Morning Session

1. Simon Maxwell opened the meeting by saying what an exciting opportunity it gave. It brought together a range of experts to take the discussion beyond current discourse and understand what it means to set targets, how these can be reached and how this impacts on other sectors. Strong commitments have been made by the international community to reduce HIV/AIDS, but this inevitably has a knock on effect for other sectors and implications for the relationship between health systems and public expenditure management. He ask why we can say there will be treatment for HIV but not guarantee to meet the nutritional needs of every under five year old?

2. Prof Gilks asked the question: Do big plans help big numbers? His talk aimed at assessing progress and achievements three years after the launch of the 3 by 5 initiative (2003) to meet the 'treatment gap' for a target of 3 million HIV positive people by the end of 2005. The set target is time limited and people bound, making it ambitious, but it does respect universal human rights.

3. It is unusual for a treatment intervention to be considered as public health as is the case with the 3 by 5 initiative. This approach provides testing and counselling including routine tests; standardised and simplified treatment strategies; and surveillance and monitoring of drug resistance.

4. The approach raises a complex set of issues such as whether routine testing is offered even if treatment is unavailable. The drug strategies involve a first and second line of treatment with 3 types of drug combinations - an approach very different from the individualised practises in North America and Europe. The system for tracking patients and follow up is enormously complicated, including the monitoring of drug resistance and the management of drug toxicity and resistance.

5. Comprehensive aims include supporting a simple treatment intervention right down to community level and into the home, providing paediatric care and bringing down drug prices. He asked what will happen after the WHO 3 by 5 initiative and made recommendations for first line therapy drugs, a market developed with 22 producers approved or pre-qualified by the FDA. With the introduction of this market prices have fallen by 40-50%, although there are some drugs with limited generic manufacture so prices remain high for some products.

6. He made the following points in his assessment of the 3 by 5 initiative:

- Treatment is extremely effective. These are very sick people with severe immuno- suppression and with clinical disease. Without treatment the median level for survival is 1.2 years. After treatment in this regime 94% of those treated are surviving 2 years. And this is before switching to second line treatment. This is better result then at some clinics in the US and Europe. After 2 years of treatment there is a 17 fold reduction in mortality.
- 1.3 million are now on treatment - so 3 by 5 did not hit the target of 3 million, but this was an over ambitious aim. There is now a global coverage of 20% of those in need of treatment so there has been substantial progress.
- Botswana, which has a prevalence rate of 25% percent of all adults, has 75% of people in need of care on treatment. Namibia and Uganda are over 50% in excess of the 3 by 5 target. Other countries, however, have done less well.
- In terms of equity (considering the top 40 countries with data) there is no real distortion in favour of men accessing treatment. Maybe in fact, a slight excess in women - this is because women are, in general, much better users of public health services. Plus they get tested during pregnancy - and this is an important entry point.
- In Malawi in 2003 there were 3 sites only with treatment. By end 2005 there were sites in 31 of 32 different districts and coverage is probably best for the non urban populations. This proves that equity for rural poor can be achieved.

7. He concluded by stating that target driven approach can work. Anti-retroviral therapy is a response to HIV/AIDS which is not prevention or treatment - it is both. He said there is a need to move towards evidence based standards, co-ordinated responses and a simple process for tracking progress. These systems are still in their infancy compared to progress made in treatment.

8. He identified two challenges:

- First, the need to be careful that as the treatment bandwagon rolls on, prevention is not left behind. Prevention is less appealing to medically trained doctors whose trade is to advance cures. It is also easy to set treatment targets but difficult to set prevention targets that have political traction and are understandable. Prevention is also multi-sectoral and involves many partners so co-ordination is challenging
- Second, the big challenge is chronic disease management - in this case sustaining lifelong treatment. It is important to build health systems which are staffed by people who are paid decently. Ultimately a focus on person centred care in the community is needed.

9. Finally, Gilks paid homage to the late director General Dr LEE Jong-wook who died on 22 may last month. He was inspiration for 3 by 5 and without him we would be languishing very far behind in closing the treatment gap. He catalysed this in the UN system and we are saddened by his untimely and early death and grateful for his immense contributions to our work in HIV/AIDS.

