HCT Campaign and ARV Expansion programme

Business sectors leaders29 March 2010

Goals

• Implement the new treatment guidelines and Presidential mandates

• Train health workers on the new guidelines and policies

• Implement the HCT campaign strategy • Expand availability of ART sites, decentralize

to PHC, implement nurse initiated ART• Plan for scale up of services, increase drug,

commodities, labs and HR

Strategy • Implement the business plans, monitor patient

uptake, monitor drugs stock levels, support nurse initiated services

• Provide support to new sites, use out reach treatment initiating teams, team up with partners and local practitioners

• Mobilize civil society, work with provincial, district and local AIDS council

• Monitor and track progress, capture data, communicate problems, challenges to the Nerve center for rapid responses

Patient profile

• 84% of public sector patients are on d4T, 3TC, EFV

• 8% of patients are d4T, 3TC, NVP • 2% of patients are d4T, 3TC, LPV/r• 2/3 of patient are women• 11 % are pregnant women

Patient profile

• Mean age of patient is 35,4 years for women and 38,7 years for men

• 1/3 of patient present with cd4 cell count below of less than 50 cells

• Most patient present with advance disease with cd4 cell count of 87 cells

• 20% of patients are under nourished

Adherence

• undiagnosed and untreated depression • Active substance abuse • Poor counseling leading to lack of insights• Failure to disclose HIV status close family• Adolescents and young adults • Lack of support from support groups and

DOTs • Co morbidities, pill burden, unmanaged drug

toxicity and stigma

High risk of mortality

• Men presented at old age, advance diseases, lower cd4 cell count and compare to non pregnant women

• Non pregnant women presented with more advance diseases than pregnant women

• 39% of death occurred in the first six months • Risk of death was almost five times higher in

among patient with cd4 < 50 cells compared to cd4 > 200 cells

Challenges

• Over a third of the patients present with advanced disease with median cd4 count of less than 87 cells count

• Rapid expansion of the ART services needing a change in the service platform

• High rate of single drug substitution • High death rate at the first six months compared

to deaths at 1 year • More than half of patient at ART initiation are

employed, need nutritional support

Presidential Mandates • Urgent cases in needs, patients with cd4 less than

200• Pregnant women who are HIV positive with cd4

equal and less than 350 start HAAR at 14 weeks• TB/HIV co infection with cd4 equal and less than

350 • Infants exposed to HIV pregnant women do PCR

if positive start treatment at once• Infants that are breast feeding to have NVP syrup

for the duration of breast feeding

Impact of Policy shift

Approach HCT ART Opportunistic infections

Palliative care

Phase 1 Deferred Treatment

Low (VCT passive client driven)

Moderate ( cd4 <200) symptomatic

High Opportunistic infections and disability

HighPalliative care and death

Phase 2. Early Treatment

Moderate (HCT provider initiated HCF )

Moderate Early ART < 350

Low disease progression and acute episode of OIs

Low Palliative care and AIDS related death

Phase 3 Test and Treat

High (population based HCT)

High universal access at cd4 > 500

Very low disease progression

Low death and palliative care

Nerve Center• Establish provincial Nerve center to coordinate,

monitor, direct and problems solve the HCT Campaign and Expansion of ART

• Provincial nerve center must provide daily update on the issues, challenges and progress to National Nerve Center

• All Hospital to establish local nerve center to monitor, validate and support health facility readiness and new site establishment

• Provincial AIDS council, civil society, local sectors of SANAC must participate, provide leadership and strategic direction on the social mobilization

New Patients

• All new patients must be put on the new regimes from 1 April, TDF, 3TC and EFV based on the national guidelines

• Nationally we have limited stock of Tenofovir/emtricitabine, abacavir, NVP syrup, provinces are asked to put their orders early for the first three months

• Truvada (TDF/emtricitabine) single dose replace NVP for women exposed to sdNVP

• TB/HIV patients, pregnant women and children must be strictly managed according to new guidelines

Drug availability • National policy is that all patients that are eligible

for ARV are put on treatment based on the new guidelines

• Patients who are stable on the old regime of d4T, FTC, EFV/NVP must be maintain on the same treatment

• The switch from d4T is based on clinical judgment and is related to adverse events

• Mono therapy switching for D4T for TDF must be kept within the national norms of less than 10% on establish patients

Prevention Programme• Implement mix of package of effective intervention

strategy to reduce new infections• Implement and rapidly expand medical male

circumcision • Increase substantial the availability and distribution of

male and female condoms • Implement the biomedical prevention strategies

include PEP and microbicide • Attain high ART coverage to achieve secondary

prevention • Eliminate or reduce to less than 5% MTCT and

transmission through breast milk

Enhanced Prevention Strategy

• Differential Communication for target groups and social mobilization ( Leadership of SANAC)

• Scale up of condom distribution and access• Implement Medical Male Circumcision • Increased access to syndromic management of STI • Monitoring and evaluation and tracking of

epidemic• Population based study to access cost

effectiveness

Screening and early detection of PHLWV

• HCT screening linked to care , provider initiated at public health facilities

• Screening for TB linked to IPT, scaling up TST implementation

• Screening for HIV in all pregnant women for early detection and access to care in ANC services l

