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Getting to 80% ART coverage

Getting to 80% ART coverage. January 2010. Dr Francois Venter Reproductive Health and HIV Research Unit University of the Witwatersrand. Thanks to: Robin Wood. HIV and South Africa. 5 million people. Estimates of New Infections in Eastern and Southern Africa, 2007.

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Getting to 80% ART coverage

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  1. Getting to 80% ART coverage January 2010 Dr Francois Venter Reproductive Health and HIV Research Unit University of the Witwatersrand Thanks to: Robin Wood

  2. HIV and South Africa 5 million people

  3. Estimates of New Infections in Eastern and Southern Africa, 2007 Global new infections, 2.7 million ESA new infections, Prov. estimate 1.5m Rest of the world 1.2 million (43%) Eastern & Southern Africa 1.5 million (57%

  4. 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

  5. The proportion of deaths due to AIDS has shown a staggering increase in the last decade % Stats SA 2009: 43% directly due to AIDS 100 100 100 54% 72% 97% 46% AIDS implicated 28% 3% 1995 2000 2005 Common, preventable, treatable… How is it not a public health priority? Source: ASSA2003 Model

  6. When Is Antiretroviral Therapy Started? • Review of data from 2003-2005 from 176 sites in 42 countries (N = 33,008) 164 200 179 187 163 192 123 157 206 102 86 95 53 103 125 134 122 100 72 97 97 239 87 181 Egger M, et al. CROI 2007. Abstract 62.

  7. High death rate while waiting for ART 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. Arch Intern Med 2008;1678:86 Expedited care decreased mortality by 60%

  8. “"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

  9. Outcomes of ART 5 year survival on ART in Botswana ART recipients do well! 88.6% (88.1 – 89.2) Puvimanasinghe JPA et al. Mexico 2008 (MOAB0204)

  10. How are we doing?

  11. How are we doing? Somewhere around 45% in 2009… (NOT retention in care!)

  12. Who did we NOT reach? Proportion of children reached probably similar

  13. 500 000 need ARV’s EACH year 380 000 dead 220 000 well on ARV’s

  14. 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)

  15. Can we achieve scale-up?

  16. 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)

  17. Number of Patients initiated on to HAART @ RHRU Supported Sites within Region F

  18. The famous cascade… • 50% loss to follow up at EVERY step

  19. Target setting • Not even done at a provincial level • Starts with HIV testing – but EVERY step needs to be counted

  20. 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

  21. 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

  22. TB… Thanks: Braamie Variava

  23. Highest TB incident and prevalence Incidence of TB per 100,000 population 1,200 1,100 1,000 900 800 +13% 700 600 500 400 MDG 2015 Target 300 200 100 56 0 2000 2001 2002 2003 2004 2005 2006 • 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 Source: Health Systems Trust reported 722 number; WHO: Global Tuberculosis Control, Surveillance, Planning, Financing reported 940

  24. ART best way to prevent TB • IPT very hard to implement

  25. 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

  26. 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

  27. 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

  28. 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

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