Decentralisation as a tool to bring HIV services closer to those most in need: Georgia’s experience

In 2023, five countries in the EECA region developed roadmaps that detail the pathway and tools for decentralising HIV services – including to increase their geographic accessibility. The Social Equation Hub worked with local consultants from the public and community sectors to develop these strategic and tactical transformation plans, and in 2024 is helping countries directly implement the changes: at both the normative and practical levels. It is from our interactions with the Hub team that this piece emerged.

WHY ARE HIV-ASSOCIATED SERVICES SO CENTRALISED AND WHAT DOES THIS MEAN FOR PATIENTS?

Practically all EECA countries, at the early stages of establishing state HIV response programmes, allocated separate medical institutions to work with patients with HIV. These structures were responsible not only for policy formation and methodological support, but also for a long time were some kind of monopolists in providing HIV diagnostic services, antiretroviral therapy (hereinafter referred to as ART) and other assistance for people living with HIV. AIDS centres also had their own separate laboratories.

As Mari Choheli, Regional Consultant of the Social Equation Hub explains, the idea of decentralisation is based on the need to improve, expand and qualitatively transform access to services for vulnerable groups. In particular, it is about including public polyclinics and private clinics before providing HIV services – so a wider range of people will get what they need closer to home: whether they live in the capital or in a more remote region of the country.

But the dynamics of demonopolisation of HIV-associated services differ from country to country EECA and Mari highlighted 5 reasons why change is not easy:

1. HIV service providers are not ready for change as they see the threat of a decline in the quality of service delivery and information collection, which could take the form of decentralisation of a single database system, logistics of drugs and tests, quality control of diagnosis and treatment.
2. Although many countries are undergoing reforms in health care and primary care, some countries are not ready for changes on less popular topics such as HIV and services for vulnerable groups. Consequently, more intensive lobbying for the needy is required and this is why the role of organisations such as the Hub is important: to ensure that the voice from the lower local level reaches the responsible institutions at the central level.
3. As long as there is vertical donor funding, there is no informed demand among top-level politicians and officials to build a sustainable, integrated response to the HIV epidemic.
4. Because of stigma and discrimination, people do not want to use HIV services in small clinics – where their neighbours and family members also come and there is a risk of disclosure of personal information or even just an unexpected encounter. On the other hand, some people avoid HIV clinics for fear of coming into contact with people who are HIV-positive.
5. Private sector entities – the bulk of clinics in the Georgian context – do not see the financial benefit of testing and/or treating people living with HIV.

GEORGIAN EXPERIENCE: AT WHAT STAGE IS DECENTRALISATION OF HIV SERVICES NOW?

Georgia already has experience of an integrated, people-centred approach within the framework of the State Hepatitis C Elimination Programme. For example, testing for hepatitis C and even treatment with new protease inhibitor drugs can be provided by trained harm reduction service points that operate on the basis of NGOs.

In the area of HIV infection, prior to decentralisation, only the Republican AIDS Centre and 3 other clinics in West Georgia could diagnose and prescribe ART. As of today, with the assistance of the Hub and under the leadership of the National Centre for Disease Control, decentralisation has advanced at the level of the regulatory framework in accordance with the roadmap. The intentions and practical steps for service distribution are reflected in the National HIV Programme approved by the Government of Georgia, the “State Health Programmes 2024”, as well as the special order of 2023 of the Ministry for Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Protection.

This government decree envisages the involvement of primary care facilities and other local clinics in the implementation of rapid tests and diagnostics in 7 regions of the country (Telavi, Akhaltsikhe, Zugdidi, Kutaisi, Khashuri, Batumi and Poti), and provision of ART in four (Telavi, Khashuri, Akhaltsikhe and Poti). Some of these locations are regional centres on a larger scale, while others are rather small settlements. Validation of the use of fourth generation rapid test systems for diagnosis is now underway – in line with WHO recommendations (see article from 2019) to move away from immunoblotting. According to the latest information from the current tender, the tests should be delivered to the country in the coming months – and this will help move from regulatory to practical decentralisation of testing.

The Hub, together with national partners, plans soon to:

• start co-operation with private clinics,
• establish a mentoring and telemedicine system for medical staff without HIV experience (to be supervised by the AIDS Centre),
  and to involve specialists responsible for information systems within the clinics.

All of this is to ensure that data from all clinics that provide ART complement the national HIV information system in a timely manner.

In addition, the Hub’s immediate plans are to train NGOs working with vulnerable populations so that in the future they will be able to use rapid HIV tests and provide more expanded services, similar to the provision of the same services for hepatitis C.

“Decentralisation of AIDS diagnosis and treatment services in Georgia is expected to increase geographical access to services while maintaining a centralised model of quality control and information collection. There will also definitely be a reduction in diagnosis time with the new algorithm – due to the introduction of fourth-generation tests prequalified by WHO,” believes Vladimir Getia, Head of the Department of State Health Programmes at the National Centre for Disease Control and Public Health of Georgia.

WHAT ELSE DO THE ROADMAPS ON DECENTRALISATION ENVISAGE?

In addition to Georgia, the Social Equation Hub works with 4 other countries: Armenia, Kazakhstan, Kyrgyzstan and Moldova. Each country is different. To prepare roadmaps, the Hub team – together with local and international consultants, and taking into account the specificities of each country – prepared separate strategic planning tools describing A) successes already achieved, B) existing barriers and peculiarities, and C) recommendations. The Oxford University assessment methodology was used to prepare the roadmaps. This significantly helped to take into account the specificities of national health systems, their readiness and needs for decentralisation, and other important aspects of the local context.

Mari notes that it is important for each country to understand the practical experience of others. In this regard, this year the Hub is organising a study visit of government and non-government sector representatives from Armenia to neighbouring Georgia to learn more about the distribution of testing services and ART dispensing. In Kazakhstan, a dialogue between the country’s specialists and WHO has laid the foundations for important reforms to change the HIV diagnostic algorithm. The country’s interest in such reforms increased after the results of the PAS Centre’s economic evaluation, which clearly demonstrated that the cost of diagnostics in the country is almost 5 times higher than the cost of HIV diagnostics in Georgia. While WHO continues to work with the public sector to reform the testing and diagnosis algorithm, the Hub sees its role as facilitating reforms by community organisations and the civil sector, and coordinating common efforts between partners.

In the future, the Hub promises to organise open regional meetings and publish the experience of other countries in the EECA region so that as many stakeholders as possible can consider ways to bring services closer to the end user. As the examples of some countries show, such changes can cost lives and health both for an individual and his/her family, and savings for the whole state.