Scaling Up Treatment in Zimbabwe: The path to high coverage

IAS Conference

Dr. Tsitsi Mutasa-ApolloART Programme Coordinator, Zimbabwe

30th June, 2013Kuala Lumpur, Malaysia

Outline

Introduction

Background

Achievements

Treatment Cascade

Challenges

Opportunities

Zimbabwe Country Context

• Population: 12,9m • 1.2 million PLHIV• HIV Prevalence (ZDHS 2010/11)

– 15-49 yrs. 15% – Female 18%– Males 12%

• 41% of the U5 Mortality Rate is attributed to HIV/AIDS as the underlying cause

• 26% of MMR is attributable to HIV/AIDS

The Zimbabwe National Response

• Multi-sectoral response with broad stakeholder involvements

• Zimbabwe introduced a 3% tax on income to increase domestic resources for the national AIDS response in 1999– 26% contribution towards ARV procurements

• 5-year 2011 to 2015 strategy– National response towards achieving zero new infections, zero

discrimination and zero AIDS related deaths by 2015

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

0

1

2

3

4

5

6

7

High estimate

HIV incidence (15-49 years old) (%)

Low estimate

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

0

0.2

0.4

0.6

0.8

1

1.2

1.4

High estimate

Annual AIDS Deaths (%)

Low estimate

Zimbabwe HIV Incidence Zimbabwe Annual AIDS Deaths

2010 UNAIDS Report

- Attributed to successful implementation of prevention strategies, especially behavior change, high condom use and reduction in multiple sexual partners- AIDS-related mortality has also fallen

HIV incidence peaked in 1993 and has fallen significantly

Identification of major policy, health systems and structural bottlenecks in paediatric ART

• A multi-country paediatric HIV assessment with support from UNICEF and WHO in 2012

• What hampered access to Early Infant Diagnosis (EID), ART and retention to paediatric HIV treatment and care?

• Major findings:– Limited linkage between EID and ART– Centralized PCR testing and a long turnaround times– The median time from diagnosis to ART initiation was 61 days for children <2

years of age while the median age at ART initiation was above 7 years. – The proportion of children remaining in care 12 months after initiation was

below 75% and high rate of lost to follow-up was more observed among the under-fives

• The country is working towards addressing the uptake of EID and linkages to, and retention in care in order to improve child survival

Progress in implementing 2010 ART guidelines

• MOHCW adapted the 2010 WHO Guidelines with a 3-year phased approach to phase in TDF-based regimens and phase out D4T- based regimens

• Due to limited resources the adaptation committee prioritized the following groups:– HIV-infected Pregnant women– TB/HIV co-infected people – Patients presenting with side effects stavudine-related side effects– Patients on ART for over 3 years

• By April 2012; 66% of adults receiving TDF-based regimens; while 34% on D4T- regimens (phasing out by Dec 2013)

• All children were prioritized for transitioning to AZT-based regimens unless medically contraindicated

Step 1: HIV Testing to enrolment into care

Step 1HIV Testing to

enrolment into care

Step 2 HIV Enrollment to

eligibility

Step 3Eligibility to

initiation

Step 4Initiation to long-

term ART

HIV Testing• An increase in proportion of people reported ever tested & received results from

22% percent to 57% among women resp. from 16% to 36% among men (from 2005 to 2010)

• A discordance rate of 12 % among couples (2010-11, ZDHS)• Challenges

• Poor links between testing & services; Lack of post-test support• Currently

• 96% of Primary Care Facilities offer Provider Initiated Testing & Counselling• 79% of facilities offer Early Infant Diagnosis using Dried Blood Spots for PCR• Couple counselling to be rollout out in 2014

Step 2: Enrolment to Eligibility

Step 1HIV Testing to

enrolment into care

Step 2 HIV Enrollment

to eligibility

Step 3Eligibility to

initiation

Step 4Initiation to

long-term ART

• Congestion at many clinics• Long distance to nearest clinic/high transport costs• Limited CD4 testing including Point of care technology• Competing life priorities e.g. seeking food• Inadequate referral information• Strategies:

• Mobilized resources for additional CD4 POC machines• Decentralization of ART services

Decentralization of HIV Care and Treatment Services

The aim of decentralization is to bring ART services closest to where people live.

