Articles tagged as "Global / multilateral and bilateral responses"

New framework for delivering high-value care to patients with HIV/AIDS and co-occurring conditions

Redefining global health-care delivery.

Kim JY, Farmer P, Porter ME. Lancet. 2013 May 17. pii: S0140-6736(13)61047-8.

Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded significantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-effectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering efforts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and co-occurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of effective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.

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Editor’s notes: In this conceptual article, the authors propose a framework to guide effective health care delivery in resource-poor settings that builds on the concept of value chains from business management, in which production processes within firms are a chain of activities that produce valuable goods and services. In this framework, value is defined as a measure of aggregate health outcomes achieved per dollar spent, rather than health programme results. Rather than considering the intervention for a particular disease or condition as the basic unit of analysis, this framework suggests that value can be created at four levels, i.e. by integrating care for every individual medical condition, by using shared delivery infrastructure, by incorporating knowledge of local socio-economic constraints into care delivery, and finally by designing health systems to maximize their contribution to economic development. The authors provide another compelling rationale for the integration of health service delivery and systems, as well as complex external determinants of heath.

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Scarcity of funding and well-trained health workers hampers large-scale implementation of ART in sub-Saharan Africa

Cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment in South Africa: pragmatic cluster randomised trial

Garry R. Barton, Lara Fairall, Max O. Bachmann, Kerry Uebel, Venessa Timmerman, Carl Lombard and Merrick Zwarenstein. Trop Med Int Health. 2013 Mar 11. doi: 10.1111/tmi.12093. [Epub ahead of print]

OBJECTIVE: To estimate the cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment (ART) for HIV-infected people.

DESIGN:  Cost-effectiveness analysis alongside a pragmatic cluster randomised controlled trial in 31 primary care clinics (16 intervention, 15 controls) in Free State Province, South Africa. Participants were HIV-infected patients, aged 16 years. Cohort 1 (CD4 count 350 cells/ μl, not yet receiving ART at enrolment): consisted of 5 390 intervention patients and 3 862 controls; Cohort 2 (already received ART for 6 months at enrolment) of 3 029 intervention patients and 3 202 controls. Nurses were authorised and trained to initiate and re-prescribe ART. Management and ART provision were decentralised to primary care clinics. In control clinics, doctors initiated and re-prescribed ART, nurses monitored ART. Main outcome measure(s) were health service costs, death (cohort 1) and undetectable viral load (<400 copies/ml) (cohort 2) during the 12 months after enrolment.

RESULTS: For Cohort 1, the intervention had an estimated incremental cost of US$102.52, an incremental effect of 0.42% fewer deaths and an incremental cost-effectiveness ratio (ICER) of US $24 500 per death averted. For Cohort 2, the intervention had an estimated incremental cost of US $59.48, an incremental effect of 0.47% more undetectable viral loads and an ICER of US$12 584 per undetectable viral load.

CONCLUSIONS: Nurse-led ART was associated with higher mean health service costs than doctor-led care, with small effects on primary outcomes, and a high associated level of uncertainty. Given this, and the shortage of doctors, further implementation of nurse-led ART should be considered, although this may increase health service costs.

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Editor’s notes: The large scale implementation of antiretroviral treatment in sub-Saharan Africa is hampered by a scarcity of finance and trained health workers (UNAIDS 2010). Task shifting of ART provision from doctors to other health workers is increasingly used to expand ART provision, and is being promoted as a means to scale up HIV treatment in an affordable way. Intervention clinics implemented STRETCH, a complex educational and organizational health systems intervention. This trial compared the impact of doctor and nurse led models of ART provision.  Importantly, the STRETCH intervention of nurse-led ART was associated with higher health service costs and a small statistically non-significant effect on mortality among patients awaiting ART and equivalent viral load suppression rates for patients already on treatment, compared with doctor-led ART. There were some improvements in TB detection, CD4 count and weight. However, levels of uncertainty were high, with wide confidence intervals around the incremental costs and effects. Surprisingly, however, the costs of nurse led care were higher, as a result of more frequent clinic visits with longer consultations. The findings provide some support for this shift as nurses were able to provide more contacts and spend more time with patients; they also achieved improvements in certain outcomes. Based on these results, implementation of nurse-led ART may, however, increase healthcare costs.

