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Dr. Yogan PillayDeputy Director General
National Department of Health, South AfricaMonday 1 July 2013
OPERATIONAL AND PROGRAMMATIC CONSIDERATIONS IN SCALING UP ART
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Major progress in scaling up ART
15 million on ART by 2015 within reach
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Elimination of MTCT (UNAIDS)
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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
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MTCT rate at 6 weeks in South Africa
5
Thousands
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Total annual AIDS deathsEPP Classic Spline
2011 2011 2012270 000 316390 221770
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Rising life expectancy associated with ART scale up
Bor et al, Science 2013
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But considerable operational challenges
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Too few take a test and get their result
Staveteig et al, DHS Comparative Reports, 2013
13% - 76%8% - 69%
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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
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
• Expanded testing scenarios• Task shifting and
decentralization• Service integration• Adherence support
Key WHO Operational Recommendations
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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
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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
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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
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Decentralization and integration
Kerstenberger et al, PlosOne, 201315
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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
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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
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HIV and TB – school health programme
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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”.
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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
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Acknowledgements
WHO working group on operational guidelines
Health Economics and Epidemiology Research Organisation (HERO)
“Modelling Group” Country Team
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