HIV/AIDS

WHO/UNAIDS Workshop on Strategic Information for Anti-Retroviral Therapy Programmes

WHO, Department of HIV/AIDS
30 June to 2 July 2003

Meeting

::Background
::Meeting Summary
::Agenda
::List of Presentations
::List of Participants

Background

Experience from high and middle-income countries has shown that national anti-retroviral therapy (ART) programmes are possible and able to significantly enhance the survival of people with advanced HIV infection or AIDS. An increasing number of low and middle income countries are now moving towards the development and implementation of ART programmes. The availability of funds from multilateral and bilateral sources enables these countries to start up or take to scale such programmes.

There is an urgent need for strategic information in conjunction with these ART programmes, including the development of monitoring and evaluation systems. We need to identify how best we can measure and assess programme success across a range of outcomes. Operational research is needed in many areas to be able to develop the most efficient and most cost-effective programmes. Strategic information will have to be generated in parallel with programme development, with the two influencing each other. The emphasis is on learning by doing.

At a recent meeting organized by NIH a comprehensive operational research agenda was developed. WHO and CDC were given a coordinating role in the field of strategic information for ART programmes. As a first step, a workshop was held in Geneva from 30 June to 2 July to:

  • Assess the strategic information needs in the context of ART programmes;
  • Share experiences in developing monitoring and evaluation systems and other strategic information efforts;
  • Explore methods and techniques that can be considered for monitoring ART programmes; and
  • Develop a list of priority strategic information issues faced by national programmes and large-scale projects and explore ways to address those issues.

The meeting agenda and list of participants can be found on this page (see below). Thirty presentations were made during the course of this meeting with over half the presentations made by representatives from government and non governmental organizations (NGOs) in Brazil, Haiti, Kenya, Malawi, Senegal, South Africa and Thailand who are involved in the development and implementation of ART programmes in these countries. All of these presentations can be found by clicking on the link at the top of this page. This document summarizes the recommendations made during the meeting in terms of strategic information needs in the context of scaling ART programmes and the methods and technologies to facilitate the compilation of this strategic information. It also identifies priorities for WHO action.

Meeting Summary

Strategic information needs in the context of scaling up ART programmes

Based on the experiences of low- and middle-income countries currently implementing or planning ART programmes and represented at the meeting (Brazil, Burkina Faso, Haiti, Kenya, Malawi, Rwanda, Senegal, South Africa and Thailand), the main strategic information priorities in the context of scaling up ART programmes identified were the following:

  • Standardization of monitoring and evaluation practices;
  • Strengthening of health and logistics management information systems;
  • Assessment of human resource needs and capacity for ART programmes;
  • Assessment of community and individual preparedness; and
  • Strengthening of HIV/AIDS disease staging and surveillance.

Standardization of monitoring and evaluation practices

What makes monitoring and evaluation of ART programmes so complex is that these interventions do not easily fit into the monitoring and evaluation pipeline shown in Box 1. The inputs into ART programmes are the only components that are easy to define, identify and monitor. Monitoring and evaluating the process, outputs, outcomes and impact of these interventions is complicated. The process of implementing ART programmes is difficult and open-ended; the programme outputs differ according to the implementation processes used; and the goals and objectives of therapy are varied and they have not yet been agreed upon.

Box 1. The monitoring and evaluation pipeline
Box 1. The monitoring and evaluation pipeline

In thinking of ways to better define ART programme processes and expected outputs and develop ways to effectively monitor these, the unique characteristics of ART must be kept in mind. First, ART turns HIV into a chronic disease with lifelong continuous therapy whose cost of poor adherence- the evolution of drug resistant stains - is high. Second, people (or patients with improved quality of life and health) do not remain in one place throughout their lives; economic, social and other factors cause people to move around. Third, ART is comprised of a variety of treatments. Problems with toxicity will mean that first or second line treatments for some patients will have to be adjusted. Finally, over time, some patients will end up failing their treatment options but will then need palliative or terminal care.

