Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa

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Operational Plan for Comprehensive HIV and AIDS
Care, Management and Treatment for South Africa

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Cabinet Mandate

• On 8 August 2003 Cabinet requested the
  Ministry of Health to
• as a matter of urgency, develop a detailed
  operational plan on an antiretroviral
  treatment programme
• by the end of September 2003

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Pillars

• Ensuring that the uninfected remain HIV negative
• Prevention and changing lifestyles and behaviour
• Broader context - social programmes of
  Government and the wider society that aim to
  reduce poverty through job creation and social
  support
• 5.3 million HIV progress as slowly as
  possible to developing AIDS
• Appropriate treatment of AIDS-related conditions
  including the use antiretroviral therapy in
  patients presenting with low CD4 counts to
• Improve functional health status
• Prolong life

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Guiding Principles

• Quality of Care
• Universal and Equitable Implementation
• Strengthening the National Health System
• Re-inforcing Prevention
• Providing a Continuum of Care

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Guiding Principles

• Sustainability
• Promotion of healthy lifestyles
• Promotion of individual choice of treatments
• Integration
• Safety of Medicines
• TB

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Goals

• Provide comprehensive care
• Strengthen the National Health System

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Prevention, Care and Treatment of HIV and AIDS

• Prevention, care and treatment
• Nutrition-related Interventions
• Traditional Medicine

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Care and Treatment Plan

• Aim
• prolonged and improved quality of life
• Approach
• Continuum of care
• Service coordination and integration
• Referral systems
• HBC approach
• Integration into current services
• E.g. VCT, PMTCT, TB, PEP, STI management,
• Add on ARVs for people who have progressed to
  stage 3 or 4

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HIV negative
HIV INFECTION DISEASE PROGRESSION
exposure to HIV
Flu like illness

• IEC
• Barrier Methods
• PMTCT
• PEP
• Ongoing counselling

HIV positive
Symptomatic -diarrhea -Oral thrush -Weight
loss -TB -Pneumonia
Asymptomatic

• VCT Avail.
• Counselling
• Support
• Nutrition
• Healthy Life Style

AIDS Disease
Treatment available for OIs
ARV
Death
Year 0
Year 5
Year 10
Year 8
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HIV Testing, Counselling and Clinical Staging
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DRUG REGIMENS
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Paediatric ARV Regimens and Routine Monitoring on
ARVs
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Nutrition

• Contextualised within broader nutritional
  strategies in Government
• Criteria
• Individual with TB and/or HIV and AIDS
• No secure food
• Monthly supply of nutritional supplement
• Monthly supply of supplementary meal
• DOH will
• Review and set specifications of supplement meals
• Review criteria for implementation
• Negotiate on pricing and supply
• Evaluate ongoing research
• Develop appropriate training material
• Coordinate with Social Development Agriculture

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Traditional Health Practitioners

• Role and function in the continuum of care if
  recognised (prevention, treatment, care and
  support)
• Compliance, adherence, adverse event reporting,
  referral system
• Ensuring safe traditional health practices
• Support the development of QA mechanisms and
  establishing training priorities
• Research
• traditional medicines on immune system
• Interaction with ARVs, TB and STI treatment

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Human Resources and Facilities

• Accreditation of Service Points
• Human Resource Training
• Provincial Site Assessments

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Strengthening and Accreditation

• Objectives
• Provision of a continuum of care
• Gold standard of care
• Equitable manner
• Service site
• Single facility or grouping of facilities which
  combined meet accreditation criteria
• Can include NGOs, private sector etc.

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Strengthening and Accreditation

• Accreditation requirements which broadly address
  capacity w.r.t. HR, labs, pharmacies, drug
  procurement distribution, referral patterns etc
• Process
• National defines requirements
• Provincial assessment teams for site evaluation
  identification of gaps and developing
  strengthening plan to address gaps (with time
  frames)

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Context of Human Resources in Health

• Public system is under-funded and resources not
  equitably spread across country
• Long-standing vacancies across categories acute
  for dieticians, nutritionists and pharmacists
• Half of hospital beds are occupied by patients
  being treated for AIDS-related illnesses
• 15 of health care workers are HIV-positive

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Short-Term Strategy

• Recruitment strategy to attract new graduates
• Service contracts with health professionals in
  private practice
• Partnerships with the private sector, NGOs and
  CBOs
• Incentives to support health professionals with
  scarce skills and in rural areas
• Streamline requirements for registration of
  foreign health professionals to work in public
  and rural health services
• Development of human resource and skills
  development plans for years 2 - 5

