Fast-track to ending AIDS in Zimbabwe: 90.90.90 opportunities Michael Bartos (bartosm@unaids.org) UZ-UCSF Annual Research Day 17 April 2015

Outline 1. Why the 90.90.90 TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

New HIV infections in low- and middle-income countries, 2010–2030, with achievement of ambitious Fast-Track Targets, compared to maintaining 2013 coverage

AIDS-related deaths in low- and middle-income countries, 2010–2030, with achievement of ambitious Fast-Track Targets, compared to maintaining 2013 coverage

Ending the AIDS epidemic: A working definition ‘Ending the AIDS epidemic as a public health threat by 2030’ is provisionally defined as ‘reducing new HIV infections, stigma and discrimination experienced by people living with HIV and key populations, and AIDS-related deaths by 90% from 2010 levels, such that AIDS no longer represents a major threat to any population or country’

Global targets for ending the AIDS epidemic

Ambitious but achievable treatment target

of all people living with HIV will know their HIV status By 2020… 90% of all people living with HIV will know their HIV status 90% of all people diagnosed with HIV will receive sustained antiretroviral therapy. 90% of all people receiving antiretroviral therapy will have durable suppression.

What would ending AIDS targets look like for Zimbabwe – 2030 results ? New infections down 13% year on year 100,000 in 2010 currently (2013) 69,000 to 63,000 in 2015 (current projection) to 25,000 in 2020 and 10,000 in 2030 AIDS deaths down from 90,000 in 2010 currently (2013) 64,000 to 27,000 in 2015 (current projection) to 9,000 in 2030

Outline 1. Why the 90.90.90 TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

Testing: volume or yield? 13m total population 40% under 15 (5.2m) Over 15 infected or at risk (7.8m) Already tested + about 1m Pool of potential unknowns around 6m Current test volume 2.5m, 2018 target 3m annually

Testing – results from the 2013 MICS % of sexually active young people tested in past 12 months All – ever tested Tested past 12 mths

Korenromp and Stover, Democratizing Testing, UNAIDS April 2015

HIVST market intervention Country # Tests Phase 1 Phase 2 Malawi 172,754 420,466 South Africa 36,000 Zambia 200,478 404,522 Zimbabwe 359,190 1,069,810 Total 732,422 1,930,798

Outline 1. Why the 90.90.90 TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

Zimbabwe ART coverage targets 2014-2016 Ending AIDS 81% coverage target

Outline 1. Why the 90.90.90 TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

Retention of Patients Initiating ART During 2007-2009, Zimbabwe Good retention in care observed in a retrospective cohort study in a nationally representative sample of patients initiating ART between 2007 and 2009 69% of patients were continuing ART treatment at 24 months, whereas 7% had died and 24% were lost to follow-up (MOHCW, 2012)

90% of those on ART virally suppressed: trade offs? Initiation vs. retention Routine viral load vs. ‘on demand’ Maximally effective regimen vs. maximally forgiving regimen

Community ART refill groups Model self-selecting patient groups (7-14) one representative picks up  ARVs for the group on quarterly basis group contribute money for transport/ lunch/in kind support (eg work their fields)   Results: 9 months pilot evaluation (n=207) 100% retention, 99% virally suppressed Time saving: normally 45mins waiting, 50 mins with staff (nurse, counsellor, pharmacist); ART refill groups: 30 mins to serve 8 patients – saving >10 person/hours per day in a busy 3 person clinic Cost savings to patients from $14 per month to $48 (more remote areas) Secondary benefits in increased resilience, reduced stigma, more participation in health governance.

Outline 1. Why the 90.90.90 TARGETS? 2. TESTING – SHIFTING TO YIELDS 3. TREATMENT ACHEIVEMENTS AND CHALLENGES 4. SUSTAINING VIRAL SUPPRESSION 5. FINANCING THE RESPONSE 6. CONCLUSION

Building on past achievements: funds invested in AIDS programmes in PEPFAR: The United States President’s Emergency Plan for AIDS Relief Sources: UNAIDS estimates, UNAIDS–Kaiser Family Foundation reports on financing the response to HIV in low- and middle-income countries, GARPR 2014, philanthropic resource tracking reports from Funders Concerned About AIDS, reports from the Global Fund and UNITAID. Building on past achievements: funds invested in AIDS programmes in low- and middle-income countries, 1986–2013

Potential room for expansion: per capita health assistance, selected countries Zimbabwe

Public resource Availability for AIDS in Zimbabwe, 2009-2016, US $ million

Resource needs for AIDS 2015-2025 in two different scenarios: current coverage and enhanced, more efficient coverage

Additional impact: infections averted

Additional impact: deaths averted

conclusion Sustainability will require much more community delivery Patient-driven diagnostics and regimen switching Testing – shift from undifferentiated to targeted yield No one turned away More money will be needed (also to turn off the tap) conclusion