Problems with toxicity will mean that first or second line treatments for some patients will have to be adjusted. Finally, over time, some patients will end up failing their treatment options but will then need palliative or terminal care.

During one session, participants discussed the most important components of ARV management from a clinical point of view (delineated in Box 2). Improving clinical staging and AIDS surveillance to better assess when to start ART or switch therapy is discussed in more detail below. Participants agreed that a simple set of standardized indicators to monitor processes and outputs should be formulated around four S’s: starting, substituting, switching and stopping ART.

Box 2. The core of ARV management: The four S's
Box 2. The core of ARV management: The four S's

Drug stocks to and within pharmacies will need to be tracked, clear records of ARV prescriptions will need to be kept and stock-outs, expiration of drugs and pilfering must be avoided. Facility-based clinical notes and patient registers as well as patient-held treatment cards will need to be available. An effective and efficient data collection system that delivers data to and from central monitoring points in timely fashion will also be required. Finally, finding ways to measure patient adherence and understanding factors facilitating and impeding patient adherence will need to be a priority. To assess implementation processes properly, it was pointed out, monitoring systems of ART programmes will need to track three flows: patients on treatment, drug supplies and (if charged) fees for service. These all intersect at the point of ARV delivery. This means that the dispensing point may be the best point at which to capture data. Certain specifics for monitoring and evaluating ART programmes can be recognized. One critical need is for patients to have a unique, non-transferable and robust identifier.

In terms of evaluating the outcomes and impact of ART programmes several different measures of effectiveness were identified. These include patient survival, quality of life of patients and their families, reduction of HIV transmission as well as the containment of antiretroviral drug resistance. In addition, costs would need to be recorded for any cost-effectiveness analysis. Participants made recommendations addressing each of these. The need for simple definitions of quality of life was highlighted. Identifying ways to quantify the interaction between prevention and care was also underlined as a priority. And the surveillance and containment of antiretroviral drug resistance following WHO guidelines was recognized as an important ART programme goal though participants stressed that it should not impede efforts to scale up programmes.

Participants repeatedly urged that the monitoring and evaluation of ART programmes be simple with data collection limited to only that information deemed to be essential for the well functioning of programmes. While implementing ART programme sites should be encouraged to collect additional data, it was felt that in general, data collected for operational and other research should be distinct from data collected in the context of routine monitoring and evaluation with the former being implemented only in select sites with extra capacity and resources. Priority areas identified for this operational research were economics and costing issues. The collection of pre and post treatment cohort survival data to construct standard HIV survival curves and calculate the number of life years saved with the implementation of ART programmes was highlighted. Another area specified was the in-depth study of different models used to implement ART programmes.

Strengthening of health and logistics management information systems

Effective health management information systems (HMIS) can provide information on service statistics including the number of patients at each site while good logistics management information systems (LMIS) can provide information on inventory, consumption, quality, losses and adjustments. However, in many resource poor countries, both HMIS and LMIS for health commodities are weak. Even in the best of cases, these systems are built on paper-based records using non-standardized data collection methods and they are slow, inaccurate, insecure and very labour intensive. So in most countries, existing systems will be unable to manage significant extra demands resulting from the large number of mobile patients on lifelong ART and the continuous distribution of large quantities of drugs. The development of agile health and logistics systems is essential to the successful implementation of ART programmes. Programmes must not be afraid to explore new technologies (see below).

Monitoring of the patient flow and drug flow which intersect at the point of the dispensing of antiretrovirals to patients must be the backbone of ART programme monitoring systems, just as they have been for directly observed therapy (DOT) programmes for TB. With well functioning HMIS and LMIS, programmes will be able to monitor and evaluate patient care effectively. They will also be able to ensure efficient procurement of drugs and maintenance of stock and delivery of drugs to programme sites avoiding stock outs or the equally problematic alternative of having large stocks of expensive drugs that go unused.

