1. Overview of the Society Presented at the Regional Workshop on HIV, AIDS and Housing Lauren Jankelowitz15 September 2014 HIV/AIDS Within the Southern African Context

2. Presented September 2014 By Lauren Jankelowitz Non-profit membership organisation of HIV health care workers Formed in 1997 by Prof Des Martin to help coordinate response to HIV/AIDS epidemic Governed by an eight member elected Board of Directors Secretariat in Johannesburg – 6 FTEs, network of consultants and clinical volunteers WHO ARE WE?

3. Presented September 2014 By Lauren Jankelowitz Society membership is inclusive of all health care workers in HIV: doctors, related professionals, nurses and emerging focus on lay HCWs as well Approximately 3 000 members 58% doctors; 50% public sector 50% private sector 28% nurse; 5% pharmacist 85% South African, remaining largely Southern African (Botswana, Namibia, Zimbabwe, Zambia) 37% reside in Gauteng; ~15% KZN, Western Cape and Eastern Cape each Paediatrics is the largest reported specialty WHO DO WE SERVE?

4. To promote quality comprehensive, evidence-based HIV healthcare in Southern Africa Objectives: To partner with governments to implement optimal HIV programmes and policies To foster evidence-based HIV related education for healthcare workers To produce evidence-based guidelines To facilitate interactions amongst HIV healthcare workers to optimise patient care To expand access to the activities of the Society To advocate for the best possible HIV treatment, care and prevention To improve TB diagnosis, care and prevention within the context of the HIV epidemic MISSION & OBJECTIVES

5. AIDS-related deaths1.7 million HIV+34 million 50% know their status New HIV infections2.5 million Eligible for treatment14.8 million On treatment8 million (UNAIDS Global Report, 2012) deaths among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention HIV Globally: The Facts

6. HIV+23.5 million (70% global total) SA5.6 million Nigeria3 million Kenya & Tanzania1.6 million each Uganda & Mozambique1.4 million each Zimbabwe1.2 million Zambia970 000 Ethiopia790 000 Botswana340 000 (UNAIDS Global Report, 2012) deaths among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention HIV in Southern Africa: The Facts

7. HIV Global Health Targets: Place 15 million people on ART Reduce TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention (United Nations General Assembly High Level Meeting on AIDS, 2011) deaths among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention Current HIV/AIDS Related Knowledge: The Way Forward In Dealing with the Current State of Health in Southern Africa

8. The WHO/UNAIDS Treatment 2.0 Initiative Achieve and sustain universal access & maximize the preventive benefits of ART The five pillars to re-energize the HIV response: I – Optimize drug regimens II – Promote diagnostics using point of care and other simplified technologies III – Reduce costs IV – Adapt delivery systems V – Mobilise communities, protect human rights TREATMENT 2.0 Adapt delivery systems Mobilize communities POC and other simplified monitoring Optimize drug regimens Reduce costs

9. Several countries are implementing or considering PMTCT Option B+ in Sub-Saharan Africa… CountryCurrent Option Transition Status MalawiB+Currently implementing B+ at national level. Revised treatment guidelines were approved in July 2011 and implementation began in September 2011. KenyaMixedPhased roll out of B+ beginning with high volume facilities. Most (60%) of the country receives Option A, with 40% receiving Option B. Revised PMTCT include B+, with a goal of 50% of HIV+ pregnant women on ART by Dec 2012. RwandaBWill begin implementing Option B+ in July 2012; already treating all pregnant women CD4<500. UgandaMixedWill conduct a phased rollout of B+ over a 14 month period, beginning in regions with high HIV prevalence. Aim is to transition all sites by March 2013. HaitiBMOH is considering transition to Option B+ in 2012. NamibiaAHas had preliminary discussions about B/B+ and will be conducting a cost and benefit/feasibility analysis, although no timeframe has been set. ZambiaA+ (treatment of discordant couples) TWG recommended transition to B/B+ in early 2010, but has not been implemented due to lack of funding and HR challenges. MozambiqueAMOH endorsed piloting B+ at 241 PEPFAR PMTCT facilities with ART facilities if ARV availability can be secured. SwazilandAB+ pilot studies planned; Discussions of a phased implementation are ongoing. CameroonAPlanned pilot of B+ in 2 districts. B+ Implementation Strategy in Place TWG has recommended B+ or under consideration by MOH Conducting B+ pilot studies PEPFAR, Feb,2012

10. How to use ARVs most strategically in a Public Health framework? Treatment 2.0 Strategic Use of ARVs Consolidated ARV Guidelines Key Populations PMTCT Countries will have to make programmatic decisions how best to use ARVs-based interventions Further simplification and optimisation of HIV treatment is needed to reach global targets New evidence on the effectiveness of ARVs for both HIV treatment and HIV prevention, requires new guidance on the strategic use of ARVs. PMTCT success directly linked with integration, service delivery and health systems strengthening Exploring the use of antiretrovirals for prevention plays an important role in key populations The architecture of WHO's normative guidance will be modified, with inclusion of operational and programmatic dimensions, and a shift towards consolidation for different populations and interventions. Cannot be done without Treatment 2.0