South Africa
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Long-term costs and health impact of continued global fund support for antiretroviral therapy

Stover J, Korenromp EL, Blakley M, Komatsu R, Viisainen K, Bollinger L, Atun R. PLoS One. 2011;6(6):e21048.

By the end of 2011 Global Fund investments will be supporting 3.5 million people on antiretroviral therapy in 104 low- and middle-income countries. Stover and colleagues estimated the cost and health impact of continuing treatment for these patients through 2020. Survival on first-line and second-line antiretroviral therapy regimens is estimated based on annual retention rates reported by national AIDS programmes. Costs per patient-year were calculated from country-reported antiretroviral procurement prices, and expenditures on laboratory tests, health care utilisation, and end-of-life care from in-depth costing studies. Of the 3.5 million patients on antiretroviral therapy in 2011, 2.3 million will still need treatment in 2020. The annual cost of maintaining antiretroviral therapy falls from $1.9 billion in 2011 to $1.7 billion in 2020, as a result of a declining number of surviving patients partially offset by increasing costs as more patients migrate to second-line therapy. The Global Fund is expected to continue being a major contributor to meeting this financial need, alongside other international funders and domestic resources. Costs would be $150 million less in 2020 with an annual 5% decline in first-line ARV prices and $150-370 million less with a 5%-12% annual decline in second-line prices, but $200 million higher in 2020 with phase out of stavudine (d4T), or $200 million higher with increased migration to second-line regimens expected if all countries routinely adopted viral load monitoring. Deaths postponed by antiretroviral therapy correspond to 830,000 life-years saved in 2011, increasing to around 2.3 million life-years every year between 2015 and 2020. Annual patient-level direct costs of supporting a patient cohort remain fairly stable over 2011-2020, if current antiretroviral prices and delivery costs are maintained. Second-line antiretroviral prices are a major cost driver, underscoring the importance of investing in treatment quality to improve retention on first-line regimens.

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Editor’s note: This analysis of the cost and impact of continuing treatment for the 3.5 million of people who are co-supported by the Global Fund, compared to stopping it, provides food for thought. For the 6.6 million people on antiretroviral therapy now, retention on treatment is excellent after the first year, based on data from 38 national AIDS programmes in 2008: 80% not dying or lost to follow-up at 1 year, 75% at 2 years, 74% at 3 years, and 73% at 4 years. If treatment were to be stopped now for those receiving it, 18% would die in the first year, 46% after two years, 64% after three years, 76% after 4 years, 84% after 5 years, and 97% after 6 years. Median survival after treatment cessation would be 2 to 3 years. If the Global Fund did not support any new people to start antiretroviral therapy, the costs to maintain those already on treatment through to 2020 would decline. Costs increase as more people are moved off d4T first-line regimens or start costly second-line regimens (24% will likely be on second-line by 2020), however deaths result in 10% reduced costs overall. Antiretroviral drugs constitute 42% of first-line regimen and 81% of second-line regimen costs, underscoring the importance of further price reductions. Routine viral load testing, CD4 cunts, and clinical monitoring for timely detection of and responses to adherence difficulties, will prevent unnecessary switching to second-line regimens. The most striking finding is the number of life-years saved each year¾it rises to 2.3 million by 2017 when virtually everyone treated today would have died in the absence of treatment. Setting aside moral, ethical, and treatment for prevention arguments, continued and increased investment in antiretroviral treatment makes economic sense, not only for those already on treatment but also for those eligible and waiting. 

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Civil society responses

The effects of national and international HIV/AIDS funding and governance mechanisms on the development of civil-society responses to HIV/AIDS in East and Southern Africa