Efforts should be made to integrate ART into existing HMIS and LMIS systems run by governments. Though creating separate systems might be more efficient in the short term, in the long term, this option was recognized as a waste of resources. Strengthening existing HMIS and LMIS systems in countries can be one of the positive externalities produced by ART programmes.

Assessment of human resource needs and capacity for ART programmes

All health systems need trained and motivated staff, properly paid and supervised to be effective and capable of delivering quality services. Yet in many resource-poor countries, inadequate investment into the human resources of the health sector has been the norm for years. Many health professionals work for extremely low pay in difficult conditions and morale is poor. And in countries heavily impacted by HIV/AIDS, the epidemic compounds these problems.

While these general indictments of the human resource situation in the health care sector of many resource poor countries is generally acknowledged, there are very few data available on the numbers of health care professionals and the level of skill they have. Assessment of human resource capacity within health systems will therefore need to precede the design and implementation of all ART programmes. Assessments will need to pay particular attention to the skills of health workers in various health professional categories since there is no universally accepted classification of health professions and there may be important differences in the skills and training across countries. These assessments will need to review how different health professionals spend their time. They will need to look at the impact of HIV on health sector personnel as well as retention and migration rates among health staff. In addition, in certain countries, assessments of human resource capacity will need to include a review of possible contributions from community workers or others outside the health sector. People living with HIV/AIDS and on treatment themselves are a potential significant resource. Without this information, human resource planning for the medium and long-term is impossible.

Different models of ART provision will have to be designed, delineating the tasks to be conducted, the full time equivalent staff required to accomplish those tasks and the training needs that need to be met. In certain cases important training needs may have to be addressed prior to scaling up.

Assessment of community and individual preparedness

Participants agreed that there are certain community and individual characteristics that facilitate the uptake of ART and that finding ways to quantify these factors should be a priority. Experience from pilot studies has shown that if communities are poorly prepared for ART, individuals will be reluctant to begin therapy and those who do start are likely to adhere poorly to treatment regimens. The potential benefits of ART - improved survival and quality of life and reduced HIV transmission - are great. But the cost of poor adherence - drug resistance - is also extremely high. Quantifying preparedness, identifying data collection needs in this area and developing ways to foster this preparedness across communities were all identified as essential to the successful implementation of ART programmes.

The understanding of local contexts including assumptions related to illness and HIV/AIDS, perspectives on health care and taking medications and relationships between health care providers and community members were highlighted in the context of this discussion. Appreciating how ART decreases stigmatization and discrimination and encourages more awareness and disclosure of HIV status were also underlined.

Strengthening HIV/AIDS disease staging and surveillance

Persons infected with HIV pass through different stages, from being asymptomatic through to advanced infection characterized by a few opportunistic diseases that eventually lead to death in the absence of ART. Disease staging is a hierarchical description of this disease progression and staging is used extensively to guide clinical decisions in ARV therapy. The stages provide treatment entry criteria and are essential in terms of treatment management especially where immunological markers are not available. WHO broadly organized these stages of disease in 1990 as shown in Box 3.

Box 3. Categories of WHO clinical staging system for HIV infection and disease
Box 3. Categories of WHO clinical staging system for HIV infection and disease

The problem with this staging system, however, is that while stage 4 in this categorization is said to be basically equivalent to AIDS, there are important differences especially as regards the classification of pulmonary TB. Furthermore, there is not one agreed upon definition of what constitutes an AIDS case. The Centers for Disease Control (CDC) gold standard is widely used, but involves intensive diagnostic evaluation to establish an AIDS diagnosis. This is not practical in centres with limited diagnostic capabilities. This has long been recognized and there are currently seven AIDS case definitions with different definitions used across countries and regions. And also problematic, no clinical criteria are provided for definitive staging diagnosis so treatment approaches vary from centre to centre and treatment trials or operational research using clinical staging may not be comparable.

