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Universal Access to HIV/AIDS, TB and Malaria Services in Africa; Challenges and Prospects

5 th Inter-Agency Meeting on Coordination and Harmonization of HIV/AIDS, TB and Malaria Strategies. Universal Access to HIV/AIDS, TB and Malaria Services in Africa; Challenges and Prospects. Overview of Presentation. For each of the 3 diseases Situation and Trends Trends in the Response

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Universal Access to HIV/AIDS, TB and Malaria Services in Africa; Challenges and Prospects

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  1. 5th Inter-Agency Meeting on Coordination and Harmonization of HIV/AIDS, TB and Malaria Strategies Universal Access to HIV/AIDS, TB and Malaria Services in Africa; Challenges and Prospects

  2. Overview of Presentation • For each of the 3 diseases • Situation and Trends • Trends in the Response • Programmatic Challenges • Prospects for the Future

  3. HIV/AIDS Situation -2012 • People living with HIV – 25 million (71% of global burden) • Children <15 years living with HIV – 2.9 million (89% of global burden) • Regional Prevalence – 4.7% • People newly infected with HIV in 2012 – 1.6 million • AIDS related deaths in 2012 – 1.2 million

  4. HIV Burden in sub-Saharan Africa, 1990-2012 Source: UNAIDS and WHO

  5. S T R A T E G I C I N F O R M A T I O N Expanding testing and counselling Maximising prevention Accelerating treatment scale up Strengthening health systems The Health Sector's Contribution to Achieving Universal Access to HIV/AIDS Interventions

  6. WHO ARV Recommendations - 2013 guidelines Clinically relevant • Earlier initiation of ART (CD4 ≤ 500) • Immediate ART for children below 5 years • Lifelong ART in pregnant women (option B/B+) • Harmonization of ART across populations (e.g., adults and pregnant women, B/B+) and age groups • Simplified, fewer, and less toxic 1st line regimens (TDF/XTC/EFV) Operationally relevant • Use of Fixed Dose Combinations as a preferred approach • Improved patient monitoring to support better adherence and detect earlier treatment failure (increased use of VL) • Recommend task shifting, decentralization, and integration • Community based testing to complement broader HTC

  7. Transition in PMTCT Regimens in the 22 Global Plan Priority Countries Rapid Change Towards B/B+ After 2010 WHO PMTCT ARV Guidelines As of June 2013

  8. Where are we…….? • Progress has been made in the provision of ART • More than 7.5 million patients received ART by the end of 2012 • ART coverage increased from 49% in 2010 to 64% by the end of 2012 • ART coverage was more than 80% in 10 countries • 63% of pregnant women living with HIV received ARVs for PMTCT in 2012, compared with 34% in 2009 – 12 countries with a coverage of 80% or more, with 5 of them having attained 90% coverage • Improved access to ART has led to a reduction in AIDS-related deaths from 1.3 million in 2009 to 1.2 million in 2012

  9. Estimated % of pregnant women living with HIV who received ARVs for PMTCT

  10. Programmatic challenges – HIV treatment cascade for sub-Saharan Africa, 2012 Source: Global AIDS Report 2013, UNAIDS People no longer covered People covered Bounds of uncertainty