Kelly KJ, Birdsall K. AIDS Care. 2010;22 Suppl 2:1580-7

This study takes stock of the exponential growth in the number of new civil-society organisations working in the HIV field in East and Southern Africa during the period 1996-2004. Kelly and Birdsall researched this development through a survey of 439 civil-society organisations in six countries and case studies focused on the evolution of community responses to HIV in specific communities in eight countries. The authors describe the types of civil-society organisations that emerged, their relationships with governments and donors, and their activities, organisational characteristics, and funding requirements. The data presented show that the vision of social mobilisation of HIV responses through community-level organisations has faced strong external challenges. Evidence from survey data, national HIV spending assessments, and case studies shows that in some respects the changing international aid environment undermines the prospects for development of the civil-society sector's contributions in HIV responses. Of particular interest is to understand how the "Three Ones" and the Paris Declaration on Aid Effectiveness have reshaped international funding for HIV responses. There has been relatively little attention paid to the impact of the new management and funding modalities - including national performance frameworks, general budget support, joint funding arrangements, and basket funds - on civil-society agencies at the forefront of community HIV responses. Evidence is presented to show that in important respects the new modalities limit the unique contribution that civil-society organisations can make to national HIV responses. It is also shown that the drive to rapidly intensify the scale of HIV responses has involved using community organisations as service providers for externally formulated programmes. The authors discuss this as a strong threat to the development of sustainable civil-society economies as well as to civil-society organisations' diversity and responsiveness. The ways in which civil-society organisations are responding to these challenges are discussed, pointing to possibilities for a new phase of development of the civil-society sector.


Editors’ note: If you work at country level, or support those that do; if you are interested in capacity building; or if you want to know how AIDS financing, the Three Ones, and the Paris Declaration on Aid Effectiveness have affected civil society responses to HIV, then this is essential reading for you. Surveys in high HIV prevalence countries (Lesotho, Malawi, Mozambique, Namibia, Swaziland, and Zambia) and case studies in these 6 countries plus South Africa and Tanzania reveal the concerning effects that AIDS funding architecture has had on the work of community- and national-level civil society organisations. A ‘scaling out’ has occurred of medium-sized national non-governmental organisations with long, strong track records that had previously received financial and capacity-building support through direct funding from bilateral donors. Pioneering, ‘on the ground’ civil society organisations, often the heart of the community-driven response reaching those most in need, now have fragile futures due to the unpredictability of funding. Further, that funding does not include investment in basic operating costs, organisational planning, or capacity development. National-level and community-level civil society organisations act predominantly now in service-provision roles, often as sub-contractors without opportunities to develop capacity to design, plan, budget, or implement programmes that are not externally mandated. Clearly, there is a need for long-term strategic thinking at national and international levels about how best to strengthen civil society’s country- and community-level contribution to the response – it is losing its diversity and its voice.

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Millennium Development Goals

Drivers of inequality in millennium development goal progress statistical analysis

Stuckler D, Basu S, McKee M. PLoS Med. 2010;7:e1000241.

Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). The authors evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. They also examined the impact of joint epidemics of HIV and noncommunicable diseases, which may limit the ability of households to address child mortality and increase risks of infectious diseases. Stuckler and colleagues calculated each country's distance from its MDG goals for HIV, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. They studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV burden (prevalence rates among ages 15-49 y), and noncommunicable disease burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, they analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not  explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and noncommunicable diseases explained more than half of between-country inequalities in child mortality progress (R(2)-infant mortality = 0.57, R(2)-under 5 mortality = 0.54). HIV and noncommunicable disease burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R(2) = 0.57), with noncommunicable diseases having an effect independent of HIV, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, the authors found that lower burdens of HIV and noncommunicable diseases were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from noncommunicable diseases would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries.  Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and noncommunicable diseases in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between noncommunicable diseases, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households--whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).