• Screening for STI, and linked care • Expand to access to access ANC to modern

contraceptive service

Early Access to Treatment Set optimal patient eligibility criteria to achieve

improved clinical interventions and reduce progression of disease to stage3, 4 and death

Select cost effectiveness ART drug combinations to improve clinical outcome, reduce toxicity and pill burden

Set optimal criteria for judicious use of laboratory services to improve patient care, quality of care and toxicity monitoring

Set policy guideline for optimal human resources generation, task shifting and right mix, numbers and distribution

Early Access to Treatment Set guidelines for appropriate service delivery

platform that is fit for purpose for prevention, screening, treatment, care and support and mitigation of impact

Provide supportive supervision to provinces to strengthen the institutional capacity, strategy planning and management to support PHC service delivery

Achieving synergies between communicable disease program and health system strengthening

Strengthening leadership role of the health sector supply side to support multsectoral response, to priority district based on their epidemiological profile and disease burden

Social Mobilization

• Avert early death due to AIDS related diseases• Mitigate impact of HIV and AIDS to targeted

groups • Mobilize and support AIDS competent

communities • Provide integrated services for affected and

infected individuals, communities• Mobilize community against stigma, gender

violence and discrimination

ART Programme

Benefit Outcomes

Benefit Coverage HSS

Benefit Reach 100% PHC New infection

Benefit Quality Adults 1,350 M

70% adult ART low cd4

Early treatment

Benefit Access HAART Women 55 000

PMTCT 100%

Disease progression

Benefit Capacity WomenChild

Retention TB/HIV66000

TB/HIV 70% Disability and OIs

Benefit Resources

R 6 billion

TestingInitiationReferral

TB/HIVLow cd4

Toxicity Clinical outcomes

Children22000

Children PCR + 100%

AIDS Death

Target Target Target Target Target Target Target 2011

NEED

Results

Base

Reduce MTCT to below 5%

Newell ML. IAS 2005. Abstract WePl102. 39% 50% FF and 50% 6m BF

100% BF for only 6 mths

Infant feeding33%

Reduced from 30% to 20%

Antenatal prevalence

33%

100% ZDV+sdNVP

35% 50% sdNVP + 50% ZDV+sdNVP

21% 50% sdNVP

PMTCT

42%

Tools Current Strategies Future Strategies

Diagnostics Diagnose symptomatic patients who present to health services.

Rely on test (ZN) with 50% sensitivity

Algorithm for smear negatives

Active case finding

Contact evaluations

Use of new technologies

Joint TB/HIV case finding

Treatment DOTS with first line drugs

INH/EMB continuation phase in many settings

Shortened treatment

Intermittent treatment

Avoid drug interactions

Preventive therapy (PT)

Primary INH PT for limited time New regimens (eg, RPT)

Continuous INH

Secondary PT

Mass PT

Other Antiretrovirals for advanced disease

No infection control

Earlier antiretrovirals

Simple infection control

TB/HIV Control

Courtesy of R. Chaisson.

Prophylaxis

• All patients who are HIV positive must be assessed for active TB if not must be put on INH prophylaxis

• All patients who HIV positive with cd4 less than 200 including children must be put on cotrim

• All patients who are exposed to HIV infection must assessed and provided with PEP at once

• All children exposed to HIV in pregnancy or whose status is unknown must be provide with NVP until their status is know

Clinical outcomes

• Reduce mortality especially in the first six months

• Reduce loss to follow up • Improve cd4 cell count gains• Increase and maintain viral suppression • Achieve long term durability of the first line

regimes

Patient Retention

Information and SPHC• The need for specific epidemiological information to

identify those conditions causing the most severe public health problems

• The data is used to indicate priorities, determine unit costs of interventions and cost effectiveness basis for decision making

• Priorities cannot be read off the results or based only on technical considerations 'priority setting involves political judgment

• Over emphasizing the immediate and spectacular may draw attention away from the other necessary conditions required for the successful reduction of ill health

Remolding health information System

• We need a system to provide data necessary for monitoring intersectoral action of health and for feedback

• We need a set of simple cross sectoral analytical tabulation to link health to more important determinants of heath from other sectors

Inadequacy o f health information systems

• Overload imposed on health workers by demand for over sophisticated information systems

• Over centralization of information system• failure to analyst the available information adequately

or use for planning or feedback• The aggregation of data at higher level which masks

inequalities on which action Should be taken• The failure to build bridges to otter sectors• The failure to analyze information or to use

Information for planning process

Weaknesses of information Systems• Breakdown in the key processes required to produce useful

automation• the unresolved tension between the demand for uniform

data and the requirement to have automaton at local level that is relevant and specific to the needs and resource availability

• Information used to check on achievements four above• Targets that are unrealistic or irrelevant• Targets set for outputs of health services give no indication

by themselves of the extent to which interventions have achieved the desired impact

• Community health coulee can be used to monitor the extent to which heeds that have been (developed are met I tastes accepted Are achieved, resource promised made available

Achieve Scaling Up

Tsague L, et al. IAS 2005. Abstract TuOa0302.

• Advocacy and social mobilization• Decentralization & integration using the district

approach• Integration of procurement & monitoring &

evaluation into existing health system• Partner public/private sectors• Multisectorial coordination mechanism• National and international leadership and

support