  11. CD4 Cell Count at Start of ART Mean CD4 cell count (95% CI) Country Indonesia 89 ( 69 to 110) Middle-income Low-income High-income China 118 ( 98 to 139) Senegal 137 ( 98 to 176) Zimbabwe 139 (133 to 145) Thailand 140 (129 to 151) Tanzania 145 (133 to 158) Benin 149 (117 to 181) South Africa 150 (148 to 152) Cameroon 154 (146 to 163) Malaysia 158 (140 to 176) Democratic Republic of Congo 163 (153 to 172) Malawi 166 (161 to 172) Singapore 169 (119 to 221) Zambia 174 (172 to 176) Uganda 176 (169 to 184) Nigeria 185 (175 to 195) Mali 187 (173 to 201) Philippines 187 (162 to 212) Cambodia 196 (148 to 244) Botswana 200 (166 to 235) Kenya 203 (199 to 207) Côte d'Ivoire 215 (209 to 221) South Korea 217 (182 to 253) Brazil 225 (211 to 239) Burundi 230 (211 to 248) Spain 231(223 to 238) India 234 (200 to 268) Canada 246 (234 to 257) Japan 252 (206 to 298) Italy 262 (241 to 284) Mozambique 263 (245 to 282) Burkina Faso 269 (257 to 281) France 278 (273 to 283) Australia 286 (265 to 306) Rwanda 287 (274 to 300) USA 307 (301 to 314) Mugglin et al. CROI 2012 0 50 100 150 200 250 300 350 Cells/µL

  12. HIV/AIDS - Programmatic Challenges • Progress made in PMTCT; however coverage in large countries like Nigeria and DRC still remains low; funding gaps for eMTCT plans • Treatment gap in children • Virtually no country in the Region is providing services for key populations on an adequate scale and intensity • Domestic investments are increasing; however donor dependence still remains a challenge -implementing the 2013 consolidated guidelines requires additional financial investment

  13. Incidence on the decline since 2003

  14. Strengthening health systems in endemic countries Key interventions - TB Surveillance, M & E • Register and report all TB cases • Monitor and document all treatment outcomes • Submit data for annual Global TB reports • TB prevalence survey • Operational Research DOTs Expansion • Early case detection • Screen all persons with cough of more than 2 weeks for TB • Screen all eligible patients for drug resistance • Case management • Treat all patients with 6 month short-course treatment • Ensure all drug resistant TB patients are treated with appropriate WHO regimens • Engagement of all health care providers in above interventions • TB/HIV Collaboration • Intensified Case Finding(ICF) • Screen all PLHIV for TB • Evaluate TB patients for HIV • Use Xpert MTB/RIF as initial diagnostic test in PLH and suspected MDR-TB • Start ART in all TB patients living with HIV irrespective of their CD4 counts • Provide CPT for HIV positive TB patients • Isoniazid Preventive Therapy (IPT) • Offer IPT to all PLHIV who do not have TB even if they are on ART • Infection Control • All facilities providing HIV care should have TB infection control measures in place

  15. TB case detection has risen from 43% in 1990 to 59% in 2012

  16. Attainment of the global target of 70% Case Detection Rate (CDR) and 85% Treatment Success Rate (TSR)- 2012

  17. TB - Programmatic Challenges • Emergence of MDR/XDR –TB and the high costs associated with managing drug resistant TB • Weak laboratory capacity for TB culture and drug susceptibility testing • TB/HIV co-infection and access to ART for TB/HIV co-infected individuals (In 2012, 78% of TB patients tested; 37% HIV positive but only 55% accessed ART) • TB in high risk/hard to reach areas e.g. mines, prisons and nomadic populations

  18. Malaria burden - 2012 • 80% of the estimated 207 million cases of malaria worldwide were in Africa • The estimated number of malaria cases per 1000 persons at risk of malaria reduced by 31% in the African Region between 2000 and 2012 • Pregnant women and children under 5 years are among the most vulnerable groups in the African Region • 90% of the estimated 627,000 malaria deaths worldwide in 2012 were in Africa • 86% of malaria deaths were in children under 5 years in 2012 • Malaria mortality rate decreased by 49% in the general population and by 54% in children under 5 years between 2000 and 2012

  19. Strengthening health systems in endemic countries Key interventions - Malaria Surveillance, M & E • Routine HMIS • Malaria surveillance systems • Household surveys • Operational research Prevention • Insecticide-treated bednets (ITNs) / Long-lasting ITNs (LLINs) • Indoor Residual Spraying In areas of moderate to high and stable transmission • Intermittent Preventive Treatment, in pregnancy (IPTp) • IPT in infancy (IPTi) In areas of high seasonal transmission • Seasonal malaria chemoprevention • Diagnosis & Treatment • Parasite based diagnosis • Microscopy • Rapid Diagnostic Tests • Artemisinin-based combination therapies (ACTs) • Case management: • Health facilities • Community Case Management (CMM) • Private sector