Another important aspect of disease surveillance is the quantification of HIV/AIDS deaths. In resource-rich countries with universal death registration, AIDS defining diseases are included as a cause of death, and electronic linkages between mortality and HIV databases can be conducted. Comprehensive data with clear time trends have been generated and these have been used to measure the outcomes of ART programmes. These data have served as highly influential advocacy tools. It is therefore important that resource-poor countries are also able to capture these mortality trends. But in most of these countries there is no universal death registration system and HIV and AIDS are rarely included among the causes of death. Estimates of AIDS deaths will therefore have to be derived using sentinel site data and such data should begin to be collected prior to the implementation of scaled up ART programmes.

Participants called for updated clinical staging criterion with specifications for both adults and children. They also called for harmonisation of clinical staging and AIDS surveillance with the formulation of one stage 4, AIDS equivalent definition congruent with both clinical and surveillance purposes. More attention needs to be paid to the recording of HIV/AIDS deaths and the impact of ART. The CDC is keen to evaluate new ways to capture morbidity in communities and pilot AIDS surveillance.

Methods and technologies for strategic information in the context of scaling up ART programmes

Participants also spent time trying to assess what methods and systems might facilitate ART programme monitoring and evaluation. Given the complicated nature of ART programmes and the limited human resources available in most countries, participants agreed that traditional facility-based monitoring and evaluation systems using paper records would not be adequate to deal with a chronic disease treatment programme with healthy, mobile patients. It was felt that new methods and technologies would have to be evaluated and implemented.

As highlighted in Box 4, fingerprint readers and smart cards and smart card readers are some optional technologies that would provide patients with a unique, non-transferable and robust identifier that could carry clinical data and ART prescription data. Bar-coding of drug cartons would facilitate the monitoring of drug stocks to and within pharmacies clear records of ARV prescriptions and avoiding stock-outs as well expiration of drugs and pilfering. As noted previously, the main intersection of drug and patient flow is at the point of ARV dispensing.

Box 4. ART programme monitoring and evaluation: What technology can offer
Box 4. ART programme monitoring and evaluation: What technology can offer

Fixed and mobile telephone-based linkages could provide an effective and efficient data collection system delivering data from facility-based clinical notes and patient registers to and from central monitoring points in timely fashion. Such easy transfers of data would serve to encourage real time management and facilitate the sustainability of this data collection. It could also foster rapid feedback and better supervision. It was noted that in order to be most efficient, and to fully harness the potential of technology, it would be important to standardize coding, forms and data programs across countries.

Participants recognized that technology was widely used in every country by people in all walks of life, and were enthusiastic about its potential. They also made clear that that novel methods and technologies would need to be piloted and evaluated before being implemented on a large scale. Noteworthy here is that some sites such as the Lighthouse Trust in Malawi are already preparing to pilot these technologies.

WHO support and coordination

In closing, participants emphasized the need for WHO to be increasingly proactive in its role as a coordinating body in terms of strategic information in the context of scaling up ART programmes. The following areas were highlighted as priorities for immediate action:

  • Development of an action plan for the processes of scaling up ART.
  • Formulation of an updated HIV/AIDS clinical staging system, better harmonized with a unitary clinical AIDS case definition as the stage 4 AIDS-equivalent.
  • Development of sentinel surveillance for the identification of the impact of ART on mortality and the number of deaths averted.
  • Formulation of simplified and more practical guidelines on ART management including clearer instructions on when to switch to second-line treatment, better developed laboratory guidelines, and revised guidelines on the treatment of opportunistic infections in the context of ART.
  • Development of simplified and standardized monitoring and evaluation tools as the basic framework for use by all ART programmes.
  • Improvement of WHO monitoring and evaluation capacity at headquarters and in the field to more adequately respond to country monitoring and evaluation needs in the context of scaling up ART programmes with a focus on sub-Saharan Africa.
  • Exploration and development of non-paper technological systems for ART programme monitoring and evaluation.
  • Identification of ways to strengthen existing HMIS and LMIS systems.
  • Elaboration of simple methods and tools to assess community and individual preparedness for uptake of and adherence to ART.
  • Coordination of assessments of human resource capacity and provision of support to countries in their capacity building efforts.