11. 11 Interventions HIV testing & counselling Adults, adolescents and children, age > 50 HIV+ with TB, HBV, HCV, HIV-2 co-infections, HIV+ pregnant women and their exposed children Key populations ARTp PrEP for specific populations PEP Different dimensions of consolidated ARV guidance (2013) ClinicalOperationalProgrammatic Adults / Adoles Pregnancy Children How? What? Where and when? (Prioritization)

12. Tx 2.0 normative pillars: Overview of short-, and medium/long-term objectives  Drug Regimen Optimisation: – Short term: Improve currently available drugs and formulations – Medium/long term: Stimulate the research pipeline towards development of better drugs, regimens and strategies  Diagnostics Optimisation: – Short term: Establish priority areas for optimisation (EID, CD4 and VL) – Medium/long term: Stimulate the PoC diagnostics´ pipeline and promote the development of QA/QC & prequalification frameworks on those areas  Adapting System Delivery: – Short term: Establish operational/programmatic guidance on system delivery (task shifting, decentralisation & integration – Medium/long term: Technical assistance to treatment 2.0 pilot countries, review implementation experience and inform policy and programmes.

13. Optimizing Drug Regimens Major Strategies Co-formulation (use FDCs or co-blister pack) Reformulation (use extended release formulation; improve drug bioavailability) Dose adjustment (improve toxicity, reduce pill burden/size) New drugs (substitution to improve toxicity or increase efficacy) New strategies (eg: induction-maintenance; intensification) Drug manufacturing process (improve API route synthesis and reduce cost)

14. Globally and in Southern Africa there has been a 50% reduction in new infections WHY? Political leadership; sustained investment; scale-up of treatment programmes; scale-up of some prevention programmes BUT: international investment dwindling and where stable, very fragile; behavioural prevention has largely failed; structural factors continue to drive the epidemic among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention The Southern African Context

15. HIV communication programmes, condom distribution and condom use in SA

16. Gender inequalities: relationship between men and women BUT why Southern Africa? Poverty: can’t afford, food, shelter, transport to collect meds Mobility and migration: lack of stability=lack of adherence if migration is unplanned BUT studies show similar adherence Economic well-being: focus on work and income vs. on healthy living and costs associated Stigma and discrimination: fear, lack of disclosure, lack of support; may equal criminalization for key pops Education: children running households, missing school Social capital: community relationships, citizenship BUT TAC Structural Factors Driving Epidemic

18. Structural Interventions Build social, legal & physical environments that enable risk reduction behaviours & encourage use of essential health & supportive services Address the factors that undermine healthy living, thereby fostering individual agency to reduce risk, adhere to prescribed regimens & remain engaged in continuous HIV care. Create & support AIDS-competent communities that prioritise community engagement & communication to promote better health outcomes.

19. HIV=Death! Stigma & discrimination Death vs. testing No/limited treatment Lots of behavioural prevention programmes Exceptionalising HIV Lack of political will Activism: a role for civil society Massive injection of funding to support any HIV work among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention The Way We Were

20. HIV=chronic illness Still stigma & discrimination (less?) Reduced mortality….still not enough testing Mass treatment programmes…treatment as prevention BUT now linked services/ issues the focus (PoC, labs, adherence, resistance) Behavioural prevention programmes failing: what now? Still exceptionalising HIV while simultaneously trying to integrate/mainstream Political will present mostly, except for key pops Changing role for activism: failings in health systems (stock outs, nurse attitudes, training, transport, medicine delivery, patient access) vs. treatment Funding reducing, threatening to reduce further; limited funding for prevention/ social programmes among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention Now, where are we?!

21. How are poverty issues (nutrition; access to water, sanitation and decent housing) impacting on ARV roll out and adherence in Southern Africa? Transport issues, distances to clinics (even logistics for labs, medicine supply), incorrect nutrition linked to increased lypodystrophy, lack of access to clean water for formula feeding & increased infections, mobility and lack of appropriate housing leading to difficulties in adherence How are capacity constraints impacting on ARV roll out and adherence in Southern Africa? Lack of HR capacity and expertise, clinics without refrigeration, lack of education, high unemployment… among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention Now, where are we?!

22. 1.Treatment as prevention 2.Knowing your status 3.Reaching HIV+ mothers and children; women; youth 4.MMC 5.Changing sexual behaviour (BUT new research shows no/contrary link to ‘sugar daddies’, polygamy, concurrent partners) 6.Consistent condom use 7.Key populations 8.Adherence support programmes: cash transfers, housing subsidies, NHI, keeping children in school, food assistance, legal reform among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention Where to?

23. Due to social drivers need 3-pronged combination prevention approach: 1.Behavioural (communications)…Prevention 2.Structural (law)…Policy 3.Technological (tools)…Treatment How do we get all 3 right? among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention Social Drivers

24. Department of Health Various NGO and private sector ART programmes Francois Venter Leigh Johnson Gottfried Hirnschall UNAIDS WHO Questions? among PLHIV by 50% children Intensify HIV prevention educe TB deaths among PLHIV by 50% Eliminate new HIV infections in children Intensify HIV prevention Acknowledgements