10. Ini Huijts presented on harmonizing scaling up efforts. She began by asking if a new consensus on aid was emerging following the Paris Declaration on Aid Effectiveness (March 2005) with its commitments to MDG-based national development plans, strong national ownership and greater predictability of aid flows.

11. She outlined an aid effectiveness pyramid, in which results and mutual accountability are clear in ownership of initiatives by partner countries, donor-partner alignment and donor-donor harmonisation.

12. She explained the 'Three Ones Principles' as:
o One agreed AIDS action framework that provides the basis for coordinating the work of all partners;
o One national AIDS authority, with a broad-based multisectoral mandate;
o One agreed country-level monitoring and evaluation system.

13. The UNAIDS Global Task Team makes recommendations in 4 areas:
1. Empowering inclusive national leadership and ownership
2. Alignment and harmonization
3. Reform for a more effective multilateral response
4. Accountability and oversight

14. She explained that the UNAID Global Task Team developed global commitments, linked to the aid effectiveness agenda, to support implementing the 'Three Ones' principles at country level. Targets are set by countries. She identified a number of challenges and opportunites. Challenges include the level of participation, deciding the centralizing authority, GIPA, reaching vulnerable groups, civil society capacity and government capacity. Opportunities exist to foster collaboration, focus on marginalized groups, harness civil society expertise, connect monitoring and evaluation and assess the progress of 'Three Ones'.

15. She outlined progress so far:
o GIST-process has resulted in problem solving and emergency assistance in nine countries and one region
o Division of Labour agreed globally
o Joint Programming & joint UN Team on AIDS including adaptation of Division of Labour to country reality and support to national strategy needs
o Assistance to countries in integrating AIDS in their PRSPs
o Co-ordinated support to procurement & supply
o Global Fund and World Bank developing strategies for greater alignment, joint missions and joint reviews
o Country Harmonisation and Alignment Tool

16. Challenges remain:
o The UNAIDs Global Task Team focuses on multilaterals. Bilaterals and INGOs also need to align to national priorities.
o There is a lack of connection between the response to AIDS and the broader international response to development more often typified by budgetary support and PRSP modalities
o Commitments and good practices espoused by the OECD, and agreed to at Paris and Rome, must be applied more robustly in the response to AIDS.
o Reforming UN structures and processes to strengthen, harmonise and align
o Support for national strategy development, costing and target setting
o Impact at country level of commitments to harmonisation in the AIDS field

17. She concluded with a summary of what is needed to scale up treatment:
o Global to country level action via
- Predictable and sustainable financing;
- Health system strengthening including human resources;
- Affordable commodities;
- Addressing stigma, discrimination, gender and human rights.
o Effective implementation of Three Ones Principles:
- Functional national coordination structures with effective participation of all stakeholders
- National AIDS frameworks and operational annual plans including realistic targets, and
- National M&E system with one consensus list of indicators and inclusive of all relevant data sources
o Real harmonisation and alignment around outcomes of Three Ones process at country level
o Accountability

18. Caroline Ryan began by providing an overview of the President's Emergency Plan for AIDs Relief (PEPFAR). It is a 5-year, USD$15 billion plan aimed at 120 countries round the world. There are 15 focus countries, mostly in Sub-Saharan Africa.

19. US contributions to funding for HIV/AIDs work in focus countries have increased since the start of the PEPFAR initiative (2004). 75% of treatment funds are required to be used for purchase and distribution of ARVs; 33% for abstinence-until-marriage programs. During 2005, PEPFAR supported training for individuals; project sites and indigenous organizations.

20. Ryan identified challenges including:
o Resource-poor nations face significant limitations in capacity
- Physical infrastructure
- Human resources
- Systems
o Management
o Financial
o Supply chain
o Quality
o Strategic information

21. She identified an advantage of 'big plans' in drug quality, approvals and regulations. The HHS/FDA introduced a review and inspection process in May 2004 whereby ARVs from anywhere, produced by any manufacturer could be rapidly assessed and if approved or tentatively approved made eligible for purchase under PEPFAR.