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Agenda

Session 1: Introduction and overall perspective

  • Opening, introduction, workshop outline and objectives
  • Strategic information for ART programmes: defining ART programmes, a framework, issues and opportunities -- Stefan Wiktor (CDC), Catherine Hankins (UNAIDS), Ties Boerma (WHO)
  • Discussion

Session 2: Pulling together and using strategic information

  • Using strategic information to shape policy and practice – lessons from tuberculosis control programmes -- Brian Williams (WHO)
  • Coordinating and using information from multi-country sites: The MTCT+ programme -- Wafaa El-Sadr (University Columbia)
  • Coordinating and using information from multi-country sites: WB Regional Treatment Acceleration Programme -- Michael Azefor (WB)
  • Coordinating and using information from multi-country sites: WHO/IAS ARV resistance monitoring network -- Stefano Lazzari (WHO)
  • Monitoring of ART programmes in relation to Global Fund -- Arletty Pinel (GFATM)

Session 3: Assessment of needs and programme inputs

  • Estimating the need for ART from mortality estimates -- Neff Walker (UNAIDS)
  • Assessing human resource needs for ARV programmes -- Norbert Dreesch (WHO)
  • M&E of care and support programmes; an update -- Kathy Marconi (HRSA)
  • Monitoring drug and commodity supply chains -- Yasmin Chandari (JSI Deliver)

Session 4a: Assessment of programme outcomes (clinical)

  • Standardized clinical staging, AIDS case definitions and mortality -- Charles Gilks (WHO)
  • AIDS surveillance strategies in the context of ART programmes -- Theresa Diaz (CDC)
  • Indicators of health status and wellbeing in people on treatment (QoL, nutrition, morbidity, productivity) -- Antonietta Medina-Lara (Liverpool School of Tropical Medicine)

Session 4b: Assessment of programme outcomes (economic)

  • Economic assessment of ART programmes -- Jean Paul Moatti (ANRS)
  • Collecting costs at the country level -- Sergio Bautista (INSP)
  • Monitoring the implications of financing options -- Jose Bermudez (FIOCRUZ)

Session 5: Sharing experiences in M&E systems and strategic information efforts

  • Brazil – a national monitoring system for the ARV therapy programme: lesson learned -- Marco Vitoria (Ministry of Health, Brazil)
  • Kenya – issues for an ambitious national programme -- Mary Wangai (NASCOP Kenya)
  • Thailand – experiences with M&E -- Sanchai Chasombat (Ministry of Health, Thailand)
  • Senegal – experiences with M&E -- Mame Awa Toure (Senegal)
  • Malawi – M&E system in Chyolo District -- Roger Teck (MSF Luxembourg, Malawi)
  • Coastal Kenya – experiences with M&E -- John Adungosi (FHI, Kenya)
  • Haiti –experiences of Clinic Bon Saveur -- Fernet Leandre (Haiti)

Session 6: Using technology to monitoring ART programmes

  • Challenges in monitoring long-term ARV therapy -- Charles Gilks (WHO)
  • Mobile phone based M&E -- Paul Meyer (Voxiva, USA)
  • Data collection needs for ART programmes: Review of existing software solutions -- Virginia Loo/Meade Morgan (CDC)
  • Electronic ART registry in Cape Town clinics -- Robin Wood (S. Africa)
  • Monitoring a provincial programme in Canada -- Robert Hogg (University British Columbia, Canada)
  • Developing integrated systems in Malawi -- Matt Boxshall (Lighthouse, Malawi)

Session 7: Monitoring individual and community knowledge, attitudes and behaviours

  • Monitoring individual and community knowledge, attitudes and behaviours in communities -- Gabriel Mwaluko (National Institute for Medical Research, Tanzania)
  • User perspectives and community contexts: Strategic information for ARV programmes -- Carla Obermeyer (WHO)

Session 8: Listing the priority strategic information issues for national programmes and large-scale projects