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Editors’ Note: This thought-provoking article is essential reading for everyone focused on the 8 Millennium Development Goals (MDG), their 21 quantifiable targets, and 60 indicators of progress. It is a first attempt to analyse the determinants of global inequalities in progress toward the health MDGs 4 and 6. The 2015 targets and indicators for the 3 health MDGs are summarised in a box that would be handy on the wall above your desk. Unmet MDG progress in infant, child, and tuberculosis (TB) mortality, as well as HIV prevalence, suggests that fewer than half of low-income countries will achieve the 2015 targets for MDGs 4 and 6. This intriguing analysis of 227 countries found that likely explanatory suspects such as economic development (gross domestic product [GDP]), health spending as a per cent of GDP, and numbers of physicians per capita together explained only one-fifth of the differences in progress on these health MDGs between countries. What is making the difference? Burdens of HIV and non-communicable diseases (NCD) explained more than half of differences in infant mortality progress and were strongly associated with unequal progress on TB. A 1% drop in HIV prevalence or a 10% decline in mortality from non-communicable diseases such as heart disease, diabetes, cancer, tobacco-related lung disease, disabling mental disease, and accidents, would improve a country’s progress on TB as much as if its GDP rose by an unlikely 80%. For child mortality, the magnitude of effect was similar to a 40% rise in GDP. We know the strong links between HIV and TB, HIV and infant mortality, and HIV and under-five child mortality. However, we have underestimated the effects in low-income countries of co-existing epidemics of obesity due to the ‘nutrition transition’, lung disease due to aggressive marketing of tobacco products, and decreased physical activity due to urbanization on achievement of the health MDGs. Since the poorest households often face the greatest burden of non-communicable diseases and HIV, as well as being the most affected by child mortality and TB, we need to investigate these interrelationships and address them explicitly to get on track for 2015.
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Universal access

Estimation of antiretroviral therapy coverage: methodology and trends.

Mahy M, Tassie JM, Ghys PD, Stover J, Beusenberg M, Akwara P, Souteyrand Y. Curr Opin HIV AIDS. 2010 5:97-102.

The purpose of this review was to present the methodology used to calculate coverage of antiretroviral therapy and review global and regional trends in antiretroviral therapy coverage. There has been a steady increase in antiretroviral therapy coverage over the last decade with a more rapid increase in recent years. Current estimates of antiretroviral therapy coverage are 43% for adults and 38% for children (ages 0-14 years). Methods for calculating coverage rely on good-quality patient monitoring systems in countries, and well informed models are needed to estimate the number of people in need of treatment. The estimated coverage rates show that antiretroviral therapy programs have improved over the past 8 years; however, approximately 58% (53-60%) of those people in need of antiretroviral therapy are still not on treatment. High quality data are needed to accurately measure changes in antiretroviral therapy coverage.

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Editors’ note:  Antiretroviral treatment coverage is defined as the percentage of people on treatment (the numerator) among those in need of treatment (the denominator). Few countries, notably Brasil and Zambia, have a monitoring system based on individual information. Elsewhere facility-based reporting of aggregated data based on patient and pharmacy monitoring is compiled to produce a national level estimate. In 2008, 91% of 149 low- and middle-income countries reported the number of people on antiretroviral treatment and 64% reported disaggregating data by sex. The estimated 9.5 million (8.6-10 million) people currently in need of antiretroviral treatment will be joined by many million more as countries begin to adopt the new WHO antiretroviral treatment guidelines. Therefore, although the numerator (those on treatment), estimated at over 4 million (3.7-4.4 million) in 2008, is steadily growing, the denominator is set to rise dramatically. Regardless of whether the old or the new denominator or both are used to determine coverage, the focus should be on accelerating the growth of the numerator!
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Knowledge translation

How can we support the use of systematic reviews in policymaking?

Lavis JN. PLoS Med. 2009;6:e1000141. Epub 2009 Nov 17.

Policymakers need many types of research evidence—synthesized and packaged for them —and the use of this evidence supported in multiple complementary ways. Stakeholders who seek to influence the policymaking process have the same requirements. Policymakers and stakeholders need many types of systematic reviews. For example, reviews of qualitative studies can help to identify alternative framings of the problem, to understand how or why a policy or program option works, and to appreciate stakeholders' perspectives on particular options. Policymakers and stakeholders now have access to many review-derived products: (1) summaries of systematic reviews highlighting decision-relevant information; (2) overviews of systematic reviews providing a “map” of the policy questions addressed by systematic reviews and the insights derived from them; and (3) policy briefs drawing on many systematic reviews to characterize a problem, policy or program options to address the problem, and implementation strategies. A range of activities are being undertaken to support the use of reviews and review-derived products in policymaking, all of which warrant rigorous evaluation. Future challenges include: (1) examining whether and when any apparent duplication of efforts occurs in the production of review-derived products at the international level; and (2) scaling up activities that are found to be effective in supporting the use of reviews and review-derived products in policymaking.