22. On addressing the needs of women and girls, Ryan said:
o Approximately 60% of those receiving antiretroviral treatment were women
o Over 3.2 million pregnant women have accessed PEPFAR-supported prevention of mother-to-child services
o Approximately 69% of those who received HIV counseling and testing were women
o Among the orphans and vulnerable children served by PEPFAR activities, 52% were girls

23.Ryan outlined the objectives of supply chain management:
To create, enhance, and promote an uninterrupted supply of high-quality, low-cost products that flow through accountable systems which can:
- Rapidly scale up to support HIV/AIDS prevention, treatment, and care
- Ensure quality of drugs, test kits, and other supplies
- Build capacity for long-term sustainable procurement and distribution of drugs and commodities
- Respect intellectual property law at international and national levels

24. She gave the example of Nigeria as a case where PEPFAR had made progress - partners are on track to meet target and the cost per patient on ARV has declined. She concluded by identifying the next challenges:
o Need for second line drugs, adherence and pediatric formulations
o Need to focus on quality and sustainability
- Closer coordination with international partners
- Investments (e.g. training) in partner capacity
- Deepening partnership with host nations
o As national responses and national ownership mature, majority of U.S. support could become more upstream

25. Simon Maxwell asked a question on the current US line on birth control. Ryan responded that condoms are supported in the PEPFAR programme. In terms of family planning she said PEPFAR does encourage wrap around programmes linked to prevention of mother to child transmission. There ar,e however, more restrictive regulations in ability to fund programmes which support abortions.

Questions and issues from the floor

26. It is important to remember the big scaling up initiatives of the past. For example, have these HIV AIDS programmes learnt from the scaling up of immunisation? What we do know is that without functioning comprehensive health systems the scaling up will not be sustained.

27. Regarding patented medicines and new generics, it's important to remember that existing medicines also show good savings but are often ignored.

28. There is certainly huge support for the global fund and much talk about the importance of coordination but no sense as to whether it is working

29. The last speaker said the UN has technical capacity. However, as you move into multisectoral issues the UN has less capacity - in fact it generally slows things down.

30. There is progress around some forms of harmonisation - but not an alignment with health sector policies. So HIV/AIDS policies and strategies are not tied up with health sector plans.

31. To what extent are resources on non drug areas HIV specific or are resources to be used for more general healthcare as well as HIV? Panel responded that in their experience there are no common funding modalities.

32. Although HIV development practice began in the early 80s, it is still the usual thing to have interventions from the top down - when looking at empowering the local level - it is still top down - even ignoring very useful local inventions. There are systems which are better then what is being recommended from the international level. What about Africans being more involved at international level?

33. Simon Maxwell said that what was described to in the meeting is an absolutely classic example of taking a big problem and driving to a solution. WHO have applied what is effectively a fantastic engineering approach to solving a problem at a cost of many billions. But at local levels health budgets are as little as USD$8 a head, even lower, at USD$4 in Nigeria. He said he had contradictory feelings - this has been a political success mobilising the world around HIV - but on the other hand - he asked how the organisation got away with it! There is a distortion around health resources. The figure to be spent on HIV is equivalent to 25 percent of aid world wide.

34. Michel Sidbe, acting as discussant, made the following points:

1. He had just come from a high level meeting in NY. He said a declaration of USD$25 billion is about a comprehensive response talking about care and prevention and dealing with 15 million orphans. So it's not just about treatment

2. Setting targets is a major issue - it is true we need to change the way we are defining targets, making sure this is done through a process of people defining their own targets. Africa is proposing their own targets set at regional level and they can try and deliver on the target they are setting. With global targets set internationally when the pressure is off the targets get forgotten.

3. He asked whether every country should set a target and decided they should all set ambitious targets. He said trends are upwards and second line treatment is urgently needed in Africa.

4. He mentioned the impossibility of dealing with the epidemic without addressing issues of trade. He asked what the trade issues related to issues of research and development are and said these are critical issues that countries need to deal with.

Conclusions

35. Simon Maxwell asked the panel to identify two big issues for the audience to take away.

36. Innie Huijts
- We must progress harmonisation on aids and at a national level. There are capacity problems whatever way we organise. We need to align around a national response and not impose an outside agenda. National targets are a good idea and we need accountability between the international and national levels.