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Short-Term Strategy

• National Training Programme
• Establishment of regional training centres
• Standardised curricula for comprehensive training
  of health professionals in the identified service
  points
• Training of existing health professionals
• Multi-skilling of available health professionals
• Training of utilisation of community service
  practitioners for 2004 to address the immediate
  gaps
• Telephonic clinical consultation support at a
  provincial level for all health professionals
  providing ART treatment care
• Development of skills development plans for years
  2- 5

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Operational Issues

• Drug procurement
• Drug distribution
• Laboratory services

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Drug Procurement

• Key elements
• Reliability, security and sustainability
• Quality
• Sufficient volumes consistently with envisaged
  demands
• Affordability
• Local production

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Drug Procurement

• Approach
• Pooled procurement
• Flexibility
• Compliance with regulatory standards Medicines
  Act, Patent Act, TRIPS
• API production
• Parallel importation
• Activities
• Tendering
• Supplier pre-qualification
• Request for proposals
• Contracts
• Monitoring Evaluation
• Administrative Issues Programme Assessment

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Drug distribution

• Reliable supply consistently through
• Inventory management
• Patient prescription information
• Secured storage facilities
• Efficient secure transport
• Improved packaging
• Key Activities
• Provincial Depot Level (Contingency stock plan)
• Public Health Service level (Pharmacy Contingency
  stock plan)
• Accreditation (checklist)
• Prescription tracking

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Laboratory Services

• Key in disease staging, monitoring
• Infrastructure
• List of baseline tests (biochemistry, full blood
  count)
• Diagnostic, clinical monitoring, viral resistance
• Viral load, CD4
• Strengthening of system
• Facility location
• Volumes
• Transportation
• Turnaround times
• Staffing
• Research

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Social Mobilisation and Communication

• Guiding Principles
• Content
• Balance prevention and care
• Clear messages on ARVs
• Information on the programme
• Healthy lifestyles
• Nutrition
• Adherence
• Process
• 3 tiers of government focus on political
  leaders and key opinion-makers
• PLWHA
• General public
• Health care providers, including traditional
  healers
• Families, communities and caregivers
• NGOs and CBOs
• Sectors of civil society

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Information, Monitoring and Research

• Patient Information System
• Monitoring and Evaluation
• Pharmacovigilance
• Research

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Patient Information System

• Aim
• collect patient-related information to monitor
  compliance, adherence, response etc.
• Standardised forms (integrated with ME)
• Patient-linked through personal identifier
• Build on existing data and IT infrastructure
• Upgrading existing data management IT
  capabilities
• Paper-based systems backup
• Integrated with electronic patient records

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Pharmacovigilance

• Aimed at providing safety profiles for patients
  and determine morbidity mortality associated
  with the use of ARVs
• Existing programme at UCT, but this initiative
  focuses on supporting the ARV rollout
• Strong technical and training support to specific
  groups/audiences

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Research

• Aim
• developing a research agenda for research which
  defines most effective provision of care and
  treatment
• Primary focus operational/health systems and
  behavioural as well as resistance monitoring
• Structures and process to build on current
  arrangements with an advisory group advising on
  priority research and support of the programme

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Strengthening and Upgrading the Health System

• Staffing Requirements
• Upgrading Facilities and Pharmacies
• Upgrading Patient Information, Monitoring
  Evaluation Systems
• Upgrading the National Health Laboratory Service
• Maintaining Health After HIV Infection
• Nutritional Support and Supplementation
• Diagnostic Monitoring Following Diagnosis of HIV
  Infection

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Funding

• Presents a national budget
• Details all resource requirements for
  implementation
• Combined to provide a uniform estimate of the
  resources required to support the integrated HIV
  and AIDS care and treatment plan over a five-year
  period

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Budget
Total Programme Budget Estimate (Millions of
Rands)
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Challenges

• Strengthening prevention programmes
• Strengthen VCT, PMTCT synergistic effect
• The recruitment, training and retention of
  health care professionals
• Building strong partnerships between health
  facilities and community support structures
• Strong communication and community mobilisation
• Additional financial resources
• Complex to manage integrated

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Challenges

• Improving the integration of services at facility
  level
• Integration of traditional and complementary
  medicines with Western therapies
• Strengthening the National Health Laboratory
  System to meet the demands of the programme
• Coordination of human resources, training,
  laboratory services, pharmaceutical services,
  drug procurement, and information systems
• Ensuring high quality of care in the private
  sector
• Pharmacovigilance in the public and private
  health sectors
• Good patient information