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Translating the Science to End New HIV Infections in Kenya

Perspectives, Practices and Lessons

Nairobi, 28 - 30 May 2017

www.iasociety.org

Challenges, Lessons Learnt and Opportunities for the Future in Implementing HIV Prevention

Combination Approach in Kenya

Nduku Kilonzo, PhDCEO, National AIDS Control Council - Kenya

Scientific SymposiumBuilding Consensus

HIV Prevention

Challenges

• We use data selectively

• We are not ready to invest for prevention results

• We are not ready to be accountable for results

Lessons

• We must become consistent in action

• It takes a few to impact change

• HIV starts and ends with behavior, everthing else is in between

Opportunities

• National and County leadership

• The Global HIV Prevention Coalition

• Sustainable financing – investments in reducing new infections

3

..

Where are we at?

• 16 Counties reduced adult infections by >50%

• 14 Counties increased new infections by >50%

• Highest #new infections in high burden areas

•Of 79,000 pregnant women, 6,613 HIV infections among children recorded

• 49% reduction in mother to child transmission of HIV

• Technical action: Option B+; free maternity; Bring back mothers initiative

• Political support: County investments; Beyond Zero Campaign

The greatest impact was felt in reduction of

mother to child transmission

Where do we need to go?…75% reduction from 2010 levels, Kenya and Zimbabwe

Challenges

7

We use evidence selectively

“In Kenya, impact of changes in sexual risk behavior, and to a much lesser extent ART, on the

course of the epidemic, with their combined impact averting approximately 4,107,000

infections between 1980 and 2015. This was mostly attributed to changes in sexual risk

behavior”

Final Report on Evaluating the Evidence for Historical Interventions Having Reduced HIV

Incidence-2016

9

*widespread micro-financing services

IMAGE Study: Testing a structural intervention to address HIV & Gender-base violence

• After 2 years, risk of physical & sexual intimate partner violence reduced by 55% (aRR 0.45 95% CI 0.23-0.91)

• Among young IMAGE participants (age <35yrs):• Reduced unprotected sex & HIV service uptake

increased(Pronyk et al. AIDS 22, 2008)

We use data selectively

Selective application of

evidence?

Education sector investments

• Keeping girls in school

• HIV Indicators for Education system

• Teacher/matron guidance for health services and support (Prevention & Rx)

10

AYPs – approx. 280,00042% ART coverage? 40% testing; Lowest adherence, lowest viral

suppression AIDS leading cause of mortality

We are not ready to be accountable for results for Kenyans

HIPORS Report

• Baseline 411 NGO’s

• Only 44 (11%) reported in FY15/16

• Total expenditure

Kshs 14,385,285,158 across the 46 counties for HIV and AIDS programmes

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Lessons

12

We must become consistent in action • Marketing our products – what can we learn from the

private sector..

‘Every young person, old person literate or now knows where to get a ‘bamba 20’ in Kenya. Why do they not know where to

get a condom?’ (Mukoma 2016)

• Do not desert ‘what works’ for the new kid on the block

• The story of condoms

• Know your HIV status - HIV testing and counselling

• Communities of persons living with HIV

• Deliver 90-90-90 as cascade is still below optimal prevention benefits

13

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HIV starts and ends with behaviour.

Everything else is in between (Dazon Dialo , 2011)

AIDS – mortality for adolescents and young people in Africa and 2nd

globally – key issue is stigma and discrimination resulting in ART non-uptake and non-adherence

Figure adapted from: “Adherence vs. efficacy in PrEP trials (Bekker L-G, Tenofovir based PrEP technologies in women: what do we currently know? IAS 2013, Kuala Lumpur, Malaysia)”

• Marketing our products – what can we learn from the private sector..

‘Every young person, old person literate or now knows where to get a ‘bamba 20’ in Kenya. Why do they not

know where to get a condom?’ (Mukoma 2016)

• Do not desert ‘what works’ for the new kid on the block

• The story of condoms

• Know your HIV status - HIV testing and counselling

• Communities of persons living with HIV

We must become consistent in action

Recognize that we need a financing mechanism‘lay man’s language’ for ARVs only

- ART = 200US$ (approx. 300M$ = 30B required)

- 40% of annual Ministry of Health budget for FY 2015/16

- Does not include costs of HIV prevention, research

- Life-time cost liability

- LMIC status vs TRIPS and public health flexibilities on access to generics

- >70% donor funding

County* Estimated PLHIV

Annual cost of ARVs only (Ksh – 20,000 )(Examples)

Nairobi 177,552 3,551,040,000 35,510,400.00

Kisumu 134,826 2,696,520,000 26,965,200.00

Nakuru 61,598 1,231,960,000 12,319,600.00

Mombasa 54,670 1,093,400,000 10,934,000.00

Total PLHV 1,500,000 30,000,000,000300,000,000.00

Opportunities

17

It takes a few to create change - Kenya’s HIV prevention revolution roadmap

From national to County clusters

High, Medium, Low incidence

cluster

Timely data on granularity of

epidemics

Timely incidence

surveillance

From interventions to populations

By age groupBy priority

populationsBy bridging populations

From biomedical only to combination

prevention

targeted packages at scale

faster research to policy

translation

coordinated R&D for HIV prevention

From health to HIV prevention as

everyone's business

Leverage political

leadership

Leverage social movements

Legal and structural reforms

Who needs HIV Prevention? (populations)

What do they need?

(risk, perceptions)

What is available?

(evidence based interventions)

How will it be delivered?(packaging, settings,

delivery )

What will it cost?(cost, effectiveness)

18

National and County leadership and

accountability

• Counties (leadership and investments)

– County AIDS Strategic Plans

• Public Sector investments

– Sector plans and indicators

• Ministry of Health investments and support

• The multi-sector role/responsibility of the National AIDS Control Council

Global HIV Prevention Coalition

• Oct 10th – 11th 2017

• NAIROBI

Lessons from the successes of ART and eMTCT

• Targets described as numbers

• Is this the time to re-think measurement

– From prevalence to incidence?

• Financing mechanism??

20

“Lets say I have a boyfriend and am against the act, but you can be forced. He will come at night

when he knows I am there because he want to do …, and to make me to give him. He knows

if he rapes me... and when others get to know, they will

reject and laugh at me saying I was raped – so I will give in”

(Jane, 16yrs, Thika - 2004)

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Global Prevention Coaltion: Investing in HIV Prevention systems

• Products forecasting, quantification, supply & management

• service delivery (for Jane): Health facilities? VCT sites? pharmacies? Youth sites?

• Surveillance: indicators? who collects?

• Community based adherence systems

• High impact interventions (behavioural/ structural): Standardize application & deliver them uniformly with high levels of Coverage

HIV Prevention – what is needed?

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• We must invest for prevention results for Kenyans (beyond projects)

• We must become consistent in action, beyond

• HIV starts and ends with behavior, everthing else is in between

• The Global HIV Prevention Coalition is an opportunity

• Sustainable financing – investments in reducing new infections