37. Caroline Ryan
- Progress been made - 3 by 5 encouraged people to make investments in tackling this problem. The numbers of people on drugs however, is not sufficient.

38. Charlie Gilks
- On the question of targets - some countries embraced 3 by 5 - others felt it was imposed. We can't afford to make this mistake - we need to help countries set their own targets. Civil society must then hold governments to account to meet their own targets.

- On the distortion of health priorities mentioned by Simon Maxwell - in fact the biggest distortion was the under-funding over many years of health systems. Without a well funded health system we cannot tackle AIDS. We need hundreds and thousands of health care workers at all levels. We won't get anywhere otherwise. Trying to squeeze AIDS treatment into under-resourced systems will fail. The distortion therefore is under-funding. For example, in Botswana they have made significant gains. They stopped large military expenditure, put substantial investment into health and made a national commitment. Treatment has fired up many countries and it is the pinnacle issue that will drive this all forward.

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Meeting Summary - Afternoon Session

1. Abdullah opened his presentation by stating that, unless treatment reaches significant numbers of people living with AIDS, its public health impact will be severely limited. He focused on how to address the issue on a large scale.

2. He gave some general epidemiological facts about South Africa starting by pointing out that the country is facing a different crisis now than it had 40 years ago. He referred to the 'Camel hump mortality' graph and stated that he was confident the epidemic is going to get worse before it gets better in South Africa. This lends a different discourse to the problem.

3. Abdullah pointed out that the WHO 3x5 targets in South Africa translate into getting 50% of people with HIV on treatment. Unless the country is committed to making a change affecting 50% or more (therefore putting a high number of people on treatment), there will not be a significant enough impact made on the epidemic in South Africa.

4. This leads back to the question raised: Where does AIDS lie in global health? It is clear to the speaker that there is a general lack of understanding of mortality rates, which in itself affects the general approach to treatment and prevention.

5. Scaling up ART in the Western Cape:
Out of a population of five million (spread over 129,370 km2), 15% anti-natal prevalence has been recorded, and is a good estimate for the Province, representing half of the estimated prevalence rate for the whole of South Africa.

6. Abdullah pointed out that his responsibility portfolio in the government had been looking after both primary and secondary health, not merely focusing on HIV, however this allowed him to take a more comprehensive approach to the treatment in the province.

7. On primary health care services he said:
- The Western Cape has a fairly good range and network of health services compared to other regions, however it does suffer from chronic understaffing, poor management and organization, and a lack of technological facilities.
- There had been a lot of planning work: It is estimated that by 2010, 23% of visits will be primary health care (PHC) visits.
- The primary care system is quite advanced (nurse driven treatment is up to 90%). At the clinical level, the nurse driven care ranges from VCT, minor ailments, ongoing counseling to workup including CD4 counts.
- A range of prevention methods are being used depending on the district.

8. He stated that the health care system works on two principles:
1. This is a simple intervention: It is possible where you have the qualified staff and the budget (approximately six percent of the entire health budget.)
2. One has to find a balance between scale and speed. Here the question is how to build the capacity of the health system while providing treatment to as many people as possible.

9. Abdullah felt that pharmacy management was a key component of treatment, and an effective parallel system needs to be put in place. The government is a key player in the scale up effort, however in order for it to be successful, strong partnerships need to be forged with NGO's.

10. Good planning and budgeting is also key to a successful scale up programme. An estimation of the costs of a comprehensive package of treatment services needs to be weighed against the number of patients by site. This informs the staff and budget allocation.

11. The government needs to find a balance between scaling up treatment where there is capacity and infrastructure to ingest it and where the epidemic is focused. Using techniques such as forecasting is a good way of knowing where the demand is, which naturally leads to a facility in deciding on the most effective treatment methods. Abdullah's message was to start scaling up in the districts with the highest burden and where infrastructure exists.

12. He cited the following achievements:
- The pediatric epidemic was targeted and won, PMTCT is universally available (using dual and triple therapy regimens) with 75% of children on treatment. Transmission has been reduced to 5%, proving that antenatal transmission can be significantly reduced. This eases the burden on treatment and subsequently the budget.
- HAART has been rolled out to all major towns (45 sites).
- The Western Cape Province is generally a well managed programme, fewer patients are having to move to second line treatment.

