The HIV/AIDS Treatment
Acceleration Program for Africa
World Bank, Africa Region
Concept Paper
June 2003
Outline
• Introduction
• Challenges
• The Proposed Africa Regional HIV/AIDS
Treatment Acceleration Program
The Status of HIV/AIDS
Treatment in Africa
• There are 30 million people infected in Africa
– Of which six million in need of ART
• Many will be difficult to reach even with the
best of effort
• Current treatment target of WHO: 3 million
by 2005
• Actual number of people treated: Less than
50,000
Recent Opportunities
• Treatments are becoming much simpler: 2 pills
per day rather than 10 to 15
• WTO negotiations allow low income countries to
use generic drugs
• Because of competition, cost of first line drugs
has dropped to around 20 dollars per month
• Diagnostic techniques options are increasing and
prices are falling
Treatment Benefits Now Exceed
Treatment Costs
• Prophylaxis of opportunistic infections and
Prevention of MTCT have proven cost effective
• Comprehensive treatment including ART can now be
made available at less than 500 dollars a year
• Treatment of employees is now a cheaper option for
employers than letting them progress to AIDS
• Large scale comprehensive treatment will reduce the
growing orphan problem, benefit the health sector,
and reduce pain and suffering
HIV/AIDS Treatment: A
Continuum of Five Components
• VCT and regular checkups for all who are HIV+
• Positive Living and Survival Skills, including
psychosocial support, nutrition, etc.
• Prophylaxis and treatment of opportunistic
infections (OI)
• Anti-retroviral treatment (ART)
• Prevention of Mother to Child Transmission, including
treatment of the mothers and infected family members
(MTCT-Plus)
Opportunities Have Not Led to
Rapid Expansion of Treatment
• Less than 50,000 people are under treatment in Africa
• Current Global Fund grants envisage ART for about
200,000 patients
• IDA funds provide for ART, but current plans envisage
treatment of less than 10 000 patients
• Promising pilot programs of Medecins Sans Frontières,
Sant’Egidio, AIDS Empowerment and Treatment
International, PharmAccess have not attracted adequate
funding
Why Has Progress Been So Slow
• Governments are struggling to formulate
treatment policies, protocols and programs
• Focus is mostly on medical control rather
than on implementation mechanisms for
scaling up
• Governments have been reluctant to finance
programs outside of the public sector
Key Challenges to Be Addressed
• Rapid adaptation of WHO treatment guidelines and
protocols to specific country situations
• Agreement on best delivery and scaling up
mechanisms
• Low and declining numbers of heath professionals
• Inadequate laboratory infrastructure
• Cost-effectiveness and fiscal sustainability
• Buy-in of governments
The Centrality of Financial and
Fiscal Sustainability
• Even at the reduced costs, treatment cannot be made
to be entirely self financing
• Co-finance of treatment by OECD countries and
African governments will be needed
• But unless overall costs of treatment decline further,
millions cannot be reached even with the expanded
resources now becoming available
Sustainability requires investing in the construction
of efficient and reliable outreach mechanisms
The Seven Margins of Cost-reduction
and Sustainability
• Target treatment subsidies to poor rural and
urban patients, and to essential health,
education, and agricultural personnel
• Recover costs from those able to afford
treatment
• Further reduce cost of the ARVs, OI drugs,
diagnostic tests via astute and reliable
procurement and distribution systems
• Mobilize drug donations from industry
More Margins
• Encourage and support health insurance
initiatives which include HIV/AIDS treatment
– in private sector or public/private partnerships
• Enhance the fund-raising capabilities of the
community organizations and NGOs involved
• Improve the capability of PLWHAs to cofinance their own treatment by supporting
their income generation activities
The Role of National AIDS
Council and Ministries of
Health
• Develop treatment policies, framework, and
guidelines
• Institute national mechanisms for assuring
pharmaceutical and treatment quality
• Coordinate and facilitate mechanisms for monitoring
and evaluation, and for sharing of lessons learned
• Facilitate continuous training and upgrading of all
involved in treatment
• Facilitate registration, imports, and in some cases
production of quality generic drugs
• Facilitate the upgrading and rational use of existing
public and private treatment and laboratory
The Proposed IDA Treatment
Acceleration Program
Objectives of the Treatment
Acceleration Program (TAP)
• Test the scalability of existing HIV/AIDS treatment
programs of NGOs and public/private partnerships
• Ensure that the treatment programs are comprehensive,
decentralized, cost-effective, equitable, and sustainable
• Monitor, evaluate and learn from these programs
• Disseminate the lessons and implementation tools across
Africa rapidly
Components of the TAP
• Country programs to accelerate the scaling
up of the five components of holistic
HIV/AIDS Treatment (four countries)
• Cross-country facilitation and learning
program
– Across and from the four countries
– To benefit other MAP countries
Links Between Multi-sector
HIV/AIDS Program and the TAP
• MAP countries have concentrated on awareness,
prevention, and voluntary counseling and testing
• Treatment programs are under preparation in
many MAP countries
– Financed by several donors, including the MAP
– Focusing primarily on the public sector
• MAP countries will draw lessons, mechanisms,
and tools from the TAP, and thereby facilitate the
use of rapidly increasing donor support
The Country Programs
• Fund scaling up of existing holistic HIV/AIDS treatment
programs of NGOs and public/private partnerships which
include all five components of treatment
• Institute M&E systems to strengthen the programs and
compare the scalability, cost-effectiveness, equity,
treatment adherence and quality among programs
• Assist countries treatment coordination capabilities and
quality assurance
• Disseminate lessons, prepare for national mainstreaming
• Assist countries in improving health insurance systems,
medical benefit plans, and the targeting and
administration of treatment subsidies
Eligibility Criteria for the TAP
• Existing treatment programs of domestic or international
NGOS, communities, or public/private partnerships, which
– include at least treatment components one to three, and preferably
all five component
– innovate on at least four of the seven margins of sustainability
– address low and declining medical personnel, and/or laboratory
infrastructure in innovative ways
– foster confidentiality and ethical approaches to treatment
– ensure equitable patient selection in rural and urban areas
• Organizations commit to freely share lessons learned and
tools developed
Other Program Characteristics
• Reach into or out from public or private centers of
excellence
– Through district and local hospitals and health centers
– Via NGOs and faith-based organizations
– By involving communities and associations of people
living with HIV/AIDS
• Establish and sustain financial accountability
• Institutionalize accountability to patients, their
families and communities, associations of people
living with HIV/AIDS
Monitoring and Evaluation
• Independent monitoring and evaluation of scalability,
treatment quality, equity, and sustainability is essential
• Must include comparison among alternative treatment
implementation mechanisms within and across countries
• Therefore the M&E indicators need to be similar or the
same all treatment programs
• They must be implemented from the start of the program
and include an adequate baseline
• They should generate comparable clinical and economic
data for research
Program Duration and Size
• TAP will be a three year program running in
four countries
• Lessons will be mainstreamed as soon as they
become available during the program and at
the end
• Overall costs likely to be US$ 50 million, the
bulk of which will be in country programs
TAP Partners
• Likely implementing partners: Sant’Egidio,
Columbia University, PharmAccess,
AIDSETI, MSF, Red Cross…
• Facilitating partners: International
Treatment Access Coalition (ITAC), World
Health Organization (WHO), United
Nations Economic Commission for Africa
(UNECA)