Results Introduction Methods Conclusions

ESTIMATING HEALTH WORKFORCE REQUIREMENTS FOR ACHIEVING THE UNAIDS 90-90-90 TARGETS IN THREE REGIONS OF UKRAINE AND DEVELOPING STRATEGIES TO ADDRESS PROJECTED GAPS A. Latypov1, Y. Sereda2, S. Belyakov1, O. Danylenko3, N. Ryzhenko4, O. Chernenko5 1Deloitte Consulting LLP, The USAID HIV Reform in Action Project, Kyiv, Ukraine, 2Independent Consultant, Kyiv, Ukraine, 3Poltava Regional AIDS Center, Poltava, Ukraine, 4Kherson Regional AIDS Center, Kherson, Ukraine, 5Mykolayiv Regional Center of Palliative Care and Integrated Services, Mykolayiv, Ukraine

Introduction Health workforce is a key resource required for a major scale-up of HIV testing, treatment and care services in Ukraine. The USAID HIV Reform in Action Project developed a tool for estimating the needs in human resources for health (HRH) to achieve the UNAIDS 90-90-90 targets by 2020. This study sought to provide an empirical evidence of the severity of HRH shortage for the provision of HIV services in three regions of Ukraine representing medium- (Poltava and Kherson) and high(Mykolayiv) HIV-burden oblasts (figure 1). Mykolayiv

Poltava • Medium HIV prevalence (236.5 per 100,000)

• High HIV prevalence (728.4 per 100,000)

Kherson

Quantification of HRH for HIV requirements included the following methods and data inputs: • Analysis of national legislation and guidelines related to HIV/AIDS. • Defining HIV service package components, annual frequencies of service provision per person and annual working hours for different categories of healthcare cadres. • Chronometric study (observation of 154 health workers at 59 facilities during 5 days; 44,735 cases of service provision measured). • Defining time spent on each service component, proportion of services provided by different groups of health cadres and proportion of time spent on other supportive HIV-related activities (not related to direct provision of an HIV service). • Forecasting service coverage targets based on annual routine surveillance data for different scenarios (ARIMA models, conditional forecasts). • Predicting HRH for HIV requirements in FTE (figure 3) and comparison of results with available HRH for HIV capacities. • Existing HRH were calculated based on data from national health workforce registry and adjusted for the proportion of time spent on provision of HIV services.

• Medium HIV prevalence (399.3 per 100,000)

Annual time inputs per service, minutes

Figure 1. HRH FOR HIV STUDY REGIONS, UKRAINE, 2017

Annual time inputs per service by staff category, minutes

Methods

FTE per service by staff category

HRH needs were estimated in full-time equivalents (FTE) for three categories of HIV service providers: (i) physicians, (ii) nurses and (iii) social workers and psychologists. Assessments were made for the period of 2017-2020 and included two scenarios: (1) continuation of ongoing trends and (2) achieving the UNAIDS 90-90-90 targets. The second scenario included two options reflecting different coverage targets for opioid substitution therapy (OST) (figure 2). (1) CONTINUATION OF ONGOING TRENDS Extrapolation of existing trends in HIV prevalence and incidence, ART coverage etc.

(2) ACHIEVING THE UNAIDS 90–90–90 TARGETS BY 2020 Test and START approach implemented and the UNAIDS 90-90-90 targets achieved by 2020: - 90% of all PLHIV will know their HIV status and would be under medical supervision - 90% of all PLHIV with diagnosed HIV infection would receive ART - 90% of all PLHIV on ART would have viral suppression (2А) OST coverage according to WHO, UNODC, UNAIDS guidelines

(2B) OST coverage according to national targets (National AIDS Program)

By 2020, 40% of all people who inject opioids would receive OST

By 2020, 40% of people who inject opioids and who are under medical supervision at narcological facilities would receive OST

Figure 2. SCENARIOS FOR PREDICTING HIV SERVICES COVERAGE TARGETS AND ESTIMATING HRH FOR HIV REQUIREMENTS

HRH requirements were estimated for 8 HIV service packages: 1. HIV counseling and testing (HCT) using rapid tests; 2. HIV counseling and testing with ELISA; 3. Enrollment in care; 4. Routine follow-up care of HIV+ patients; 5. Initiation/prescription of antiretroviral therapy; 6. On-going ARV treatment and monitoring; 7. TB prevention and treatment in HIV+ patients; 8. Opioid substitution therapy.