  20. Progress: Scaling up malaria treatment with ACTs - 2012 Where ACT use is currently planned Where malaria (treatment) occurs • 43 out of 44 endemic countries have adopted use of ACT as a policy • Only 18 countries are reporting country-wide implementation • 20 countries have a policy on parasitogical testing of suspected malaria cases in individuals of all ages • Proportion of suspected malaria cases receiving a diagnostic test in the public sector increased from 20% in 2005 to 47% in 2011 • 31 have introduced the use of ACTs at community level but only 6 have scaled up its deployment

  21. Progress: Implementation of CBIs and use of ACTs at community level in 2009 & 2012 Non AFRO Non AFRO CBIs planned to include use of ACTs (39) CBIs planned to include use of ACT (7) ACTs at community level (17) ACTs used at community level (31) CBIs not implemented (7) CBIs not implemented (8)

  22. Progress made in Malaria Control - 2012 • IPTpadoptedin all the 33 countries whereitisrecommended • Increased households owning at least one LLIN from 3% in 2000 to 53% in 2012 • IRS implementation expanding in the region; population at risk protected rose from les 5% in 2005 to 11% in 2010 • Pre-elimination initiative in 8 countries • Reduction of more than 50% of malaria cases and deaths in 12 countries

  23. Decreasein incidence of malaria cases in AFRO: 2000–2012

  24. Malaria - Programmatic Challenges • Lack of Universal Access to malaria interventions • Emerging resistance to pyrethroids and other insecticides • Threat of resistance to artemisinin-based medications and other anti-malarials • Lack of quality trend data in several countries • Moving from accelerated control towards malaria elimination

  25. MDG Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS. 38.5% reduction in the regional incidence of HIV between 2001 and 2012. 34 countries with decreasing trend, with notable reductions in the incidence MDG Target 6B: Achieve, by 2010, Universal Access to treatment for HIV/AIDS for all those who need it. By the end of 2012, 68% of eligible PLH were receiving ART, an increase of more than 90% since 2009. Most countries in the region have scaled up access to ART, but only 10 countries have attained the target of 80% ART coverage 16 countries with coverage below 50%. More needs to be done to achieve the HIV/AIDS-related MDG Targets Prospects for the Future – HIV/AIDS

  26. Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. Incidence of tuberculosis decreased in 25 countries while it increased or remained the same in 21 countries On the whole, the MDG target for TB has been achieved for the African Region The gains made need to be sustained and the challenges related to HIV and TB drug resistance addressed Prospects for the Future – TB

  27. Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases. The incidence of malaria reduced by 31% between 2000 and 2012 in the African region It is expected to decrease by 39% in the Region by 2015, if the current annual rate of decrease is maintained. 12 countries are on course to meet the MDG target However, the 2015 projected reductions in malaria incidence and mortality are well below the WHA and RBM 2015 targets of reducing malaria incidence rate by 75% and achieving near zero malaria deaths. More needs to be done to achieve the Malaria-related MDG Target Prospects for the Future – Malaria

  28. Countries to make smart investments for enhanced impact on disease burden More effectively target interventions to “hotspots” or areas or populations with the greatest needs Focus on areas where progress has been limited Make use of new opportunities Increase investment in health systems Improve the monitoring of progress made and the use of data for decision-making Countries to plan for the post-2015 era to improve Universal Health Coverage Prospects for the Future – HIV, TB & Malaria

  29. Partners to Focus on areas of comparative advantage to enhance coordinated support to countries Development partners to focus on strategic and catalytic upstream actions Implementing partners to focus on operational level actions Improve collaboration among ourselves Prospects for the Future – – HIV, TB & Malaria

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