Group work around countries (Burkina Faso; Haiti; Kenya; Malawi; Rwanda; Thailand)
Each group will start with a brief overview by the country on current status and plans for ART programmes, with a focus on strategic information. List priority strategic information issues for national programmes and large-scale projects issues focusing on the focal country of the group

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List of Presentations

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List of Participants

Dr John E. Adungosi
FHI IMPACT Project
Mombasa, Kenya

Mr Keith Alcorn
DFID (Department for International Development)
London, United Kingdom

Dr Marco A. de Avila Vitoria
STD/AIDS Program
Ministry of Health
Brazil

Dr Michael Azefor
World Bank
Senior Public Health Specialist
and Task Team Leader Africa Regional HIV/AIDS Treatment Acceleration Program
Washington, USA

Dr Didier Bakouan
Coordinator, HIV/AIDS
Ministry of Health
Burkina Faso

Sergio Bautista
Health Economics & Policy
National Institute of Public Health
Mexico

Dr Jorge A.Z. Bermudez
Director Fundaçao Oswaldo Cruz (FIOCRUZ)
National School of Public Health
Rio de Janeiro, Brazil

Dr Hans Binswanger
World Bank
Director for Rural Development and Environment Africa Region
Washington, USA

Dr Matt Boxshall
The Light House
Lilongwe Central Hospital
Malawi

Ms Yasmin Chandani
JSI/Deliver (Deliver John Snow Inc.)
Regional Logistics Adviser
Nairobi, Kenya

Dr Sanchai Chasombat
Division of AIDS, Communicable
Disease Control
Ministry of Public Health
Bangkok, Thailand

Dr Issaka Compaoré
WHO
Burkina Faso

Dr Henry Damisoni
NPO, WHO
Malawi

Dr Theresa Diaz
CDC (Centers for Disease Control)
CDC Global AIDS Program
Team Leader, Surveillance
Atlanta, USA

Professor Matthias Egger
University of Berne
Switzerland

Mr Tim Evans
Head of Health Equity
The Rockefeller Foundation
New York, USA

Dr Koen Frederix
Deputy Medical Coordinator
Medecins Sans Frontieres (Belgium)
Bangkok, Thailand

Dr Mary J. Freyder
USAID
Monitoring and Evaluation Fellow
Office of HIV/AIDS, Bureau for Global Health
New York, USA

Ms Robin Gorna
DFID (Department for International Development)
London, United Kingdom

Dr Hervé Hien
Centre Muraz
Bobo Dioulasso
Burkina Faso

Dr Robert Hogg
Director, Population Health Program
BC Centre for Excellence in HIV/AIDS
Vancouver, Canada

Mr Gerald Jennings
USAID
New York, USA

Dr Harm J. Hospers
Reshape Institute
University Maastricht
Faculty of Psychology
Maastricht, Netherlands

Dr Jeanne d’Arc Kabagema
NPO/FHP, WHO
Rwanda

Dr Inoussa Kabore
FHI
Arlington, USA

Dr Jean Claude Karasi
University Centre Hospital
Kigali, Rwanda

Dr Antonieta Medina Lara
Health Economist
HIV/AIDS and STI Knowledge Programme
Liverpool School of Tropical Medicine
UK

Dr Fernet Leandre
Project Director, HIV/TB Programmes
Clinique Bon Saveur
Haiti

Dr Virginia Loo
CDC (Centers for Disease Control)
EISO, HIV Care and Treatment Branch
Global AIDS Program
Atlanta, USA

Ms. Elizabeth Lule
World Bank
Co-Task Manager, Treatment Acceleration Program
Washington, USA

Dr Katherine Marconi
HRSA (Health Resources and Services Administration)
Director, Office of Science and Epidemiology HIV/AIDS Bureau
Rockville, USA

Mr Paul Meyer/Ms Lakshmi Sundaram
Voxiva
Washington D.C., USA

Dr Paolo Miotti
NIH (National Institute for Health)
Office of AIDS Research
Bethesda, USA