By end of 2007, only 9 ART sites open

By March 2013, 1006 (64%) ART sites

Target is to reach 1,560 health facilities offering ART services by 2015

Step 3: Eligibility to Initiation

Step 1HIV Testing to

enrolment into care

Step 2 HIV Enrollment

to eligibility

Step 3Eligibility to

initiation

Step 4Initiation to

long-term ART

Males poorer clinical and immunological status prior to initiating ART when compared to females

Males generally presenting late for HIV treatment and care when compared with their female counterparts

Currently no waiting lists for ART initiation

Zimbabwe ART Programme Scale Up

2004 2005 2006 2007 2008 2009 2010 2011 20120

100

200

300

400

500

600

700

800

900

1000

0

10

20

30

40

50

60

70

80

90

100

5 49 71 80 104 117 128 1412200 5

5 9

27

263

382449

760

ART INITIATING ART FOLLOW-UP SITES ART TREATMENT COVERAGE (%)

Period

Num

ber

of S

ites

ART

Cove

rage

(%)

Step 4: Initiation to long-term ART

Step 1HIV Testing to

enrolment into care

Step 2 HIV Enrollment

to eligibility

Step 3Eligibility to

initiation

Step 4Initiation to

long-term ART

• Too many appointments when ARV supply is insecure• Challenges with migrant workers resulting in high defaulters and loss to follow

• Nurse led ART initiations have bolstered ART scale up particularly in remote areas• At 12 months after initiation of ART; 89.8% participants achieved viral suppression of

below 1000 copies/ml

Strategies: • Introduced an E-Patient Tracking System;• Secured ARV commitments under the Global Fund NFM;• Community support groups

Retention of Patients Initiating ART during 2007-2009, Zimbabwe

• Good retention in care observed in a retrospective cohort study in a nationally representative sample of patients initiating ART between 2007 and 2009

• 69% of patients were continuing ART treatment at 24 months, whereas 7% had died and 24% were lost to follow-up (MOHCW, 2012)

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 -

100,000

200,000

300,000

400,000

500,000

600,000

8,000

565,675

120,000

62,000

160,000

86,000

No of PLHIV receiving ART No of People Newly Infected with HIVNo of people dying from AIDS related causes

Zimbabwe ART coverageAIDS mortality & new HIV infections

Source: Zimbabwe HIV Estimates, 2013

Recent modelling exercise has shown substantial impact of the ART programme with 71,970 deaths averted by ART in 2012 alone

Analysis of ART Programme Impact

Challenges while Scaling UpMismatch between numbers of HIV care providers and patient volumeNeed to review staff establishment

Insufficient counsellors for adherence counselling & support

Expensive to run in-service trainingsNeed to strengthen pre-service curriculum and internship

Lack of adequate competencies for Paediatric ART and counselling skillsWhen to switch patients to 2nd lines; management of co-morbidities

Limited viral load capacity for patient monitoring; long TAT for Early Infant Diagnosis using PCR

Difficulties in linking patients to care, adherence, and viral suppression

The paper-based system for M & E is difficult to implement in a large programme

Opportunities

Zimbabwe an early applicant for the Global Fund New Funding ModelGF board recently approved USD 311m for HIV

Anticipation of additional USD 244m from GF replenishment funding to support new initiatives:- ART initiation at CD4 < 500 and ART for children < 5 yrs

Planned development of a 3-year Strategic Plan for the National ART programme starting July 2013

Large and diverse private sectorParticularly vibrant health insurance industry for possible private-public partnerships

Implications for the 2013 HIV Guidelines

• CD4 500 threshold– Estimated 28% annual increase in number of PLHIV in need for ART– ART Coverage will drop from 85% (2012) to below 70%

• Triple ARVs for HIV+ pregnant women– Support the e-MTCT country agenda

• Treatment for the Under 5s– Help overcome treatment eligibility challenges experienced by health workers – Support scale up

• Efavirenz-based regimens– Increment of US$ 1-50 to 2 per patient per month compared to NVP-based

regimens– Improve adherence

I Thank You