Adjusted FTE per service by staff category

Time input per service, minutes Annual time inputs per service, minutes

Annual frequency of service provision per client

Annual target for service coverage, clients

Proportion of service provided by staff category

Annual time inputs per service by staff category, minutes Annual weighted average of number of working hours

60

FTE per service by staff category

Proportion of time input on other activities

1

Example: FTE for pre-test HIV counseling (HCT with rapid tests) among nurses in 2020, scenario #1. Time input: 5 minutes (((5*1.03*30000)*0.12)/(1689*60))*(1+0.37) = 0.25 FTE Annual service frequency per client: 1.03 Target for 2020 for scenario #1: 30,000 persons Proportion of service provided by nurses: 12% Annual weighted average of working hours for nurses: 1,689 Proportion of time input on other supportive HIV-related (non-service provision) activities among nurses: 37%

Figure 3. DATA INPUTS FOR ESTIMATING HRH REQUIREMENTS IN TARGET REGIONS OF UKRAINE

FOR

HIV

Results • Physicians spent significant proportions of their time on providing HIV services that could be provided by health workers with shorter training and fewer qualifications (table 1). • In Poltava region, the availability of HRH for the delivery of HIV services was estimated at 122 FTE, while HRH for HIV availability was lower in Kherson (79 FTE) and Mykolayiv (85 FTE) regions (figure 4). • To achieve 90-90-90 targets by 2020 and generate major scale-up of OST (WHO, UNODC, UNAIDS recommended target), the required HRH would be 101 FTE (95% CI: 88-115) in Poltava, 143 FTE (95% CI: 124-162) in Kherson, and 257 FTE (95% CI: 225-289) in Mykolayiv regions. If lower level OST coverage is aimed at (National target), the required HRH would be 82 FTE (95% CI: 72-93) in Poltava, 78 FTE (95% CI: 69-88) in Kherson, and 197 FTE (95% CI: 173-221) in Mykolayiv regions. • While Poltava region has sufficient HRH capacity to meet projected HRH for HIV requirements and achieve 90-90-90 by 2020 in both scenarios, other regions demonstrated significant gaps (Kherson region, scenario 2A (-65 FTE); Mykolayiv region, scenario 2A (-172 FTE) and scenario 2B (-112 FTE)).

MYKOLAYIV REGION

Table 1. TIME INPUTS INTO HIV SERVICES AND THEIR COMPONENTS HIV service package

HIV service package components

HIV counseling and Obtaining informed consent testing using rapid Pre-test counseling tests HIV rapid testing Post-test counseling (total: 43-62 min.) Paperwork Additional counseling in case of positive test result HIV counseling and Obtaining informed consent testing with ELISA Pre-test counseling Blood sampling (total: 43-64 min.) Organization of the sample delivery Post-test counseling Paperwork Additional counseling in case of positive test result Enrollment in care Initial examination, medical history and initial complaint documentation (total: 74-116 min.) Referral for medical examinations and appointment scheduling Enrollment in care, defining clinical and immunological stage of HIV infection Counseling on HIV-related issues Psychologist / social worker counseling Hepatitis B and C counseling Referral for hepatitis B and C testing STI counseling Referral for STI testing Counseling on other opportunistic infections and complications Referral for opportunistic infections testing TB clinical screening (screening survey) Referral for chest X-ray/ fluorography examination Sampling of sputum to be transported to the microbiological TB diagnostic laboratory Organization of the sample delivery Paperwork Routine follow-up Repeated examination care of HIV+ patients Referral for medical examinations and appointment scheduling Counseling on HIV-related issues (total: 59-77 min.) Psychologist / social worker counseling Hepatitis B and C counseling Referral for hepatitis B and C testing STI counseling Referral for STI testing Counseling on other opportunistic infections and complications Referral for opportunistic infections testing TB clinical screening (screening survey) Referral for chest X-ray/ fluorography examination Paperwork Initiation/ Initial examination, medical history and initial complaint prescription of ART documentation Selection and preparation of patients for ART (total: 23-31 min.) Selection of ART regimens Referral for medical examinations and appointment scheduling Paperwork On-going ARV ART counseling treatment and Adherence counseling monitoring Follow-up and management of ART patients Provision of ARVs (total: 31-36 min.) Psychologist / social worker counseling Paperwork TB prevention and Counseling, including prevention and treatment treatment in HIV+ prescription patients Isoniazid-based prevention (prescription) Referral of patients with suspected TB to TB specialist (total: 33-49 min.) Administration of DOT and ensuring compliance with the recommendations of a TB physician Sampling of sputum to be transported to the microbiological TB diagnosis laboratory Organization of the sample delivery Psychologist / social worker counseling Paperwork Opioid substitution Counseling for OST patients therapy Counseling and treatment related to other co-morbidities (total: 22-31 min.) Determining OST dosage Adjustment of OST dosage Monitoring of patient’s condition Referral for medical examinations and appointment scheduling Keeping records on OST drugs Administration and control of OST drug dose intake (oral examination) Psychologist / social worker counseling Other paperwork (not related to administration/control of OST drugs)

Presented at the 22nd International AIDS Conference – Amsterdam, the Netherlands This study was made possible due to the funding provided by the U.S. President’s Emergency Plan for AIDS Relief through the United States Agency for International Development (USAID) under the terms of the HIV Reform in Action project, award number AID-121-A-13-00007. The content of this publication is the sole responsibility of Deloitte Consulting LLP and its implementing partners and does not necessarily reflect the opinion of PEPFAR, USAID, or the United States Government.