Professor Jean Paul Moatti
ANRS (Agence Nationale de Recherches sur le Sida)
Marseilles, France

Dr Meade Morgan
CDC (Centers for Disease Control)
National Center for HIV, STD and TB Prevention
Atlanta, USA

Dr Gabriel Mwaluko
TANESA/National Institute for Medical Research
Mwanza, Tanzania

Dr Fidèle Ngabo
University Centre Hospital
Kigali, Rwanda

Dr Abdoulaye P. Nitiema
Focal Point HIV/AIDS
Office of Studies and Planning
Burkina Faso

Luke M. Nkinsi, MD, MPH
Bill & Melinda GATES Foundation
Senior Program Officer, HIV/AIDS & TB
Global Health Program
USA

Mr Martin van Oostrom
AIDS Fonds
Manager, Policy Department
Amsterdam, Netherlands

Dr Arletty Pinel
GFTAM (Global Fund to Fight AIDS, Tuberculosis and Malaria)
Geneva, Switzerland

Dr Deborah Rugg
CDC (Centers for Disease Control)
National Center for HIV, STD and TB Prevention
Atlanta, USA

Dr Wafaa El-Sadr
Director, MTCT Plus Program
Mailman School of Public Health
Columbia University
USA

Dr Yves Souteyrand
ANRS (Agence Nationale de Recherches sur le Sida)
Head of Office for Public Health and SBS Research
Paris, France

Ms Lara Stabins
Harvard University
Boston, USA

Dr Miriam Schneidman
World Bank
Senior Health Specialist
Africa Human Development Unit 3
Washington, USA

Dr Roger Teck
Head of Mission
Medecins Sans Frontieres (Luxembourg)
Malawi

Dr Mame Awa Toure
Division SIDA/IST
Institut d’Hygiene Sociale
Dakar, Senegal

Dr J. Valadez
World Bank
Washington, USA

Dr Mary Wangai
Deputy Director
National AIDS and STD Control Programme (NASCOP)
Kenya

Dr Stefan Wiktor
CDC (Centers for Disease Control)
Chief, Surveillance and Infrastructure Development Branch
Atlanta, USA

Professor Robin Wood
Waterfront
Cape Town, South Africa

Dr Panumard Yarnwaidsakul
Chief of AIDS, TB, STIs and Leprosy Group
Department of Disease Control
Ministry of Public Health
Bangkok, Thailand

Secretariat WHO

Dr Ties Boerma, Coordinator
Dr Charlie Gilks, SRM
Dr George Loth, SRM
Dr Carla Makhlouf Obermeyer, SRM
Ms Marjorie Opuni-Akuamoa, SRM
Surveillance, Research and Monitoring & Evaluation (HIV/SRM)
Geneva, Switzerland

Dr Veronique Bortolotti
Regional Office for Western Pacific
WHO Office Cambodia

Dr Paloma Cuchi
Regional Office for the Americas
USA

Mr Norbert Dreesch
Human Resources for Health (HRH)
Department of Health Service Provision (OSD)/HQ
Geneva, Switzerland

Dr Chris Dye
Dr Brian Williams
TB Strategy and Operations (TME)
Stop TB Initiative (STB)/HQ
Geneva, Switzerland

Dr Stefano Lazzari
Coordinator National Capacity Strengthening (NCS)
Department of Communicable Disease Surveillance and Response (CSR)/HQ
Geneva, Switzerland

Dr Craig McClure
Manager
International HIV Treatment Access Coalition (ITAC) Secretariat
Geneva, Switzerland

Dr Jos Perriens, Director
Dr Vincent Habiyambere, CRE
Department of HIV/AIDS/HQ
Care (HIV/CRE)
Geneva, Switzerland

Secretariat UNAIDS

Dr Catherine Hankins
Director, Strategic Information (SIF)

Dr Paul De Lay
Evaluation

Dr Neff Walker
Strategic Information (SIF)

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