HIV This Week

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.

Abstract 

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.

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!

"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”!

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.

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.