It was a missed opportunity not to invest more resources earlier in standardized, realistic, and useful monitoring of outcomes. Recommendation 6-2: To contribute to sustainable care and treat ment programs in partner countries, PEPFAR should build on its experience and support efforts to develop, implement, and scale up more effective and efficient facility- and community-based service delivery models for the continuum of adult and pediatric testing, care, and treatment.
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From page 322... ...
• This data-collection effort should be designed by first identifying and prioritizing the key questions that require longitudinal data and then focusing on relevant key outcomes with measures that are standardized across the sample. Priorities should include core out comes related to clinical care and treatment, including adherence and retention; outcomes related to the reduction of HIV transmis sion through biomedical and behavioral prevention interventions for people living with HIV; quality measures; and program mea sures, such as the costs of services, that can help inform strategies for efficiencies, sustainable management, and resource planning for the trajectory of need.
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From page 323... ...
. In addition, the current understanding of who is eligible depends on where the partner country is in the transition to implementing the revised WHO HIV treatment guidelines, which expand eligibility and thus the number in need (934-2-USG; 934-10-PCGOV; 9345-USG; 934-12-CCM; 542-3-USG; 542-9-PCGOV; 272-32/35-PCNGO; 116-7-USG; 116-18-PCNGO)
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From page 324... ...
NOTES: The area of the green circles, as well as the height of the center of these circles on the vertical axis, represents the estimated magnitude of advanced HIV infection within each country (UNGASS indicator 4, denominator)
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From page 325... ...
NOTES: The area of the green circles, as well as the height of the center of these circles on the vertical axis, represents the estimated magnitude of advanced HIV infection within each country (UNGASS indicator 4, denominator)
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From page 326... ...
. As care and treatment services were expanded, the need arose for an adequate health care workforce to oversee ART.
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From page 327... ...
Conclusion: Despite progress in the availability of and access to HIV services, there remains a large unmet need for care and treat ment in PEPFAR partner countries. Intrinsic limitations of the health system infrastructure continue to pose barriers to the deliv ery of care treatment services, including clinical care, clinical and laboratory monitoring, and antiretroviral therapy.
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From page 328... ...
Improved access to pediatric treatment depends on the ability to identify women and children routinely through maternal–child care service entry points such as services in maternal and child health, including PMTCT, and to refer them to care and treatment facilities or provide integrated care. PEPFAR has put in place several efforts -- described previously in this chapter -- to increase pediatric enrollment by improving linkages to care and treatment after identification of children in need, but this continues to often be lacking.
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From page 329... ...
Another challenge is meeting the specific needs of HIV-positive adolescents in care and treatment programs and transitioning them to adult care and treatment programs. There are some PEPFAR-supported programs in a few countries that have developed strong adolescent components, including, for example, adolescent-specific care and support programs, bimonthly provider forums to discuss challenges in the adolescent population, and facilitation of referrals between clinics and community services (Sharer, 2012)
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From page 330... ...
Limitations in health systems for the support of pediatric HIV services are also a major factor. PEPFAR has contributed to increas ing pediatric treatment, but the coverage of pediatric HIV remains proportionally much lower than the coverage for adults, despite the goal in the reauthorization legislation to provide care and treat ment services in partner countries to children in proportion to their percentage within the HIV-infected population.
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From page 331... ...
There is a critical need for PEPFAR, its partner countries, and other global stakeholders to focus on how to support countries in discussing what resources are needed to respond to the HIV/AIDS epidemic, how to prioritize the large unmet need for treatment of adults, adolescents, and children, and how to identify resources for the gap. Currently in many partner countries the vast majority of treatment is funded by PEPFAR, the Global Fund, or, most commonly, some combination of the two.
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From page 332... ...
Interviewees conveyed their awareness of a desire by PEPFAR to foster sustainability and, in that light, to reduce or eliminate support for the HIV response in partner countries. Their central concern was the continuing availability of funding for ARVs.
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From page 333... ...
The large numbers of currently enrolled patients who need to be maintained, those currently eligible but not yet enrolled, and the potential for expansion of eligibility if changing WHO guidelines are adopted and implemented are fundamental challenges for achieving adequate coverage and for the sustainability of care and treatment across PEPFAR partner countries. Intrinsic limitations in the health system and other systems involved in the response continue to be barriers to the delivery of services, as do the realities of resource constraints, especially with the possible flattening or decreasing of external resources.
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From page 334... ...
2007. National guidelines for the use of pediatric antiretroviral therapy in Cambodia.
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From page 335... ...
2011. Presumptive diagnosis of severe HIV infection to determine the need for antiretroviral therapy in children less than 18 months of age.
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From page 336... ...
2011. National guidelines for the clinical management of HIV infection and antiretroviral therapy in adults (Pedoman nasional tatalaksana klinis infeksi HIV dan terapi antiretroviral pada orang ewasa)
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From page 337... ...
2004. The President's Emergency Plan for AIDS Relief: U.S.
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From page 338... ...
2011b. The President's Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance technical considerations.
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From page 339... ...
2011c. The President's Emergency Plan for AIDS Relief: Guidance for the prevention of sexually transmitted HIV infections.
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From page 340... ...
2004b. Clinical protocol for conducting antiretroviral therapy in children with HIV infection and AIDS.
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From page 341... ...
2010b. Antiretroviral therapy for HIV infection in adults and adolescents: recommen dations for a public health approach.
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