13. Abdullah warned that adherence to treatment needs to be a focus of the health care service. A regimented approach to treatment is key. There is a real threat to drug resistance, and limiting it is a challenge which needs urgent attention. Key steps to doing so include good regimen selection, appropriate site and patient selection, adherence support, drug literacy programmes and strong secondary referrals, which in itself raises the quality of medical care. Documenting the approaches, achievements and challenges of the system in the Province needs a lot more attention than it is currently getting.

14. He concluded that HAART is a simple and feasible intervention which should be appropriately implemented at PHC level, requiring the engagement of a doctor for treatment initiation and follow up support and care from a nurse. Good pharmacy management, planning and budgeting are key to the success of the programme. This was done successfully in the Western Cape and is entirely affordable within the broader SA context. The entire discussion on HAART must always aim at finding the balance between treating as many people as possible and protecting against drug resistance.

15. A question as to whether any of these achievements would have been possible without the WHO global targets was raised. Abdulla was clear to point out that, without the 3x5 targets, a 50% success rate would never have been set and subsequently achieved. An approximation of $1,000 per person per treatment is a good measure of the scale up achieved.

16. Sam Phiri outlined three parts to his presentation:
1. A brief outline of the Malawi national ART scale up programme
2. Lighthouse operations as a support centre
3. ART scale up implications on the general health care service delivery.

17. Phiri prefaced his presentation by stating that the Lighthouse Trust in Malawi has ambitious plans to reach big numbers. The case study of the Lighthouse Trust in Malawi demonstrates an effective model supporting national scale up of ART provision.

18. He gave a general overview of the AIDS situation in Malawi. Out of a population of 10.5 million, 900,000 are thought to be infected, of which 170,000 are seen to be in need of ART. By March 2006, 46,000 patients had started on ART. This shows a very high unmet need for ART in Malawi.

19. Key steps of the scale up programme in Malawi:
- Malawi was awarded Global Fund money in 2002
- Following a consultative process, treatment guidelines and a National ARV Scale up Plan were developed following the WHO clinical criteria.
- Free treatment is available in the public sector, and subsidized treatment in the private sector.

20. There has been a noted progress in ART delivery in the public sector. In 2003, only three facilities were providing ARV to 1200 patients (including the Lighthouse Trust). 2004 saw a fee-sharing programme in place, with 9 facilities providing to 4,000 patients, which evolved into a free treatment programme in 2006, with 60 facilities with 38,000 on HAART. On gender distribution, he said approximately 60% of patients are female, which is proportional to the infection rates in sub-Saharan Africa.

21. The Lighthouse Trust is a local initiative started in 1993 by local staff and is part of the public heath sector. Initially set up as a primary care ART provision clinic, it has evolved into a recognized integrated centre for treatment, care, support, training and research. Its main functions are:
- HIV testing and counseling (supported mainly by trained nurses.)
- Clinic (nurse driven HAART provision and supervision, patient education, adherence, nutrition, back to care.)
- Home Based Care (working with a network of community volunteers.)
- Capacity building (training centers, mentoring and supervision programmes.)

22. Phiri explained other initiatives piloted by the Lighthouse trust include:
- Operational research, including safety and efficacy of different treatment programmes and approaches and pediatric ART formulations.
- Modelling Strategies, including In-session testing, ARV group education, nurse review for screening and back to care (developed to support patients who had abandoned their treatment due to financial constraints before ART was free).

23. He outlined the challenges the Lighthouse Trust faces and said these reflect those at a national level. They are:
- Equity and access to treatment-balancing service quality with an overwhelming demand.
- Parallel vs integrated approach to ARV delivery.
- Balancing service delivery with capacity building and operational research.
- The role of the community in ART delivery-maintaining high community volunteer retention.
- Addressing the implication of ART scale up on the general health care system.

24. He concluded that ART national scale up is feasible. Its challenging aspect should not hamper other crucial elements in a comprehensive response to HIV/AIDS. Innovative initiatives and partnerships are being piloted and more focus on them is needed.