Median time Proportion of services provided in minutes, by different categories of health 95% CI cadres, % Psychologists Lower Upper Physicians Nurses and social limit limit workers 3 4 59% 23% 18% 5 6 68% 12% 20% 10 15 27% 49% 24% 4 5 67% 7% 26% 5 6 36% 45% 19% 16 26 100% 3 4 41% 14% 45% 5 6 42% 8% 49% 4 5 13% 87% 5 10 19% 81% 5 7 19% 7% 73% 5 6 36% 45% 19% 100% 16 26 6 3

7 3

48% 55%

52% 45%

-

5

5

59%

41%

-

6 15 5 3 4 4

7 42 6 4 5 4

74% 88% 63% 93% 74%

14% 12% 37% 7% 26%

13% 100% -

3

4

90%

10%

-

3 4 2

5 5 2

72% 58% 70%

28% 32% 30%

9% -

3

4

52%

48%

-

3 5 5

7 6 5

26% 36% 84%

74% 45% 16%

19% -

3

3

55%

45%

-

6 12 5 3 4 4

7 21 6 4 5 4

74% 88% 63% 93% 74%

14% 12% 37% 7% 26%

13% 100% -

3

4

90%

10%

-

3 4 2 5

5 5 2 6

72% 58% 70% 36%

28% 32% 30% 45%

9% 0% 19%

6

7

48%

52%

-

5 4

9 6

100% 100%

-

-

3

3

55%

45%

-

5 5 5 5 6 5 5

6 5 5 5 7 8 6

44% 84% 70% 100% 32% 36%

56% 16% 15% 68% 45%

15% 100% 19%

7

10

100%

-

-

4 2

5 4

100% 74%

26%

-

4

5

20%

80%

-

3

4

52%

48%

-

3 5 5 3 2 1 2 1

7 8 6 4 3 1 3 1

26% 36% 100% 100% 100% 100% 83%

74% 45% 17%

100% 19% -

1

2

68%

32%

-

1

2

47%

53%

-

1

1

4%

96%

-

5

8

-

-

100%

5

6

36%

45%

19%

Psychologists and Social Workers

Nurses

Physicians 140 120 100 80 60 40 20 0

140 120 100 80 60 40 20 0 2017

2018

2019

2020

140 120 100 80 60 40 20 0 2017

2017 2018 2019 2020

KHERSON REGION Physicians

Nurses

70

70

70

60

60

60

50

50

50

40

40

40

30

30

30

20

20

20

10

10

0

0

10 0 2017

2018

2019

2020

POLTAVA REGION 90 80 70 60 50 40 30 20 10 0

90 80 70 60 50 40 30 20 10 0 2017

2018

2019

2020

2020

2018

2019

2020

Psychologists and Social Workers

Nurses

Physicians

2019

Psychologists and Social Workers

2017

2017 2018 2019 2020

2018

90 80 70 60 50 40 30 20 10 0 2017

Available HRH for HIV capacity (2015) Scenario 1

2018

2019

2020

2017

2018

2019

2020

Scenario 2A Scenario 2B

Figure 4. PROJECTED HRH FOR HIV REQUIREMENTS FOR 2017-2020 BY DIFFERENT COVERAGE SCENARIOS AND CATEGORIES OF HEALTH CADRES, 3 regions of Ukraine, FTE (bars represent 95% CI)

Conclusions • In all study regions, existing capacity of AIDS Centers would not be sufficient to meet HRH needs under any scenario. Rapid decentralization of HIV services to primary care and integration of ART/TB/OST services are recommended. • Assuming a major scale-up of OST by 2020 (according to scenario 2A), as much as half of projected HRH needs would be related to the delivery of opioid substitution therapy. Expanded provision of take-home doses and implementation of novel OST program delivery approaches (e.g. pharmacy-based delivery) can considerably reduce the frequency of unnecessary visits, thus alleviating requirements in HRH. • As up to one third of total HRH for HIV needs by 2020 would be related to rapid HIV testing, extensive involvement of primary health care workers in HCT service provision is warranted, as well as implementing adequate rapid test procurement and supply mechanisms. • By 2020, ART initiation, on-going ARV treatment and monitoring would make up approximately one fifth of total HRH needs. Interruptions in supply of ART drugs and poor treatment adherence can increase the number of visits to facilities, exacerbating demands on HRH. It is therefore critical to plan for timely supply of ART drugs and focus on improving patient adherence to treatment. • While psychologists and social workers could potentially provide a significant percentage of HIV services, their availability in state-run medical facilities is extremely low. As supply of new cadres might be limited, task-shifting from specialized providers to primary healthcare practitioners and nurses with shorter training and fewer qualifications need to be be fully embraced, including through legislative amendments and provision of required training for those who assume new HIV tasks. • Health service delivery standards need to be reviewed/adopted and enforced to address HRH inefficiencies. #AIDS2018 | @AIDS_conference | www.aids2018.org