Getting to 80% ART coverage

Dr Francois VenterReproductive Health and HIV Research Unit

University of the Witwatersrand

January 2010

Thanks to: Robin Wood

HIV and South Africa

5 million people

Kenya, 245,162

16%

Mozambique, 156,108

10%

Tanzania, 139,151

9%

Uganda, 78,769, 5%

Eritrea4,838 Madagascar

1,491Mauritius

584

Comoros28

South Africa, 473,499

31%

Zambia, 103,077

7%

Ethiopia, 94,489

6%

Malawi, 86,905, 6%

Rwanda, 9,225, 1%

Botswana, 13,518, 1%

Swaziland, 15,131, 1%

Namibia, 16,082, 1%

Angola, 21,777, 1%

Lesotho, 22,666, 1%

Zimbabwe, 45,652, 3%

Eastern & Southern Africa

1.5 million (57%

Rest of the world1.2 million (43%)

Global new infections, 2.7 million ESA new infections,

Prov. estimate 1.5m

Estimates of New Infections in Eastern and Southern Africa, 2007

South Africa: Why is it important?

• Size of the country; size of the epidemic; size of ART programme

• Rich country!

• De Cock: If South Africa fails, we all fail

The proportion of deaths due to AIDS has shown a staggering increase in the last decade

 0%

 10%

 20%

 30%

 40%

 50%

 60%

 70%

 80%

 90%

 100%

97%

3%

28%

54%

46% AIDS implicated

2000

100

1995

72%

100 100

2005

Source: ASSA2003 Model

Stats SA 2009: 43% directly due to AIDS

Common, preventable, treatable… How is it not a public health priority?

164

187

102

181

200192

87 239

163

97

134

179

97

100125

12386

122103 53

157 20695

72

Review of data from 2003-2005 from 176 sites in 42 countries (N = 33,008)

When Is Antiretroviral Therapy Started?

Egger M, et al. CROI 2007. Abstract 62.

High death rate while waiting for ART

Arch Intern Med 2008;1678:86

Braitstein, P et al. High Risk Express Care: a novel care model to reduce early mortality among high risk HIV-infected patients initiating combination antiretroviral treatment. HIV Implementers Meeting, Namibia, abstract 1556, June 2009.

Expedited care decreased mortality by 60%

• “"There is a need for honesty and peer review in situations that impact public health policy. When AIDS denialism enters public health practice, the consequences are tragic. The implications start in honest science but extend to the need for accountability and, perhaps, public health reform." Chigwedere P, Essex M. AIDS Denialism and Public Health Practice. AIDS and

Behavior, 2010; DOI: 10.1007/s10461-009-9654-7 http://www.sciencedaily.com/releases/2010/01/100118132134.htm

Outcomes of ART

5 year survival on ART in Botswana

0 1 2 3 4 5 6

survival time

0.0

0.2

0.4

0.6

0.8

1.0

Cum

sur

viva

l

Main survival function

88.6% (88.1 – 89.2)

Puvimanasinghe JPA et al. Mexico 2008 (MOAB0204)

ART recipients do well!

How are we doing?

Proportion of New AIDS Sick Cases Treated, per Year and Province

0.0%

20.0%40.0%

60.0%80.0%

100.0%

MP LP NW GP EC FS KZN WC NC RSA

2005 2006 2007

NSP Target 2011

NSP Target 2007

How are we doing?

Proportion of New AIDS Sick Cases Treated, per Year and Province

0.0%

20.0%40.0%

60.0%80.0%

100.0%

MP LP NW GP EC FS KZN WC NC RSA

2005 2006 2007

NSP Target 2011

NSP Target 2007

Somewhere around 45% in 2009… (NOT retention in care!)

Who did we NOT reach?