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Editors’ note: Informative systematic reviews of the evidence are needed at different steps in the policymaking process and can include reviews of qualitative studies of people’s views to help identify alternative framings of a problem. The insights derived from reviews can compete with institutional constraints, interest group pressure, citizens’ values, and policymakers’ past experiences, to name some of the influences, but they should be on the table throughout the process. Political events can create windows of opportunity for the results of reviews to be considered. Factors that increase the use of research evidence in policymaking include increased interactions between researchers and policymakers, timeliness, and good agreement between research evidence and the beliefs, values, interests or political goals of policymakers.

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Health systems strengthening

"Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings.


Braitstein P, Einterz RM, Sidle JE, Kimaiyo S, Tierney W. J Acquir Immune Defic Syndr. 2009 Nov;52(S1).


Health care for patients with HIV infection in developing countries has increased substantially in response to major international funding. Scaling up treatment programs requires timely data on the type, quantity, and quality of care being provided. Increasingly, such programs are turning to electronic health records to provide these data. The authors describe how a medical school in the United States and another in Kenya collaborated to develop and implement an electronic health records system in a large HIV care program in western Kenya. These data were used to manage patients, providers, and the program itself as it grew to encompass 18 sites serving more than 90,000 patients. Lessons learned have been applicable beyond HIV to include primary care, chronic disease management, and community-based health screening and disease prevention programs. Electronic health records will be key to providing the highest possible quality of care for the funds developing countries can commit to health care. Public, private, and academic partnerships can facilitate the development and implementation of electronic health records in resource-constrained settings.


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Editors’ note: Quality health care depends, among other things, on collecting, analysing, and using timely health information. Well managed health information management systems can help programme managers plan deployment of personnel, avoid drug stockouts, and maximise resource use. But, first and foremost, meeting clinicians’ requirements for complete and accurate data is key to ensuring high-quality care for patients. Electronic medical records using unique identifiers while protecting patient confidentiality and data security help coordinate care across multiple venues and specialities. Patients can be notified quickly of drug recalls or eligibility for novel treatments and can use their laminated personal card to access care throughout the health system. Investment in electronic health records for patients in antiretroviral treatment programmes is reaping benefits in low- and middle-income countries that are expanding data capture and management to support the scale up of efficient, effective clinical services for other conditions. We really are “talkin’ about a revolution”!

Strategies for More Effective Monitoring and Evaluation Systems in HIV Programmatic Scale-Up in Resource-Limited Settings: Implications for Health Systems Strengthening.


Nash D, Elul B, Rabkin M, Tun M, Saito S, Becker M, Nuwagaba-Biribonwoha H. J Acquir Immune Defic Syndr. 2009 Nov;52(S2).


Program monitoring and evaluation has the potential to be a cornerstone of health systems strengthening and of evidence-informed implementation and scale-up of HIV-related services in resource-limited settings. The authors discuss common challenges to monitoring and evaluation systems used in the rapid scale-up of HIV services as well as innovations that may have relevance to systems used to monitor, evaluate, and inform health systems strengthening. These include (1) Web-based applications with decentralized data entry and real-time access to summary reporting; (2) timely feedback of information to site and district staff; (3) site-level integration of traditionally siloed program area indicators; (4) longitudinal tracking of program and site characteristics; (5) geographic information systems; and (6) use of routinely collected aggregate data for epidemiologic analysis and operations research. Although conventionally used in the context of vertical programs, these approaches can form a foundation on which data relevant to other health services and systems can be layered, including prevention services, primary care, maternal-child health, and chronic disease management. Guiding principles for sustainable national monitoring and evaluation systems include country-led development and ownership, support for national programs and policies, interoperability, and employment of an open-source approach to software development.


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Editors’ note: This article starts with a diagnosis of the challenge of providing timely and useful feedback to key staff at individual health facilities when information is hand tallied from paper-based sources and reported up to district, regional, national, and international agencies on schedules that reflect the latter’s needs. When the objective is continuous improvement of quality, scale, equity, and impact of services, the benefits of web-based real-time systems using solar powered mobile phones for data entry (such as Rwanda is developing) are evident. Overcoming silos in HIV monitoring and evaluation systems, each one designed for its own programme (e.g. antiretroviral treatment, prevention of mother-to-child transmission, voluntary counselling and testing), is key to moving forward to systems that integrate disease- or programme-specific data within broader primary care.

