Arv programme summary

2

▪ National level HIV prevalence data suggest that HIV prevalence has stabilized– In adults aged 15-49 years, HSRC

surveys estimated HIV prevalence at 15.6% (2002), 16.2% (2005), and 16.9% (2008)

▪ Although HIV prevalence is stable, the total number of PLHIV1 is rising (~100,000/year) due to population growth and reduction of mortality due to ARVs

▪ On average, females are infected about five years earlier than males, with 7% of young women aged 15-19, and 14% of pregnant teenage girls, already infected

▪ Females have a statistically significant, higher HIV prevalence than men, nationally and in 7 of the 9 provinces (not in N Cape and North-West)

South Africa faces the world’s worst HIV epidemic –HIV prevalence seems to have stabilized, but at a very high level

SOURCE: KYE/KYR reports, 2011; Spectrum estimations and mid-year population estimates from www.statssa.gov.za

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

0

10

20

30

40

50

921990 2008060402200098

Number(infected, newly infected, died)

9694

PopulationMillions

AIDS-related deaths

Annual new HIV infections

People living with HIV

Total population

1 People Living with HIV/AIDS

3

ARV roll-out is driving HIV prevalence up even further

SOURCE: HSRC survey reports; ART-adjusted data: Rehle et al., 2010; KYE/KYR reports, 2011

▪ ART has begun to have an important effect on HIV preva-lence levels (adding ~2% to HIV prevalence through PLHIV who would already have died in the absence of ART)

▪ The life-prolonging effect of ART is the chief reason for the observed increases in HIV prevalence in older people. This ‘ART effect’ is estimated to be largest in people in the mid-20s to late 40s

0

2

4

6

8

10

12

14

16

18

HIV prevalencePercent

2002

2006 2008

2008, ART adjusted

Pre-2002 level

4

South Africa’s treatment program is the largest in the world, but there is need to further slow infections and further expand coverage

SOURCE: Nathea Nicolay, Summary of provincial HIV and AIDS statistics for South Africa, Metropolitan, 2008; NDOH programme data 2008,2009,

▪ Highest uptake on ARV is in the Western Cape (75%)

▪ Highest number of people on treatment in Gauteng (175,000)

▪ Largest number of people who are still in need of treatment but not accessing it are in KZN followed by Gauteng and Eastern Cape

Provincial distribution of those in need of ARV and those receiving treatment

2008 figures, ‘000

5544

8165

2008 2009

% of those in need of treatment enrolled in the ART programme

ChildrenAdults

297

43%73 7187

Mpuma-langa

44%

Free State

49%

North West

44%

92

293

47%

Eastern Cape

60%

111

44%

Kwazulu-Natal

Gauteng Western Cape

55

75%

Limpopo Northern Cape

1155%

Total people accessing ART (mid year)

Total people in need of ART (mid year)

5

New South Africa guidelines have expanded coverage, but there is still a way to go to align with international standards

Old South African guidelines

Eligibility▪ Adults: CD4 <200 cells/mm3 or WHO Stage 4▪ Children: CD4 15% to 20% or WHO Stage 3 or 4

Regimens▪ Adults: d4T + 3TC + EFV/NVP; AZT + ddI + LPV/r▪ Children <3 yrs: d4T+ 3TC + LPV/r; AZT + ddI + NVP

New South African guidelines

Eligibility▪ Adults: CD4 <350 cells/mm3 for TB/HIV co-infected or pregnant pts,<200

cells/mm3 or WHO Stage 4 for all others▪ Children: Early Paediatric Treatment

Regimens▪ Adults: TDF + 3TC + EFV/NVP for all new initiates; TDF + 3TC + LPV/r if failing d4T-

or AZT-containing regimens/AZT + 3TC + LPV/r if failing TDF-containing regimens▪ Children <3 yrs: ABC + 3TC + LPV/r; AZT + ddI + NVP

Full WHO guidelines

Eligibility▪ Adults: CD4 <350 cells/mm3 or WHO Stage 4 for all▪ Children: Early Paediatric Treatment

Regimens▪ As in “New South African Guidelines”

SOURCE: Total cost and potential cost savings of the national antiretroviral treatment (ART) programme in South Africa 2010 to 2017; Author: Gesine Meyer-Rath et. al; Date: April 12, 2011

6

Aggressive task shifting and strengthened, centralized procurement capabilities are required to keep costs under control


2,245

New guidelines 1,161 2,994

Old guidelines 1,055

2010/112016/17

711

754 1,969

1,504 8,180

9,946

-33

-35

Change on old GL (full cost)Percent

10 33 -29 -12 -18 –

Full WHOguidelines

1,415 3,494 934 2,345 12,077 -33

Reduced cost (with task-shifting and cheaper fixed-dose combinations) Total

Full cost (staffing and drug cost as current) TotalScenario

Change on full costPercent

Change on old GL (full cost)Percent

34 56

12,200

15,251

25

18,125

49 -11 4 -0.1 –

▪ The total cost of the programme increases by 25% and 49%, respectively, for the new guidelines and full WHO guidelines scenarios, as a result of increased eligibility and higher drug cost for TDF-containing regimens