Number of Untreated AIDS Cases per Year and per Province

0

20000

40000

60000

80000

100000

120000

NC WC LP NW FS MP EC GP KZN

Untreated AIDS cases 2005 Untreated AIDS cases 2006

Untreated AIDS cases 2007

Proportion of children reached probably similar

500 000 need ARV’s EACH year

220 000 well on ARV’s

380 000 dead

• Our models: 1 hospitalisation, 2-3 clinic visits per person put on ART

• “Test and treat” modellers – 2-9 days hospitalisation averted per person on ART

• Hugely cost saving in SA WHATEVER CD4 you use (in Kenya, not so)

Can we achieve scale-up?

RHRU programme?

• Urban and rural: Initiation CD4 80-100 since 2004

• Johannesburg inner city – average CD4 106, despite 70%

coverage, and massive escalation of HIV testing

• ¼ of all South Africans had an HIV test in 2008 (Shisana, HSRC

Mandela survey, 2009)

Number of Patients initiated on to HAART @ RHRU Supported Sites

within Region F

0

50

100

150

200

250

300

350

400

450

500

Apr

May Jun

Jul

Aug

Sep

tO

ctN

ovD

ec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep Oct

Nov

Dec Jan

Feb

Mar

Apr

May Jun

Jul

Aug

Sep Oct

Nov

Dec Jan

Feb

Mar

Apr

May

June

July

Aug

Sep

tO

ctN

ovD

ec Jan

Feb

Mar

Apr

ilM

ay

2004 2005 2006 2007 2008

Num

ber o

f Pat

ient

s

The famous cascade…

• 50% loss to follow up at EVERY step

Target setting

• Not even done at a provincial level

• Starts with HIV testing – but EVERY step needs to be counted

Paediatrics

• Decent maternal ART=unemployed HIV paediatricians

• BUT hard to identify, hard to treat

• Suffer the most in poor health systems

• Prevention is better than treatment

Task shifting

• Cost of SA health care workers is very high

• Excuse for not scaling up, despite relatively high staffing levels

• Paradoxically, meant that task shifting has not happened

TB…

Thanks: Braamie Variava

Highest TB incident and prevalence

2006

+13%

0

100

1,000

1,100

1,200

200

300

400

500

600

700

800

900

2000 2001 2002 2003 2004 2005

Incidence of TB per 100,000 population

MDG 2015 Target

56

Source: Health Systems Trust reported 722 number; WHO: Global Tuberculosis Control, Surveillance, Planning, Financing reported 940

• TB-HIV co-infection was approximately 55% in 2002• The number of people diagnosed with TB trebled between 1996 and 2006 (from 269 to 720 cases of TB per 100 000) • 900 cases of Extensive Drug Resistant TB were reported between 2004 and 2007

• ART best way to prevent TB

• IPT very hard to implement

The role of donors

• History – confrontational

• Patch up the gaping holes in the programme

• Now: sustainability and technical ability – ESPECIALLY critical reviews of data and resource usage

In summary:

• We’re still treating HIV as an acute illness

• Mortality is driven by late diagnosis, poor referral, and delayed ART – we aren’t acting urgently post diagnosis

• People who get ART, generally stay on it DESPITE the system (commonest reason for LTFU – changing jobs)

• Adherence is good, but failures are costly

What would I do?

• Quick and (relatively) easy: TDF, FDC’s, use tender process to get better deals on drug packaging, PMTCT

• ANC and TB clinics to test and start ART• Programmatically hard: Targets for every step – starting

with the provinces, down to a clinical level• Creative and expensive: Chronic disease grants,

medicine pick ups• Expand HIV testing in health facilities• Critically review certain programmes for LTFU – ‘know

your status’ not good enough• Review SANAC

The two elephants in the room

• Health systems and retention in care• The average South African does not want to

attend a state health facility (for good reason!)• Retention in care affects – OI prophylaxis, IPT,

‘prevention for positives’, discordant couple interventions, etc etc

• ? A chronic care system is the silo we need• Finally: Public health leadership – tough

choices, tough priority setting – focus on using existing resources more intelligently