25. Boxshall opened by stating that it was important to realise is that the Lighthouse Trust is, essentially, a public sector clinic operating under similar constraints to many other health care facilities in Malawi and elsewhere, and therefore it is not unreasonable to take it as a model for scale-up.

26. He emphasized that this is unknown territory, and Malawi is taking a lead internationally of necessity. Assumptions made will vary wildly and any evaluative information at this stage is no more than an educated guess.

27. He continued by saying that the focus now should be on the human resource constraints faced when rapid scale up is rolled out. Malawi is already facing a human resource crisis in the health sector, which will worsen as the national 5 year ARV scale-up plan is implemented. The plan's targets for 2010 are ambitious, but necessary, and adherence and sustainability remain the main challenges to its success.

28. Boxhall stressed he wanted to make it clear that we still do not know what a rapid scale up will do to infection rates. People on ART are likely to be less infectious than those not, however people on ART will live longer, so incidence is hard to predict - behavioural change will remain the key. Statistics only give part of the picture; however some we are able to draw some conclusions from them:
- There is little or no supervision due to a drastic shortage of nurses and doctors
- Existing staff are inappropriately deployed
- Drugs and materials are unavailable.

This is leading to a very low staff motivation and a breakdown of standards. However it is worth noting that routine, protocol driven programmes function effectively.

29. The question posed was whether scale-up will bring additional work to the existing overstretched health care service, and if it does, where will the burden of work fall? Some have argued that ART will reduce the overall burden on the Health Sector, however the speaker disagrees. His argument was that ART does not cure people. It is complex to manage, and is especially labor intensive in the early treatment stages. Unfortunately, people on ART will still eventually get sick and die, and will need palliative care towards the end of their lives.

30. For the sake of argument, the speaker made an assumption that there will be no impact on clinical management workload due to ART scale-up. As the number of patients on treatment rises, so will the proportion of routine, review visits.

31. In Malawi, these reviews are carried out by nurses, and can include screening for infections, drug resistance, drug dispensation, adherence and monitoring and evaluation. The rise of people on ART and the maturing of the clinics need to be matched with an increase in nurses and clinicians available to meet the needs of new patients as well as existing stable, healthy and adherent ones.

32. He concluded that reducing the targets is not an option in the speaker's opinion, and reducing the time per patient for the nurse review or the frequency of visits has serious implications. Reviews should be mainly nurse led, however solutions to shift the burden to other cadres needs to be explored.

33. One approach is to introduce HAS ARV officers, which would require less clinical input, reducing the burden on nurses, clinicians and councilors and would enable them to better utilize their professional skills. Clinicians and nurses time would be spent primarily on adherence support and screening for and treating clinical problems - the TB programme can be used as a paradigm.

34. Questions such as programme integration, crossing of professional boundaries, supervision and decision-making responsibilities need to be addressed if this approach is to be taken up.

35. Susie McLean stated that in order to reach large numbers and maintain adherence to treatment, broader options should be looked at. Treatment is a community issue, and community-based interventions are the answer to scale up and access treatment. This is due to the following factors:

- HIV lives in the community, it is not merely a medical issue.
- Fear, stigma and discrimination are due to a lack of understanding of the community, which create barriers stopping people from accessing testing and treatment.
- Increased understanding and knowledge around HIV in a community can increase support to those in need of accessing services and promotes behavior change.

36. The speaker went on to identify the different roles the community has, ranging from policy, advocacy, planning, programme implementation and education to evaluation and quality control. These are increasingly recognized, and tools have been developed to facilitate community engagement in treatment. The speaker emphasized the importance of the work happening on all levels, utilizing existing formal and informal networks

37. McLean's presentation looked at three models developed by Alliance partners in Burkina Faso, the Ukraine and Zambia:

- Burkina Faso-AAS (Association Africaine Solidarité): A community led initiative which started with HIV prevention activities and has progressed to provide a holistic and comprehensive support for treatment, adherence, income generation (to poor households and those caring for orphans) and prevention in the community, engaging people with HIV in all aspects of its work. This initiative has led to the AAS staff sharing lessons and supporting other civil society organizations in developing similar treatment programmes.
Proof of the effectiveness of the model lies in AAS's recognition and influence at government level. The project however faces financial challenges which threaten the scale up targets set: "Energy and expertise in the community is often a strong drive in treatment programmes, as well as donor funds and expertise in the health system." (AAS member of staff)

