Thirty Years of HIV Programming: What’s Next?

Thirty Years of HIV Programming: What’s Next?

Thirty years ago, we learned of a disease that began with a few cases and quickly transformed into an epidemic the world had not seen before. We were not exactly sure what it was, how it was spread, or how to care for people who had it. HIV & AIDS has had a dramatic impact on the world – and especially on people in low and middle income countries. Over the past 30 years, AIDS programming responses have changed due to developments in public health science, politics, economics, and organizational capacity.

As we look through the past thirty years, there have been three distinct generations of AIDS responses and programming. In the 1980s, what we refer to as the Zero Generation, there was no effective response. Little was known and little was done about HIV & AIDS. Prevention was rudimentary, treatment nonexistent, and funding limited.

By 1990, the epidemic was already showing signs of spiraling out of control. The First-Generation programs were characterized by limited funding, a focus on prevention, continued denial in many parts of the world, and—as before— essentially no treatment in low- and middle-income countries.

As we reached the Second-Generation, in the 2000s, programming switched to an emergency response.
Since 2000, the expansion of political and financial support has been massive, through the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the US President’s Emergency
Plan for AIDS Relief (PEPFAR), and other mechanisms. By 2008, Second-Generation AIDS programs had achieved the largest scale-up of public health treatment in the history of Africa. However, prevention efforts still lagged, and less than half of people eligible for anti-retroviral therapy in low and middle income countries could access it.

Now, we are in the Third-Generation of AIDS programming, in which the focus must be on a sustainable, health systems response, especially in the countries most affected by HIV & AIDS. Mounting a health systems approach requires a shift from a fragmented approach to an approach based on a vision of holistic, high-performing system. This response will depend on three characteristics: integration, efficiency, and sustainability.

Integrating AIDS services with other health services helps revitalize primary health care services and strengthen the whole system. In Haiti, for example, HIV services are being integrated with family planning services. Over 88 Preventing Mother-to-child Transmission of HIV (PMTCT) sites are offering family planning services and other sites throughout the country are interested in not only integrating family planning services, but maternal health services as well. Integrating services maximizes the potential of scarce resources. To integrate services successfully, our colleagues in Haiti say it requires: initial investments from donors, training and motivation of staff, reorganization of health sites, a steady supply of inputs, and infrastructure renovations. It can be done and when done with a heavy community component it brings health services much closer to the people most in need.

Achieving the same or higher quality of services for the same or lower cost and focusing on cost-effective interventions that achieve greatest impact is essential for a health systems response. The Supply Chain Management System (SCMS) project, part of PEPFAR and administered by USAID, is a model of true efficiency. Today, SCMS provides about 63% of all anti-retroviral (ARVs) medicines supplied by PEPFAR, supporting about 1.2 million people on treatment. SCMS has procured more than $860 million worth of ARVs and other health commodities and saved more than $700 million on ARV purchases. While helping lower the cost of HIV medicines, SCMS has simultaneously almost completely eliminated stock outs of HIV & AIDS commodities in PEPFAR-supported countries. Thanks to a groundbreaking initiative by U S Food and Drug Administration to approve generic ARVs for use in PEPFAR-supported countries, more than 95 percent of ARVs procured by SCMS are generic at prices that beat or match those of every other international supplier in almost every instance. SCMS has helped lower the average cost of ARVs to an affordable $100 to $200 per year per patient, down from about $1,500 per patient per year in 2003. SCMS innovative supply chain solutions prove that it is possible for struggling health systems to improve their services and streamline their efforts to provide better care to their patients. The improvements SCMS has made in providing HIV & AIDS medicines and supplies make the entire health system stronger. Emphasis on efficiency of AIDS programs reduces the waste of resources. SCMS is led by the Partnership for Supply Chain Management—a nonprofit organization with 17 international partners established by MSH and John Snow, Inc.

Sustainability is also critical to the success of a health systems approach to HIV & AIDs programming. We must continue to build the local capacity of people and organization as well as strong partnerships that have the potential to expand with need; using available resources wisely. MSH is working to host more capacity building events to empower local organizations and build their capacity, similar to the event held in Nigeria for local civil society organizations. At the ministry level, programs must work in a close partnership with the Government, so they own the services and interventions provided in their countries. In Ethiopia, the Government is leading the way in HIV programming. This leadership, as our colleague Haile Wubneh describes, will make the interventions sustainable and long-lasting.

The Third-Generation response of health systems strengthening will help prepare countries not only for a continued HIV response, but also will position them to provide quality care for chronic diseases and non-communicable diseases. Third-Generation programs will need both policy and programming modifications to succeed, but together we can ensure that this approach works.

Jonathan D. Quick, MD, MPH is President and Chief Executive Officer of MSH. Dr. Quick has worked in international health since 1978, he is a family physician and public health management specialist.