Caribbean Regional Strategic Framework

Care, Treatment and Support

Throughout the region, countries are faced with the challenge of absorbing the full costs of treatment programmes. At the same time, the number of people on treatment will steadily increase as programmes move towards earlier initiation of treatment, provision of lifelong ART for pregnant women and ultimately, to a ‘test-and-treat’ approach. The scale of this challenge in evident in Table 4 below which shows how coverage rates drop sharply with the application of the 2013 WHO Treatment Guidelines of initiation at a CD4 count of 500 or lower.

The region as a whole falls below 50 percent, and it is estimated that full implementation of guidelines for pregnant women (Option B Plus) would amount to initiating lifelong treatment for an additional 75 percent of HIV positive pregnant women. Further, moving towards universal access to treatment will require developing and implementing targeted programmes to better reach underserved key populations. This will add to the immediate and significant increases in treatment costs. In this context, the expansion of treatment programmes must be strategic, driven by national priorities and with capacity constraints taken into account.

Stepping-up regional efforts to mobilise resources and to implement measures to reduce the cost of ART will be essential. National programmes must also reduce inefficiencies associated with vertical procurement and delivery systems (SPA 5), and remove structural barriers which contribute to low rates of entry and retention (SPA 1). Adherence is a key issue for the region, as the numbers of people on second- and third-line regimens contribute to high costs and increased potential for drug resistance. With more people on treatment for longer periods, provision of a continuum of care and effective co-management of STIs, TB and NCDs, including mental illness, is increasingly important. Expanding treatment and increasing the proportion of PLHIV who achieve viral suppression, at a pace that countries can sustain, are critical for achieving the goal of an AIDS-free Caribbean. In the long term, the benefits to countries will be reduced transmission rates and fewer people entering treatment programmes.

Strategic objective 4.1: Expand and sustain access to high-quality care, treatment and support, including management of STIs and comorbidities.

Expected results:

1. Access to ART is expanded, in a way that is sustainable and in keeping with national priorities and capacity, including increasing the treatment threshold.
2. Early identification and treatment of STIs and contact-tracing is strengthened.
3. Comprehensive clinical care and treatment which integrates preventive services and strategies for positive health and living across the life course, including for NCDs, mental health and psychosocial support, is provided.
4. Efficiency of procurement and access to ARVs and other supplies is improved, including through integration of service delivery.

Strategic objective 4.2: Improve linkage, adherence and retention in care, treatment and support.

Expected results:

1. The continuum of care is strengthened to improve service uptake, adherence and retention, including by optimising ART drug regimens, strengthening linkages, referral and counter-referral and integrating essential health services.
2. Access to CD4 and viral load testing and other technologies is increased to better monitor people on ART, and to support retention in treatment.
3. Prevention and monitoring of HIV drug resistance is conducted utilising a public health approach that includes appropriate operational/implementation research and strengthening of surveillance systems.
4. Quality of care, treatment and support, including home- and community-based care, is improved.
5. Paediatric care, treatment and support are strengthened for all infants who are exposed to HIV.