▪ If new drug purchasing mechanisms and task-shifting are implemented, the cost of the new guidelines is below, and the cost of the full WHO guidelines the same as the cost of the old guidelines

$ Millions, 2009

7

10

8

8

13

10

9

15

12

10

Full WHO guidelines

New guidelines

Old guidelines

If new drug purchasing mechanisms and task-shifting are implemented, costs can be kept under control even with expanded guidelines


[BUDGET REVIEW 2010,NATIONAL TREASURY

2012/132011/122010/11

7

5

5

8

7

6

10

8

7

Full WHO guidelines

New guidelines

Old guidelines

%

Percentage of budget at full cost

Percentage of budget at reduced cost (TS and RL/FDC)

8

Summary of patients initiated on ARVs vs. cost under each set of guidelines

SOURCE: Total cost and potential cost savings of the national antiretroviral treatment (ART) programme in South Africa 2010 to 2017; Author: Gesine Meyer-Rath et. Al; Date: April 12, 2011

9,946

8,180

18,125

12,200

3,592,0003,331,000

2,932,000

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

Total costUSD millions Total patients

12,077

Full WHO guidelines

New guidelines

15,251

Old guidelines

Total cost (full cost)

Total cost (reduced cost)

Total patients initiated on ART

9

Health System constraints

▪ >300,000 patients per year, however, significant capacity challenges in expansion including human resources, infrastructure and drug supply

▪ Need for greater decentralisation of ARV treatment services, and greater recruitment and retention of health workers in the public health sector

Estimating need for ART treatment is difficult

▪ Even with the best systems in place, calculating number enrolled in ARV programs can be difficult

▪ South Africa’s ART program lacks one unified, centrally coordinated patient monitoring system– Hard to collate accurate figures of those receiving treatment or survival rates– DoH currently piloting an IT system in the Western Cape

Other challenges

▪ Monitoring capacity of patients

▪ Numbers of doctors to provide ARV therapy

▪ Communication by leaders to communities to overcome stigma and confusion regarding efficacy of ARV treatment relative to traditional medicines

SOURCE: Global Fund; UNAIDS; Press search, NDOH programme data 2008/09

There are significant capacity challenges in the programme expansion

Key challenges scaling up the ARV programme

10 SOURCE: Global Fund; UNAIDS; Press search, NDOH programme data 2008/09

Recently, the government has taken steps to address these capacity gapsKey actions taken by the government

Increasing coverage of facilities▪ Increase in number of patients reflects ongoing expansion as service points accredited, counselling and

testing, HR and lab infrastructure put into place▪ Rapid increase in number of HIV, CD4 and viral load tests performed by National Health Laboratory

Service▪ Measures taken by DoH to upgrade existing health infrastructure includes upgrading and accreditation

of sites, training programs for health-workers to deliver treatmentImplementation▪ In February 2010, the national ART budget was increased by 96%, providing care for up to 2.3 million

patients by the end of 2012/13 ▪ To increase coverage, a HCT campaign was started in April 2010, aiming at testing 15 million South

Africans by June 2011▪ Treatment guidelines expanded to include all pregnant women and patients with a CD4 >350Recommended improvements to the programme▪ New treatment guidelines in April 2010, adhering to WHO recommendations to initiate ARV at a CD4

count of <350 cells/mm3

▪ New drug purchasing system: ARV drugs at prices set in reference list mechanism issued for 2010 tender, ultimately decreasing the cost of drugs by 26% and saving ~$120 million

▪ Task shifting: ARV initiation and management by nurses under physician supervision; ARV dispensing by pharmacy assistants under pharmacist supervision

▪ Programme cost (including new drug purchasing and task shifting under new guidelines) would be 25% less than under the Old Guidelines, while reaching 15% more patients1

1 See next slide for cost breakdown

11

Coordination complexity archetypes – South Africa (province)

1 Includes provider-initiated VCT

SOURCE: South Africa HIV/ AIDS stakeholder interviews

Medium HighLow Extreme

Intervention type (primary)

▪ Clinical ▪ Clinical ▪ Clinical/ Behavioural

▪ Behavioural

Number of funders

▪ 0-2 ▪ 3-5 ▪ >10 ▪ 3-5

Number of implementers

▪ 1 ▪ 2-10 ▪ 11-25 ▪ >25

Examples of programs in archetype

▪ N/A ▪ N/A ▪ PMTCT

▪ ART

▪ MMC

▪ VCT

▪ OVC

▪ BCC

12

Complexity of the programme

LowMediu

mHig

hExtrem

e

Funders▪ SAG provides majority (85%) of funding; In February 2010, the national ART budget

was increased by 96%, providing care for up to 2.3 million patients by the end of 2012/13

▪ Drugs are purchased centrally and make up roughly 20% of the global market for ARVs

▪ 43% of CDC funding is directed towards ARV treatment, and 46% of the total from USAID

Implementers▪ ARV’s are dispensed only from accredited primary health care facilities and clinics

Size▪ Over 1 million HIV positive people are currently on ARV treatment, however, the total

need is 5.7 million

▪ Additional 300,000 people in need every year

▪ Measures taken by DoH to upgrade existing health infrastructure includes upgrading and accreditation of sites, training programs for health-workers to deliver treatment