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Influenza and HIV

Pandemic influenza: implications for programs controlling for HIV infection, tuberculosis, and chronic viral hepatitis.


Heffelfinger JD, Patel P, Brooks JT, Calvet H, Daley CL, Dean HD, Edlin BR, Gensheimer KF, Jereb J, Kent CK, Lennox JL, Louie JK, Lynfield R, Peters PJ, Pinckney L, Spradling P, Voetsch AC, Fiore A. Am J Public Health 2009; 99(S2)


Among vulnerable populations during an influenza pandemic are persons with or at risk for HIV infection, tuberculosis, or chronic viral hepatitis. HIV-infected persons have higher rates of hospitalization, prolonged illness, and increased mortality from influenza compared with the general population. Persons with tuberculosis and chronic viral hepatitis may also be at increased risk of morbidity and mortality from influenza because of altered immunity and chronic illness. These populations also face social and structural barriers that will be exacerbated by a pandemic. Existing infrastructure should be expanded and pandemic planning should include preparations to reduce the risks for these populations.


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Editors’ note: This article highlights the importance of pandemic influenza plans that include specific actions to reduce the risk of influenza among people living with HIV, tuberculosis or viral hepatitis and maintain continuity of care and prevention services. In the case of HIV, it is critical to prevent disruptions in the supply of antiretroviral drugs and to anticipate and mitigate personnel shortages to avoid the erratic dosing and sub therapeutic drug levels that can lead to disease progression and viral resistance. Improving rates of annual vaccination against seasonal influenza among people living with HIV, their caretakers, and health care providers is an obvious step. The higher risk of complications among young people with chronic medical conditions, in the case of the H1N1 influenza, underscores the importance of receiving the H1N1 vaccine if this description fits you.

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Monitoring and Evaluation

Are We on Course for Reporting on the Millennium Development Goals in 2015?

Rugg D, Marais H, Law BA, Carael M, De Lay P, and, Warner-Smith M. J Acquir Immune Defic Syndr. 2009;52(S2)

At the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS), Member States agreed to regularly review progress made in national responses to HIV. This article provides a brief overview of how the resultant global UNGASS reporting system was developed; the origins, background, limitations and potential of that system; an overview of the articles in this supplement; and crosscutting institutional and methodological issues. The United Nations Member States biennially provide The Joint United Nations Programme on HIV/AIDS (UNAIDS) with data on 25 core indicators of national responses to HIV, collected in Country Progress Reports. This article critically reviews and interprets these data in light of international political considerations and overall data needs. There has been a considerable improvement in response rates, accompanied by an increase in data quality and completeness. Both nationally and internationally, the UNGASS process is viewed as being more substantial and important than a reporting exercise to the United Nations General Assembly. The process has catalyzed the development of national monitoring systems and has created opportunities for civil society to monitor and challenge government commitments and deeds. Although the UNGASS global reporting system now comprises an unequalled wealth of data on HIV responses, collected from a broad range of countries, it cannot yet answer several critical questions about the progress and effectiveness of those responses. Evaluation studies that go beyond indicator monitoring are needed, but they will take time to design, fund, implement and interpret. In the meantime, this global monitoring system provides a good indication of the overall progress in the global response to HIV and whether Millennium Development Goal (MDG) 6 (to halt and reverse the HIV epidemic) is likely to be reached by 2015.

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Editors’ note: Providing an overview of the monitoring effort underway to track progress toward achieving the 2001 UNGASS Declaration of Commitment, Universal Access by 2010, and Millennium Development Goal 6 by 2015, this article sets the stage for 10 accompanying related papers. There has been significant progress in harmonising indicators and reporting schedules, and strengthening rather than bypassing or overburdening domestic monitoring systems and capacities. However, tensions between, on the one hand, the need for locally useful data to inform programming decisions and improve accountability toward beneficiaries and, on the other hand, the need for data to meet national and international reporting requirements should be acknowledged and addressed. Effective implementation of evidence-informed appropriate HIV prevention, treatment, care and support programmes at scale, with feedback loops to improve quality and outputs, will translate into fewer HIV infections and longer, more productive lives for people living with HIV. Monitoring and evaluation play a supportive but essential role in keeping the train on the track. 

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