Build on What We Know: Leveraging Successful HIV & AIDS Interventions

Build on What We Know: Leveraging Successful HIV & AIDS Interventions

{Photo credit: MSH, South Africa.}Photo credit: MSH, South Africa.

The prospect that we may see the end of AIDS in our lifetime has never been greater. Over the last decade, the global HIV & AIDS community has achieved stunning successes, including a steady decrease in new HIV cases, a massive scale-up of antiretroviral therapy (ART), and proof that treatment is prevention. As we begin the XIX International AIDS Conference, we are also excited by new scientific advances in prevention and treatment, such as Option B+  for prevention of maternal-to-child transmission (PMTCT). As new possibilities develop, we must also build on the successes of the last decade. Only by "turning the tide together" through the simultaneous pursuit of new possibilities, leveraging of proven interventions for scale and sustainability, and strengthening of health systems overall, can we hope to reach our goal of ending the HIV & AIDS epidemic.

What Do We Know Now?

What have been some of the greatest large-scale successes? Let me share examples that illustrate three principles for long-term success: build for sustainability, empower local leaders, and achieve high value-for-money.

Build for Sustainability

We know that the most successful health development efforts are designed for sustainability from the beginning. Programs gain broad and lasting support when they are rooted in local realities, honor local culture, and build on untapped local potential.

The Ethiopian government, partnering with Management Sciences for Health (MSH), US President's Emergency Plan for AIDS Relief (PEPFAR), and US Agency for International Development (USAID), has implemented one of the largest HIV & AIDS prevention and treatment programs in Africa by decentralizing care from hospitals to health centers, communities, and individual households through new cadres of local, non-professional health workers. The program was built for operational sustainability by relying on these locally available health workers—including health center case managers and community volunteers—to provide services where they are needed most.

One benefit of this approach has been a reduction in ART patients who are “lost to follow-up”—those who stop visiting health facilities for care—from the national average of 17% to 9% at health centers in program areas. Shewareged Kassie, a health center case manager in the Kirkos district who is HIV-positive herself, convinces lost-to-follow-up HIV patients to accept home visits by HIV-positive community volunteers, explaining that they provide adherence counseling and other important community services. Clients are more likely to visit or return to health centers after these volunteers have been to their homes or hosted educational “coffee ceremonies,” a community practice rooted in Ethiopian culture. In one year, Shewareged and her team reached 65 individuals who were lost to follow-up and then restarted treatment.

By the end of the USAID program in 2011, health centers and community workers in the program area had enrolled almost 200,000 HIV-positive people on care and support and were providing ART to more than 86,000 clients—a substantial subset of the more than 260,000 people on treatment nationwide. They also provided services to prevent mother-to-child transmission of HIV to an average of 4,000 pregnant women and HIV testing and counseling to 3.5 million people per year. Today, the Ethiopian government continues the expansion of these services to more health centers in its drive to provide universal access to HIV & AIDS services.

Empower National Leaders

We know that empowered national and local leadership can create dramatic results. When local leaders take ownership of health care initiatives and can access the tools necessary to administer them, the initiatives are more effective and sustainable.

The Global Fund to Fight AIDS, Tuberculosis and Malaria – despite recent accountability challenges – is a remarkably effective example of multilateral funding for health that relies heavily on local leadership. To build the capacity of Global Fund countries to manage grants, USAID’s Grant Management Solutions (GMS) project, led by MSH and four partners, provides short-term support to local leaders whose decisions affect grant implementation. This support often helps transform a troubled Country Coordinating Mechanism (CCM), the national multisectoral governance body that provides strategic leadership and oversight for Global Fund grants.

In Mauritania, for example, the CCM had signed grants for $32 million by 2008, but poor grant performance and financial accountability resulted in grant suspension in 2009. Government transition and incomplete reforms left the CCM with a divided membership unable to carry out its responsibilities. With assistance from GMS and other international partners, the CCM initiated elections of new civil society representatives. It engaged 85 civil society organizations in defining and executing transparent election procedures, resulting in a successful membership renewal. The other sectors represented on the CCM renewed their membership as well. The reformed CCM was then able to work with the national government and the Global Fund to meet all the necessary conditions for Mauritania to regain eligibility for further grants.

In the past five years, GMS has assisted 78 countries, supporting 360 grants worth a total of $5.1 billion (25% of the Global Fund’s total portfolio). In doing so, GMS has provided governance training for over 2,000 CCM members and staff, and capacity-building for nearly 400 civil society organizations. Among CCMs assisted by GMS, 100% have been deemed eligible for additional grants.

Achieve High Value-for-Money

We know that achieving high value-for-money is essential, especially when demand is continuing to grow and resources are increasingly strained.

USAID’s Supply Chain Management System (SCMS) project, a key element of the PEPFAR program, is one of the world’s largest procurement and distribution sources for antiretroviral drugs and related AIDS supplies to developing countries hardest hit by HIV & AIDS. It supports more than 2 million people on ART— nearly a quarter of the worldwide total—in more than 50 countries. Through pooling of country requirements, generic procurement, and long-term contracts, SCMS has saved the U.S. government at least $1 billion since its inception in 2005. SCMS also has saved more than $76 million in freight by switching from 100% air to 80% sea and land. This has been possible through the combination of global reach, regional distribution centers, and local presence to ensure strong forecasting. The net result of these efforts has been to lower the average delivered cost of ART drugs to $100-200 per patient per year – down roughly 90% from the 2003 figure.

SCMS is implemented by the Partnership for Supply Chain Management (PFSCM), a nonprofit organization led by MSH and John Snow, Inc., with 13 international partners. The SCMS model has not only proven remarkably cost-efficient for PEPFAR purchases, but also has helped host countries achieve better value-for-money. In 2009, PEPFAR committed to a one-time, two-year infusion of $110 million for SCMS to purchase ART drugs on the international market and distribute them to 10 South African provincial warehouses. The project achieved 48% savings over prices paid by the South African government in its previous tender and succeeded in distributing more than 20 million units of ART drugs in less than two years. The South African ministry of health credits the project with playing a major role in establishing procurement and distribution reforms in the country. The ministry announced in December 2010 that these efforts resulted in a 53% reduction in the prices it paid for ART drugs, resulting in savings of US$630 million.

“Turning the Tide Together”

After two decades of denial and dithering through the 1980s and 1990s, AIDS 2000 in Durban, South Africa, proved to be the tipping point for scaling up the HIV response. In rapid succession came the Millennium Development Goals (2000), UN Generally Assembly Special Session on AIDS (2001), creation of the Global Fund (2002), and launch of PEPFAR (2003). A decade later, we know a great deal more about how to build programs that are organizationally sustainable (even if not yet financially sustainable), that empower local leadership, and that provide high value-for-money. We know these programs can be scaled up to reach those people most in need. And we know strengthening health systems for AIDS can contribute to other health initiatives.

Turning the tide together may mean different things to different people. But to realize the vision of the end of AIDS, one thing it must mean to all of us is leveraging successful HIV & AIDS interventions by building on what we know.

Jonathan D. Quick, MD, MPH, is president and chief executive officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.