Dr. Yogan PillayDeputy Director General

National Department of Health, South AfricaMonday 1 July 2013

OPERATIONAL AND PROGRAMMATIC CONSIDERATIONS IN SCALING UP ART

Major progress in scaling up ART

15 million on ART by 2015 within reach

2

Elimination of MTCT (UNAIDS)

3

Some South African Data

6.4 million people living with HIV and AIDSHIV associated with

50% of maternal mortality55% of under 5 mortality

HIV Prevalence: 30% amongst pregnant women2.1 million on ARTART Coverage: 80% of women, 65% of children and menMTCT: 8% in 2009

2.7% in 2011All this in a relatively weak health system

4

MTCT rate at 6 weeks in South Africa

5

Thousands

Total annual AIDS deathsEPP Classic Spline

2011 2011 2012270 000 316390 221770

7

Rising life expectancy associated with ART scale up

Bor et al, Science 2013

But considerable operational challenges

8

Too few take a test and get their result

Staveteig et al, DHS Comparative Reports, 2013

13% - 76%8% - 69%

9

Retention is a challenge as programmes expand

Western Cape Provincial Dept. of Health, South Africa, 2013

50% lost to careAfter 5 years

Mugglin et al, Trop Med Int Health, 2013

15-30% drop out of care at each step

from testing to ART

Kuala Lumpur, Malaysia , 30 June - 3 July 2013

• Expanded testing scenarios• Task shifting and

decentralization• Service integration• Adherence support

Key WHO Operational Recommendations

Expanded testing in South Africa

2009VCT rates 2m testing per year in health facilities

April 2010National HIV Counselling and Testing Campaign led by the President

Stigma reductionKnow your statusHIV, TB, other chronic

diseases screening20 million tested in 20 months

1/3 men!2011/12

Return to PICT: 9m tested in HCT Campaign to be reactivated with MMC in August Target every SA to test annually

12

Task shifting

WHO 2013 Recommendations:

• Trained non-physician clinicians, midwives and nurses can initiate and maintain ART

• Trained and supervised community health workers can dispense ART

Sanne et al, Lancet 2010; Fairall et al, Lancet 201213

Task shifting in South Africa

Nurse initiation of ART (2009)23 000 nurses trained in initiation of FDCs

Prescribing and dispensing

Lay counselors trained to conduct counseling and testing (rapid tests) – 2010

Ward based outreach teams trained in HIV, TB and MCH10 000 reoriented during 2011/12

14

Decentralization and integration

Kerstenberger et al, PlosOne, 201315

Adherence support

WHO 2013 Recommendations:

• Minimizing out of pocket payments

• Use of fixed-dose combinations

• Strengthening drug supply• Patient counselling and

education• Mobile phone text messages

Wilkinson, SAJHIV Med, 201316 Lester et al, Lancet 2010

Examples of integration

60% co-infection rate (HIV and TB)50% of deaths in pregnant women and children

associated with HIVNeed for integration is obviousSince 2010 all PHC facilities that provide TB,

sexual & reproductive, ANC and child health services, including school health services, also targeted for HIV servicesCurrently most public health facilities and over 3500

of 4200 public health facilities offer ARTMany challenges to integration still exist, including

infection control!17

HIV and TB – school health programme

18

19

    

A record 10 million PLHIV now have access to antiretroviral

treatment, June 2013, UNAIDS Press Release

“Significant successes in reducing costs have been achieved in recent years. For example the price of medicines to prevent mother to child transmission of HIV was reduced from US$ 800 in 2011 to below US$ 100 in 2013.

Through a more competitive bidding process, South Africa has reduced the cost of procurement of antiretrovirals to the lowest price anywhere in the world at US$ 127 per person per year for the fixed dose combination recommended in the new guidelines.

This has resulted in a 53% reduction in expenditure on antiretroviral treatment for South Africa”.

20

21

Conclusions

Guidelines by the WHO are based on the best possible evidence

Some operational research evidence is available BUT there are many gaps – need more operational research/implementation science

Expertise to model resources required to implement new guidelines exists but need data for modeling

Each country should carefully assess what is needed to implement new treatment guidelines

22

Acknowledgements

WHO working group on operational guidelines

Health Economics and Epidemiology Research Organisation (HERO)

“Modelling Group” Country Team

23