- ARV treatment in the Ukraine: The Alliance is the principal recipient of the Global Fund-funded project for ART provision in the Ukraine. This has allowed the Alliance to introduce a strong community approach into the health system, working with national and regional AIDS Centers. The programme faces many challenges. The low levels of access to testing, treatment and support services for key populations (primarily injecting drug users and sex workers) for social, economic, medical and political reasons have led to their heightened vulnerability, and challenges community organisation's ability to provide for and support them. Local NGOs have an essential role in treatment programmes. NGO social workers are involved in ART treatment programmes, National PLHA networks advocate for rights, and NGOs are implementing community based adherence support, advocacy, prevention and information programmes. Community preparedness remains a challenge however, and there is a noted slow uptake on ART still due to the lateness of the start up.

- ARV treatment in Zambia-Community Education and Referral Project (ACER): This community project works with health systems and stakeholders in supporting treatment programmes. It builds on existing community structures, and the model involves all aspects of the community such as networks, religious leaders, local NGOs, traditional healers and local health workers in supporting treatment, treatment literacy, home care, nutrition, counseling, education and advocacy efforts. A key element of the project is to employ people living with HIV as treatment support workers and mobilisers.

38. She highlighted lessons learnt from the three different models:
- It takes time and effort to build up the community models and get respect and acceptance from the community as well as the official government health systems.
- To be successful, it needs to build on and mobilize existing resources and relationships.
- The initiative must be an active and integrated part of the formal health system, both responding to and informing it.
- For this approach to be successful, it is vital to combat stigma and discrimination in order to improve HIV testing and PMTCT as gateways to ARV treatment.
- The clinical benefits of the community approach is that it supports adherence to treatement. The Alliance is currently trying to evaluate the model.

39. McLean posed the question whether this is vital to adherence to treatment. She concluded that scale-up has to happen in the communities first, and the more this model is broken down and understood, the better we can see the problems and plan to address them in order to have successful scale up ARV treatment.

Questions and issues from the floor

- HIV is a priority due to its exceptional circumstance. In terms of development, there is a strong link to most other development issues facing us today (e.g poverty, nutrition, TB).

- Community involvement will lessen the burden on nurses and health systems. The community can also support adherence to treatment, which in turn has knock on effects on prevention. People are more likely to test if they know there is treatment available.

- The use and efficiency of mobile clinics was raised, which access hard to reach rural communities, reversing the direction of communities accessing health services. The problem of an added burden on the already overstretched human resources in the health care system was raised, however it was agreed that in some cases it was an appropriate measure to be implemented.

- Are we able to scale-up community based support? It was agreed that such an approach has not been documented nor experienced to a significant level in HIV, however it is possible. The aim is to replicate the model, adapting processes to specific contexts. Dr Fareed pointed out that in South Africa, NGOs were not opposed to community model scale up, but health systems and governments were still challenging it.

- Community initiatives are not getting funded or supported by donors (VSO experience in Tanzania) despite the availability of volunteers and planning committees from the community. The flow of resources should be addressed.

- There should be a range of models to meet the varying levels of skill within the community.

- Drug resistance is something that needs addressing. The West is not being very successful so far, lessons should be shared from African programmes.

- The vertical approach is too powerful for politicians, national health programmes and donors to ignore, however it will not work if it is only a medical approach, community intervention is key.

Concluding Remarks from the Chair:

- There is a need to understand what we are scaling up, treatment or prevention?

- There needs to be more discussion on societal and structural determinants of HIV (sex trade, gender, incarceration etc)

- We need to understand at what cost scale up will work. There needs to be a creative approach if it is to be successful.

- There is a debate on which model is more effective, vertical or horizontal approach.

- Do global targets work? When expectations are raised, whose responsibility is it to implement?

- We do not have evaluation processes and systems in place. Accountability systems need to be clearer, as are monitoring systems.

- We should attempt to harness HIV funds being released to support different models of access to treatment.