PEPFAR South Africa Care and Treatment Technical Considerations & Priorities Dr Raymond Chimatira Dr Olarotimi S. Oladoyinbo 1

Outline Care and Treatment priority approaches Treatment expansion strategy and activities Differentiated service delivery models HIV/TB program Advanced Clinical Care Program Cryptococcal Antigen (CrAg) Screening Program 2

Care and Treatment Priority Approaches 1.Continued support for District Implementation Plans 2.Scale-up of PITC & strategies for reaching men 3.Linkage to care 4.Test and Treat 5.Differentiated Service Delivery Package 6.Viral Load Scale-up 7.Strengthened community-program 3

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Care and Treatment Priority Approaches Massive scale-up of facility-based PITC Treatment expansion strategies Implementation of National Adherence Guidelines Rationalized/ focused/ targeted training Intensified monitoring Community-facility programme linkage, referral networks Increase private sector engagement & services support Patient data systems: Tier.Net, ETR, EDR Community mobilization (HTS, Treatment Literacy) Clinical services integration Clinical systems (lab, pharmacy, supply chain) Planning & monitoring of program implementation Program & site level monitoring 6

Treatment Expansion Strategy & Activities Appropriate linkage across OVC, KP, MMC and other programs: link HIV+ to care and treatment; link HIV- to MMC; link children to OVC DSPs to engage with CBOs for household HTC / linkage and retention in care / treatment adherence support / defaulter tracing DSP/facility partners to coordinate the district CBOs; WBOTs; CCGs to support the adherence strategy; support mother infant pair tracking; identification and referrals of OVCs to facility; support tracking of TB/HIV defaulters, etc. Intensification of rationalized training and mentoring for comprehensive HIV/TB care, support and treatment ‘Roving Teams’ to support HCT, ART initiation, data entry, etc, Increase private sector engagement and support Continue with supporting the ART clinics in the hospital Targeted training and mentoring (all entry points) for improved PICT and linkages to the Gateway Clinics Early initiation of ART/TB (all entry points) and down referral of stable patients to PHC level Hiring roving teams to help with treatment initiation REGIONAL & DISTRICT HOSPITALS PHC & CHC clinics & Private sector engagement COMMUNITY LEVEL 1: Linking with HTC, MMC, OVC & key pops COMMUNITY LEVEL 2 : Linking with WBOTS, CBOs & CCGs DSP 7

Target PopulationServiceCommunityFacility Newly Diagnosed Test & Treat (September 2016)X Fast-track initiationX Adherence counselling and educationX Disclosure supportX New on Treatment support groupsXX Interactive reminders (SMS, social media apps, CHW call)XX Stable Decanting PatientsXX Adherence ClubsX 2-3 month drug supplyXX Spaced / Fast Lane AppointmentsX Community-based dispensation of ARVS (clubs, PDUs)X Patient Services through GPsX Unstable patients Regular appointment reminders until stableXX Enhanced Adherence CounselingXX Tracking and Tracing LTFUX Differentiated Service Delivery Models 8

HIV/TB Program 9 Percentage of deaths by broad cause by district, 2008–2013: KwaZulu-Natal Province* * Source: Massyn, N., Peer, N., Padarath, A., Barron, P., & Day, C. (Eds.). (2015). District Health Barometer 2014/2015. Durban, South Africa: Health Systems Trust.

HIV/TB Program (2) Drug-Resistant Tuberculosis (DR-TB): addresses clinical training and cross-infection in facilities – Nurse Initiated Management of DR-TB (NIMDR) – EDRweb – Centre for Scientific & Industrial Research (CSIR): training on infection control; ensuring appropriate design solutions for drug-resistant TB facilities in South Africa 10

ACC Program 11 Goal: To strengthen capacity for quality and sustainable clinical care for PLHIV with complicated HIV and TB/HIV co-infection, including 2nd, 3rd and alternate ART To establish/strengthen systems and capacity to manage ART & TB treatment failure To build capacity of PHC providers to better manage complex medical problems To establish/strengthen capacity for specialized clinical, laboratory and pharmaceutical services To collect strategic information (SI) to track patient and program outcomes Develop clear referral criteria Referral pathways mapping for complicated HIV Toll free helplines Referral Triage Lines CHAT (virtual experts) CPD accredited didactic ACC training M&M meetings Outreach support mentorship & case- based training by clinical specialists Outreach support On-site training and mentorship Clinical chart & facility audits Quality improvement Viral suppression & triage of complicated patients

CrAg Screening Program Reflex lab screening: – Sequentially implemented at approx. 200 facilities in Gauteng, Free State, Western Cape and KwaZulu-Natal – “Hub-&-Spoke” district model with central CD4 lab and referring facilities Implementation steps: – Stakeholder engagement, lab set up, clinical training, procurement and distribution of fluconazole, START, routine program monitoring 12

Specimens with CD4 count <100 cells/µL, n=50,327 Specimens reflexively tested with CrAg lateral flow assay, n=50,324 Patients with CD4 count <100 cells/µL and CrAg test results, n=42,666 Patients eligible for CrAg screening, n=41,999 (98%) Specimens not tested, N=3 Duplicate specimens tested, N=7,658 (15%) Prior cryptococcal meningitis, N=667 (2%) CrAg-positive (new diagnosis), n=1,271 (3%) CrAg-negative, n=40,728 (97%) 13

14 Thank You