Transcript Document

Getting to 80% ART
coverage
Dr Francois Venter
Reproductive Health and HIV Research Unit
University of the Witwatersrand
January 2010
Thanks to: Robin Wood
HIV and South Africa
5 million people
Estimates of New Infections in Eastern
and Southern Africa, 2007
Global new infections,
2.7 million
Rwanda, 9,225, 1%
Botswana, 13,518, 1%
ESA new infections,
Prov. estimate 1.5m
Swaziland, 15,131, 1%
Namibia, 16,082, 1%
Angola, 21,777, 1%
Lesotho, 22,666, 1%
Eritrea
4,838 Madagascar
1,491
Comoros Mauritius
28
584
Zimbabwe, 45,652, 3%
South Africa,
473,499
31%
Uganda, 78,769, 5%
Malawi, 86,905, 6%
Rest of the world
1.2 million (43%)
Eastern & Southern
Africa
1.5 million (57%
Ethiopia,
94,489
6%
Zambia,
103,077
7%
Tanzania,
139,151
9%
Kenya,
245,162
16%
Mozambique,
156,108
10%
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
The proportion of deaths due to AIDS has shown a
staggering increase in the last decade
100%
100
100
100
90%
80%
54%
70%
72%
60%
50%
Stats
SA
2009:
43%
directly
due to
AIDS
97%
40%
30%
46%
20%
AIDS implicated
28%
10%
0%
3%
1995
Source: ASSA2003 Model
2000
2005
Common, preventable, treatable… How
is it not a public health priority?
When Is Antiretroviral Therapy
Started?

Review of data from 2003-2005 from 176 sites in 42 countries (N = 33,008)
164
200
187
179
123
102
86
125
181
Egger M, et al. CROI 2007. Abstract 62.
122 100
97
97
87
163
192
157 206
95
103 53
72 134
239
High death rate while waiting for ART
Arch Intern Med 2008;1678:86
Braitstein, P et al. High
Risk Express Care: a
novel care model to
reduce early mortality
among high risk HIVinfected patients
initiating combination
antiretroviral treatment.
HIV Implementers
Meeting, Namibia,
abstract 1556, June
2009.
Expedited care
decreased mortality by
60%
• “"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
Outcomes of ART
5 year survival on ART in
Botswana
0.8
1.0
Main survival function
0.6
0.2
0.4
88.6% (88.1 – 89.2)
0.0
Cum survival
ART recipients do well!
0
1
2
3
4
5
survival time
Puvimanasinghe JPA et al.
Mexico 2008 (MOAB0204)
6
How are we doing?
Proportion of New AIDS Sick Cases Treated, per Year and
Province
2005
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
2006
2007
NSP Target 2011
NSP Target 2007
MP
LP
NW
GP
EC
FS
KZN
WC
NC
RSA
How are we doing?
Proportion of New AIDS Sick Cases Treated, per Year and
Province
2005
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
2006
2007
NSP Target 2011
NSP Target 2007
MP
LP
NW
GP
EC
FS
KZN
WC
NC
RSA
Somewhere around 45% in
2009… (NOT retention in
care!)
Who did we NOT reach?
Number of Untreated AIDS Cases per Year and per Province
Untreated AIDS cases 2005
Untreated AIDS cases 2006
Untreated AIDS cases 2007
120000
100000
80000
60000
40000
20000
0
NC
WC
LP
NW
FS
Proportion of children reached probably similar
MP
EC
GP
KZN
500 000 need ARV’s EACH year
380 000 dead
220 000 well on
ARV’s
• 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)
Can we achieve scale-up?
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)
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
April
May
Number of Patients
Number of Patients initiated on to
HAART @ RHRU Supported Sites
within Region F
500
450
400
350
300
250
200
150
100
50
0
2004
2005
2006
2007
2008
The famous cascade…
• 50% loss to follow up at EVERY step
Target setting
• Not even done at a provincial level
• Starts with HIV testing – but EVERY step
needs to be counted
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
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
TB…
Thanks: Braamie Variava
Highest TB incident and prevalence
Incidence of TB per 100,000 population
1,200
1,100
1,000
900
800
700
600
500
400
300
200
100
56
0
+13%
MDG 2015
Target
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
• ART best way to
prevent TB
• IPT very hard to
implement
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
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
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
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