▪ Scale up of task shifting to increase the ability of nurses to provide ARV treatment, and ensuring proper supervision/mentorship

▪ Reduction of the cost of drugs to allow for increased coverage at a reduced cost per patient

Capabilities required

SOURCE: South Africa HIV/AIDS stakeholder interviews

13

Structure of the HIV response is complex: ARV example

SOURCE: Interviews

1 HIV/ AIDS, TB and STD director

ILLUSTRATIVE

ART lead

Provincial

National

District

SANAC

TreatmentTask Team

ART lead

NGOsNGOsNGOsGvt clinics/ hospitals

NGOsNGOsNGOsNGOs (provideTA/ mobile CT)

Implementers

NGOsNGOsNGOsNationalNGOs

NGOsNGOsNGOsTreatmentleads

DistrictAIDS council

DG=>MoH=>HIV Director

Directorate for Treatment

Premier=>MEC=>Head of department

District HASTDirector

Provincial HAST1

director

ART lead

National & provincial ARTleads meet quarterly to exchange ideas & information

Provincial AIDS council



NGOsNGOsNGOsNationalNGOs

NGOsNGOsNGOsInternationaldonors

14 14

Key ART programme players and roles

SOURCE: South Africa HIV/AIDS stakeholders interviews

PRELIMINARY

Strategy/ Policy

Resource allocation (budgeting)

PlanningImplement-ation

Monitoring & reporting

Evaluation

Donors and providers of technical assistance

▪ Provides analysis on resource needs

▪ Facilitates planning

▪ Provide TA

▪ Supports imple-mentation

▪ Monitors program

▪ Lead evaluations

▪ Sets global guidance and provides TA to government

Civil society organisations

▪ Advocates for resources

▪ Plan for service delivery

▪ Implement programs (ART , home based care, follow up)

▪ Report on programs

▪ Lead evaluations

▪ Advocates for PLWHA policies

▪ Allocates domestic resources

▪ Negotiates with donors

▪ Forecast treatment needs and allocates resources

▪ Monitors programs

▪ Reports to donors

▪ Conduct and participate in evaluations

▪ Sets national ART policy and guidelines

Government

▪ Distributes ART to clinics

▪ Trains clinicians

Private sector

▪ Allocates resources to treat workers

▪ Develops workplace programs

▪ Provides treatment to workers and families

▪ No formal mecha-nisms in place

▪ No formal mecha-nisms in place

▪ Input through SANAC

15

Landscape of programme execution

SOURCE: South Africa HIV/AIDS stakeholder interviews

PRELIMINARY

Strategy/ PolicyResource allocation (budgeting)

Planning ImplementationMonitoring & reporting

Evaluation

▪ Strategy and policy is set at the national level, and guidelines are communicated effectively down to the implementing level

▪ Communication often in the form of media e.g. recently guidelines adopted from President Zuma’s speeches

▪ Generally done well, implementing agencies have taken ownership

▪ However, policies are often set without taking into account capacity constraints

▪ Resource allocation done at provincial level based on district health plans

▪ Districts allocate to hospitals and facilities according to funding requests

▪ However, a lot of bureaucracy/ complexity relating to budgeting

▪ Lack of trained resources with financial management skills at all levels results in inaccurate budget allocation

▪ Issues around drug supply from the depot

▪ Operational planning is done at the facility level

▪ Plans are tied in with the budget which are then sent to district, and subsequently to provincial level

▪ Poor under-standing of plans and lack of management capability results in funds being returned to the treasury at the year end or running out mid year

▪ Lack of evidence of ‘forward thinking’ in planning e.g. taking into account growth

▪ Implementation is carried out by government hospital and facilities at the sub district level

▪ There are a number of public private partnerships where NGO support is given to government hospitals

▪ Initiation of task sharing/shifting from doctors to trained nurses

▪ Need to increased system efficiency e.g. booking/ queue management

▪ DoH chosen IT system to pilot

▪ There is no centralised IT system for monitoring and reporting

▪ Currently, 3 sets of indicators requested from district office (planning and procurement), DORA (finance) and internal reporting

▪ Donor specific reports requested from funded partners

▪ Challenges in collecting information as much of the data in facilities is paper based

▪ Little or no feedback against plans or targets

▪ No interpretationof the data collected in the previous stage for managerial implications

16

Funding flows, technical support, and accountability lines flow through multiple stakeholders in the ARV programme

Funding flowsReporting/account-ability mechanisms

Technical support

SOURCE: The Second Botswana National Strategic Framework for HIV and AIDS, 2010-2016; PEPFAR; UNGASS 2010 Botswana Country Progress Report; PEPFAR Partnership Framework; UNAIDS Country Harmonization and Alignment Tool (CHAT); interviews; team analysis

District Health

Facilities

NGOs/CSOs

International Partners

Government of South Africa

National DOH

Mobile Clinics

Provincial DoH

SANAC

NGOs/CSOs

EU+ donors

PEPFAR Global Fund

PRELIMINARY

Documents

Arv programme summary